Application
Deploying Counterfactual Intelligence
U.S. insurers face soaring costs from total knee arthroplasty (TKA), yet up to one-third of patients experience little to no improvement after surgery, leading to wasteful spending, patient dissatisfaction, and poor outcomes.[15][16]
Predictive Decision Support
- Delivers individualized counterfactual predictions showing outcomes with surgery versus conservative care.
- Achieves ~93% AUC accuracy on real-world pre- and post-operative data, ready for clinical deployment.
- Generates SHAP-based explanations to meet transparency, auditability, and fairness requirements.[22]
- Aligns with CMS’s 2025 prior authorization final rule, which mandates evidence-based, patient-specific justification for orthopedic procedures.[17]
Optimizes Orthopedic Workflow
- Prioritizes “hot-lead” OA patients so surgical teams focus on members most likely to achieve meaningful benefit.
- Improves OR throughput and surgical ROI by elevating high-benefit cases—critical as CMS requires KOOS Jr. outcomes for reimbursement tracking.[18][19]
- Reduces low-value specialist visits by steering low-benefit patients away from unnecessary imaging and consults.
Boosts Conservative Care Pathways
- Redirects low-benefit patients toward GLP-1-based weight management programs proven to improve OA outcomes.[20][21]
- Promotes structured physical therapy and lifestyle programs that delay surgical need.
- Delivers AI-personalized education where patients compare surgical versus non-surgical benefit, powered by SHAP explanations.[22]
- Empowers shared decision-making that reduces regret and unnecessary interventions.[23]
For Payers
Reduced spend on low-benefit TKA surgeries, fewer downstream costs, and transparent ROI tracking.
For Providers
Higher outcome metrics, optimized OR utilization, and avoidance of poor-value care episodes.
For Patients
Clearer choices, fewer unnecessary surgeries, and improved access to alternatives that deliver meaningful improvement.