Decline in Medicare Utilization and Reimbursement Rates in Ophthalmic Plastic and Reconstructive Surgery: 2010-2019

Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties

OBJECTIVE

This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties.

BACKGROUND

Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement.

STUDY DESIGN

The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics.

RESULTS

After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001).

CONCLUSIONS

This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

Trends in Medicare Reimbursements for Commonly Performed Laryngeal Procedures from 2000 to 2021

OBJECTIVE

Numerous studies among different specialties have suggested that inflation-adjusted Medicare reimbursements have steadily declined in the last few decades. The objective of this study is to investigate whether this is true within the field of laryngology.

STUDY DESIGN

Retrospective Cross-Sectional Study.

SETTING

Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule.

METHODS

2000-2021 fees for laryngeal surgeries (Current Procedural Terminology [CPT] codes 31530, 31531, 31535, 31536, 31540, 31541, 31545, 31546, 31551-31554, 31560, 31561, 31570), and laryngectomies (CPTs 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 31390, 31395) were gathered. United States consumer price index (CPI) was used to adjust all gathered data for inflation to 2021 US dollars.

RESULTS

During the study period, unadjusted reimbursement for non-facility and facility laryngeal surgeries decreased an average of 6.1% and 6.6%, respectively. When adjusting for inflation, non-facility and facility laryngeal surgeries saw an average decrease of 17.8% (p < 0.001) and 28.5% (p < 0.001), respectively. Unadjusted reimbursement for facility laryngectomies saw an average increase of 40.2%, correlating to an inflation-adjusted decline of 8.9% (p < 0.001). Among laryngeal procedures overall, there was an average nominal increase of 17.0%, correlating to a 20.3% inflation-adjusted decline.

CONCLUSION

In terms of inflation-adjusted dollars, reimbursements for laryngeal procedures have seen a large decrease in the last two decades. Understanding reimbursement trends is critical for sustainability of otolaryngology practices, and can be used by surgeons, hospital systems, and policymakers to guide future healthcare legislation.

Decreasing Reimbursement of Pituitary Tumor Surgery: An Analysis of Medicare Data From 2010 to 2020

BACKGROUND AND OBJECTIVES

Despite the extensive amount of research aimed at comparing patient outcomes between microscopic transsphenoidal surgery (MTSS) and endoscopic transsphenoidal surgery (ETSS) approaches, there has been relatively little recent investigation into the nationwide utilization and reimbursement trends of both techniques. This study aimed to identify trends in pituitary tumor surgery utilization, charges to Medicare, and reimbursement dependent on (1) MTSS/ETSS surgery type, (2) provider type (ie, neurosurgeon vs ear, nose, and throat), and (3) cosurgery status.

METHODS

This study used publicly available data from the Medicare Physician/Supplier Procedure Summary for the years 2010-2020. Linear regression was used to quantify temporal trends for submitted service counts, submitted charges, reimbursements, and reimbursement-to-charge across the 2010-2020 period.

RESULTS

Regarding service count trends from 2010 to 2020, our results demonstrate a significant increase in ETSS utilization ( = 1.55, CI = 0.99-2.12, P < .001), a significant decrease in MTSS utilization ( = -0.86, CI = -1.21 to -0.51, P < .001), a significant increase in services submitted by otolaryngologists ( = 0.59, CI = 0.24-0.93, P = .0040), and a significant increase in cosurgeries ( = 1.03, CI = 0.24-0.93, P = .0051). Importantly, our results also demonstrated a significant decrease in reimbursements for ETSS procedures ( = -12.74, CI = -22.38 to -3.09, P = .015) and for pituitary tumor surgeries submitted by neurosurgeons specifically ( = -41.56, CI = -51.67 to -31.63, P < .0001).

CONCLUSION

Our results demonstrated a significant increase in ETSS utilization and a significant decrease in MTSS utilization. We also noted a significant decrease in reimbursements for ETSS procedures and among procedures submitted by neurosurgeons specifically. We hope that our study highlights nationwide utilization and reimbursement patterns that may be useful for guiding future reimbursement-oriented policy development.

