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Mitzman B, Wang X, Haaland B, Varghese TK. Variation in Treatment Charges and Reimbursement Among Individual Thoracic Surgeons. Ann Thorac Surg 2024; 117:645-650. [PMID: 37479124 DOI: 10.1016/j.athoracsur.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/11/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Health care use and costs have undergone an increase in public scrutiny. Other specialties have evaluated practice patterns of their most highly reimbursed surgeons and found unique billing and procedure overuse. In this study, we evaluate Medicare payments to general thoracic surgeons and evaluate those with the highest reimbursements. METHODS The 2018 Medicare Provider Utilization Data were queried to identify thoracic surgeons. Services were grouped into common categories: Evaluation and Management, Lung/Pleura, Foregut, Chest Wall, Airway, Diaphragm, Mediastinum, Endoscopy, and Transplant. Payment data were analyzed for surgeons receiving the top 1% of Medicare payments and the remainder of the workforce. RESULTS In 2018, 2000 unique self-identified thoracic surgeons received a total of $54,734,736 in payments from Medicare for thoracic-related services. The top 1% of thoracic surgeons (n = 20) received $4,607,561, or 8.4% of total payments. Inpatient Evaluation and Management was the leading payment category for the top 1% (48.5% of payments), whereas Outpatient Evaluation and Management led for the remaining workforce (43.5% of payments). Whereas the surgical procedure code with overall highest reimbursement for both groups was Current Procedural Terminology (American Medical Association) 32663 (video-assisted thoracic surgery lobectomy), there was a difference with an increased use of high relative value unit unbundled Current Procedural Terminology codes in the highest earners. CONCLUSIONS A disproportionate amount of Medicare reimbursement went to top 1%. The highest earners appeared to earn the most from inpatient treatment codes and also used unbundled codes more often. Because billing code use is not regulated and often subjective, a deeper evaluation by the major surgical societies may be warranted.
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Affiliation(s)
- Brian Mitzman
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah; Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
| | - Xuechen Wang
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Ben Haaland
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah; Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Thomas K Varghese
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, Utah; Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Mitzman B, Wang X, Haaland B, Varghese TK. Variability in Excess Lobectomy Billing Among US Thoracic Surgeons. Ann Surg Oncol 2023; 30:7492-7498. [PMID: 37495842 DOI: 10.1245/s10434-023-13940-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/28/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Transparency in physician billing practices in the United States is lacking. Often, charges may vary substantially between providers and excess charges may be passed on to the patient. In this study, we evaluate Medicare charges and payments for minimally invasive lobectomy to obtain a sense of national billing practices and evaluate for predictors of higher charges. METHODS The 2018 Medicare Provider Utilization Data was queried to identify surgeons submitting charges for Video-Assisted Thoracoscopic Lobectomy. Excess charges were determined by each provider. Additional demographic variables were collected including geographic region for general surgery and cardiothoracic surgery training, years in practice, and current practice setting. A multivariate gamma regression was utilized to determine predictors of high billing practices. RESULTS A total of 307 unique providers submitted charges ranging from $1,104 to $25,128 with a median of $4,265. The average Medicare Payment amount ranged from $163 to $1,409, with a median of $1,056. Male surgeons were estimated to charge 1.3 times more than female surgeons, while those in an academic setting were estimated to charge 1.4 times more than private practice (p < 0.01). Surgeons practicing in the South or West were estimated to charge 0.76 and 0.81 times as much as those practicing in the Northeast (p < 0.01). CONCLUSIONS Billing practices vary widely across the United States. Charges submitted to Medicare likely represent a provider's charges across all payers. In today's healthcare economy, it is important for patients to understand the true cost of care and for providers to be mindful of reasonable and appropriate charges.
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Affiliation(s)
- Brian Mitzman
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA.
- Huntsman Cancer Institute, Salt Lake City, UT, USA.