20-year Inflation-Adjusted Medicare Reimbursements (Years: 2000-2020) For Common Lumbar and Cervical Degenerative Disc Disease Procedures

OBJECTIVE

Reimbursement trends for common procedures have persistently declined over the past 2 decades. Spinal instrumentational and fusion procedures are increasingly utilized and have increased in clinical complexity, yet longitudinal inflation-adjusted data for Medicare reimbursements of these procedures have not been evaluated.

METHODS

The Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements for the 5 most common spinal procedures and associated instrumentations from 2000-2020. Current Procedural Terminology (CPT) codes include 22551, 22600, 22633, 63030, and 63047 as well as instrumentation CPT codes 22840 and 22842-6. The nominal values were adjusted for inflation according to the latest consumer price index (U.S. Bureau of Labor Statistics; reported as 2020 USD) and used to calculate average annual percent changes and compound annual growth rates (CAGRs) in reimbursements.

RESULTS

After inflation adjustment, the physician fee reimbursement decreased by 11.05% ± 8.46% (mean ± s.d., from $2,009.89 in 2011 to $1,787.85 in 2020) for anterior cervical discectomy and fusion (ACDF), 28.38% ± 8.42% (from $1,889.38 in 2000 to $1,353.14 in 2020) for posterior cervical fusion, 7.85% ± 8.20% (from $2,111.20 in 2012 to $1,945.49 in 2020) for transforaminal lumbar interbody fusion (TLIF), 28.17% ± 13.88% (from $1,421.78 in 2000 to $1,021.22 in 2020) for lower back disc surgery, and 31.88% ± 8.22% (from $1,700.38 in 2000 to $1,158.25 in 2020) for lumbar laminectomy. Instrumentation reimbursements showed an average decrease of 33.43% ± 8.4% over this period. Average CAGR was -1.7% ± .41% for procedures and -2.02% ± .14% for instrumentation.

CONCLUSION

Our analysis reveals a persistent decline in reimbursement rates of the most common spine procedures and instrumentation since the year 2000. If unaddressed, this trend can serve as a substantial disincentive for physicians to perform these procedures and can significantly limit access to spinal care at the population level.

Glaucoma Surgery Shifts Among Medicare Beneficiaries After 2022 Reimbursement Changes in the United States

PRCIS

This study revealed the best-estimated surgical procedural counts for 2021 and 2022 and suggests a direct influence of coding and reimbursement changes on surgical device selection.

PURPOSE

To analyze utilization rates of glaucoma surgeries and minimally invasive (microinvasive) glaucoma surgery among US Medicare beneficiaries between 2021 and 2022.

DESIGN

Retrospective comparative analysis of 68,118 unique patients.

METHODS

National claims data from a 5% sample of all Medicare beneficiaries were utilized to compare glaucoma procedure counts between the first quarter of 2021 and the first quarter of 2022. Duplicate claims were excluded, and 50 modifiers were counted as 2 distinct procedures. A multiplier was applied to estimate annual utilization for the entire Medicare population. χ 2 analysis was employed to compare categorical data from the 2 time periods.

RESULTS

Current Procedural Terminology codes for angle-based stenting decreased by an estimated 20,960 procedures between 2021 and 2022 (28.60%). Goniotomy increased by an estimated 11,680 procedures (66.97%) and canaloplasty increased by an estimated 6640 procedures (47.43%). Glaucoma surgeries decreased by an estimated 5760 procedures (4.25%) despite an increase of cataract surgery by 234,960 procedures (15.63%), an increase in YAG capsulotomy by 19,280 procedures (3.31%), and an increase in intravitreal injections by 146,320 procedures (3.86%).

CONCLUSION

Despite overall surgical volume increases among the ophthalmology procedures, angle-based stenting utilization decreased significantly with an accompanying trend change following the coding and reimbursement changes implemented in January 2022. Of the minimally invasive (microinvasive) glaucoma surgery procedures, goniotomy and canaloplasty counts increased the most between these periods. Trabeculectomy and glaucoma drainage device procedures continued to decrease, following well-established trends. Future studies are warranted to examine how these shifts in utilization may impact patient care outcomes.

Reimbursement Trends in Reduction Mammoplasty: A Single-Center Analysis of Insurance Reimbursements From 2012 to 2021

BACKGROUND

Medicare reimbursement for plastic surgery procedures increased by 2% while inflation increased by 19% in the past decade. Given increasing national breast reduction case volume and the negative impact decreased reimbursements have on surgeon well-being, we sought to evaluate actual surgeon reimbursements for bilateral breast reduction over a decade.

METHODS

A retrospective review was performed including all identifiable breast reduction procedures (Current Procedure Terminology 19318) performed at a tertiary academic hospital between October 2011 and September 2021 (fiscal year 2012-2021). The annual number of patients undergoing breast reduction, the payor, and average yearly amounts reimbursed were evaluated and trended over time. Percent change from Medicare average yearly reimbursements was evaluated and trended over time. All values were adjusted to 2021 US dollars.

RESULTS

During our study period, there were 486 bilateral breast reduction procedures with 36 outlier payments; therefore, 450 reimbursements were included in the study. There were 5 payors, and the average adjusted reimbursement amount was $2418.74 ± $1123.83. All private payors had significantly higher average reimbursement than Medicare ( P < 0.0001), and Medicare was the only payor with significant decrease in reimbursement over time (-$58.58 per year, 95% confidence interval, -$110.80 to -$6.33, P = 0.033).

CONCLUSIONS

Our data demonstrate that a difference exists between public and private payors for bilateral breast reduction procedures. Private payor reimbursements outpaced inflation. Medicare is an unreliable benchmark that may indirectly lead to declining reimbursements over time.

The Implications of the Emergency Medical Treatment and Labor Act and the No Surprises Act for Plastic and Reconstructive Surgeons

SUMMARY

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted by Congress in 1986 to protect uninsured patients against economic discrimination. Although this law has been established for several decades, recent passage of the No Surprises Act may invoke new implications for the health care system under EMTALA. Therefore, it is worthwhile to review EMTALA's applications to the practice of plastic surgery and review EMTALA in the context of the recently passed No Surprises Act. First, providers are mandated by EMTALA to administer a medical screening examination to any patient presenting for emergent care. Second, providers must administer medical stabilization if the medical screening examination reveals an emergent condition. If the hospital lacks specialized capabilities to provide stabilizing care, they are required to transfer the patient to a facility that can provide care. Although EMTALA's provisions protect patients and provide them with leverage to obtain emergency care, the act has been associated with out-of-network, or "surprise," medical bills for the insured population and, ultimately, may be detrimental to plastic surgeons in emergency settings. The concerns related to EMTALA within plastic surgery involve the overburdening of surgeons at tertiary care centers because of uncompensated care and high rates of interfacility transfers. In addition, the recent passage of the No Surprises Act to end out-of-network emergency bills may further impact care provided by plastic surgeons in emergency settings under EMTALA's mandate. Potential methods to address these concerns include increasing on-call reimbursement rates and implementation of emergency department telemedicine services.

Neurosurgical Utilization, Charges, and Reimbursement After the Affordable Care Act: Trends From 2011 to 2019

BACKGROUND

An estimated 50 million Americans receive Medicare health care coverage. Prior studies have established a downward trend in Medicare reimbursement for commonly billed surgical procedures, but it is unclear whether these trends hold true across all neurosurgical procedures.

OBJECTIVE

To assess trends in utilization, charges, and reimbursement by Medicare for neurosurgical procedures after passage of the Affordable Care Act in 2010.

METHODS

We review yearly Physician/Supplier Procedure Summary datasets from the Centers for Medicare and Medicaid Services for all procedures billed by neurosurgeons to Medicare Part B between 2011 and 2019. Procedural coding was categorized into cranial, spine, vascular, peripheral nerve, and radiosurgery cases. Weighted averages for charges and reimbursements adjusted for inflation were calculated. The ratio of the weighted mean reimbursement to weighted mean charge was calculated as the reimbursement-to-charge ratio, representing the proportion of charges reimbursed by Medicare.

RESULTS

Overall enrollment-adjusted utilization decreased by 12.1%. Utilization decreased by 24.0% in the inpatient setting but increased by 639% at ambulatory surgery centers and 80.2% in the outpatient setting. Inflation-adjusted, weighted mean charges decreased by 4.0% while reimbursement decreased by 4.6%. Procedure groups that saw increases in reimbursement included cervical spine surgery, cranial functional and epilepsy procedures, cranial pain procedures, and endovascular procedures. Ambulatory surgery centers saw the greatest increase in charges and reimbursements.

CONCLUSION

Although overall reimbursement declined across the study period, substantial differences emerged across procedural categories. We further find a notable shift in utilization and reimbursement for neurosurgical procedures done in non-inpatient care settings.

Trends in Medicare Reimbursement for the Top 20 Surgical Procedures in Craniofacial Trauma

BACKGROUND

Research regarding financial trends in craniofacial trauma surgery is limited. Understanding these trends is important to the evolvement of suitable reimbursement models in craniofacial plastic surgery. The purpose of this study was to evaluate the trends in Medicare reimbursement rates for the top 20 most utilized surgical procedures for facial trauma.

METHODS

The 20 most commonly utilized Current Procedural Terminology (CPT) codes for facial trauma repairs in 2018 were queried from The National Summary Data File from the Centers for Medicare & Medicaid Services (CMS). Reimbursement data for each procedure was then extracted from The Physician Fee Schedule Lookup Tool. Changes to the United States consumer price index (CPI) were used to adjust all gathered data for inflation to 2021 US dollars (USD). The average annual and the total percent change in reimbursement were calculated for the included procedures based on the adjusted trends from the years 2000 to 2021.

RESULTS

From 2000 to 2021, the average reimbursement for all procedures decreased by 16.6% after adjusting for inflation. Closed treatment of temporomandibular joint dislocation and closed treatment of nasal bone fractures without manipulation demonstrated the greatest decrease in mean adjusted reimbursement at -48.7% and -48.3%, respectively, while closed treatment of nasal bone fractures without stabilization demonstrated the smallest mean decrease at -1.4% during the study period. Open treatment of nasal septal fractures with or without stabilization demonstrated the greatest increase in mean adjusted reimbursement at 18.9%, while closed treatment of nasal septal fractures with or without stabilization demonstrated the smallest increase at 1.2%. The average reimbursement for all closed procedures in the top 20 decreased by 19.3%, while that for all open procedures decreased by 15.5%. The adjusted reimbursement rate for all top 20 procedures decreased by an average of 0.8% each year.

CONCLUSIONS

To the best of our knowledge, this is the first study to comprehensively evaluate trends in Medicare reimbursement for facial trauma surgical repairs. Adjusting for inflation, Medicare reimbursement for the top 20 most commonly utilized procedures has largely decreased from 2000 to 2021. Consideration of these trends by surgeons, hospital systems, and policymakers will be important to assure continued access to meaningful surgical facial trauma care in the United States.

United States Medicare Reimbursement Trends for Glaucoma Procedures: 2000 to 2020

PURPOSE

To investigate United States medicare reimbursement trends for common glaucoma procedures from 2000 to 2020.

MATERIALS AND METHODS

Current Procedural Terminology codes for Glaucoma procedures in the United States Centers for Medicare and Medicaid Services database were used to conduct this economic analysis. Reimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for the selected procedures and compensation trends were investigated after adjusting for inflation in 2020 US dollars from the unadjusted data between 2000 to 2020.

RESULTS

The average adjusted reimbursement for the analyzed procedures decreased by 20.5% (95% confidence interval [CI], -15.4% to -25.6%) over the twenty-year period. On average, there was a 1.03% decrease in reimbursement rates per year (95% confidence interval [CI], -0.74% to -1.33%) with an adjusted Compound Annual Growth Rate of -1.35% (95% confidence interval [CI], -1.07% to -1.64%). The results show an overall declining rate in reimbursement for the glaucoma procedures analyzed in this study.

CONCLUSIONS

United States medicare reimbursement for glaucoma procedures in the United States showed a significant decline between 2000 to 2020. These findings may be relevant to understanding changing practice patterns for glaucoma care.