| | - Xuechen Wang
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Ben Haaland
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
- Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Thomas K Varghese
- Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT, USA
- Huntsman Cancer Institute, Salt Lake City, UT, USA
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Liu DH, Ge M, Smith SS, Park C, Ference EH. Geographic Distribution of Otolaryngology Advance Practice Providers and Physicians. Otolaryngol Head Neck Surg 2021; 167:48-55. [PMID: 34428088 DOI: 10.1177/01945998211040408] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Advanced practice providers (APPs), namely physician assistants (PAs) and nurse practitioners (NPs), play an increasing role in meeting growing demands for otolaryngologic services, particularly in rural communities. This study analyzes the geographic distribution of otolaryngology providers, which is essential to addressing future demands. STUDY DESIGN Cross-sectional study. SETTING Medicare Provider Utilization and Payment Data for 2017. METHODS Current Procedural Terminology codes were used to identify APPs providing 10 common otolaryngologic services. Geographic distribution was evaluated by calculating densities of APPs and otolaryngologists per 100,000 persons in urban versus rural counties as defined by the National Center for Health Statistics Urban-Rural Classification Scheme. RESULTS We identified cohorts of 8573 otolaryngologists, 1148 NPs, and 895 PAs. There were significantly higher population-controlled densities of otolaryngologists and APPs in urban counties as compared with rural counties. The majority of otolaryngologists (92.1%) and APPs (83.3%) were in urban counties. However, the proportion of APPs (16.7%) in rural counties was significantly higher than the proportion of otolaryngologists (7.9%) in rural counties (P < .01). A significant majority of rural counties (72.2%) had zero identified providers, and a greater proportion of rural counties (5.0%) were served exclusively by APPs as compared with urban counties (3.2%). CONCLUSIONS Although otolaryngologists and APPs mostly practiced in urban counties, a relatively higher proportion of APPs practiced in rural counties when compared with otolaryngology physicians. The majority of rural counties did not have any otolaryngologic providers. Given the expected shortages of otolaryngology physicians, APPs may play a critical role in addressing these gaps in access.
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Affiliation(s)
- Derek H Liu
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Marshall Ge
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Stephanie Shintani Smith
- Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Christine Park
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Elisabeth H Ference
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Exilus SD, Haut ER, Canner J, Boss EF, Rowan NR. Otolaryngologist Characteristics and Outlier Use of Balloon Sinuplasty in the Medicare Population. Laryngoscope 2021; 132:1340-1345. [PMID: 34405899 DOI: 10.1002/lary.29824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/28/2021] [Accepted: 08/08/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Balloon sinuplasty (BSP) is associated with varied practice patterns. This study sought to identify otolaryngologist characteristics associated with BSP utilization. STUDY DESIGN Retrospective analysis of Medicare claims data and the National Physician Compare database. METHODS Outlier otolaryngologists were compared to non-outliers. Otolaryngologist characteristics included sex, practice size, geographic setting, years of experience, procedure setting, 10 or fewer endoscopic sinus surgeries per year for 3 or more years, and high number of services per unique Medicare beneficiary. Outlier status was defined as performing an annual total of balloon procedures of 2 standard deviations (SDs) above the mean for all otolaryngologists in the same year. RESULTS Between January 2012 and December 2017, 1,408 otolaryngologists performed 101,662 endoscopic sinus surgeries and 97,680 BSP procedures. Sixty-six outlier otolaryngologists (4.7%) accounted for 44.3% of all BSP procedures. Outlier status was associated with practice size of 10 or fewer individual providers (OR, 5.15; 95% CI, 2.73-9.74; P < .001), performance of 10 or fewer total endoscopic sinus surgeries per year for 3 or more years (OR, 3.90; 95% CI, 1.59-9.57; P = .003), and high number of overall services per beneficiary (OR 6.70; 95% CI, 1.19-37.84; P = .031). Provider sex, years of experience, and geographic setting were not associated with outlier status. CONCLUSION Outlier BSP patterns are associated with a few otolaryngologists who are more likely to be identified in small practices and record low numbers of endoscopic surgeries. Although BSP is an appropriate and effective tool, identification of outlier patterns may help to facilitate peer-to-peer counsel. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Smirnov D Exilus
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.,The Johns Hopkins Surgery Center for Outcomes Research, Baltimore, Maryland, U.S.A
| | - Elliot R Haut
- The Johns Hopkins Surgery Center for Outcomes Research, Baltimore, Maryland, U.S.A
| | - Joe Canner
- The Johns Hopkins Surgery Center for Outcomes Research, Baltimore, Maryland, U.S.A
| | - Emily F Boss
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
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Ge M, Kim JH, Smith SS, Paul J, Park C, Su P, Ference EH. Advanced Practice Providers Utilization Trends in Otolaryngology From 2012 to 2017 in the Medicare Population. Otolaryngol Head Neck Surg 2020; 165:69-75. [DOI: 10.1177/0194599820971186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Nurse practitioners and physician assistants form a growing advanced practice provider (APP) group. We aim to analyze the trends and types of services provided by APPs in otolaryngology. Study Design Cross-sectional study. Setting Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use Files, 2012-2017. Methods The Medicare database was searched for 13 commonly used otolaryngology-specific Current Procedural Terminology ( CPT) codes, and 10 evaluation and management (E/M) codes were evaluated by provider type. Changes in code utilization were compared between physicians and APPs over time. Results From 2012 to 2017, there was a 51% increase in the number of otolaryngology APPs, compared to a 2.2% increase in physician providers. APPs increased their share of new and established patient visits from 4% to 7%d 11% to 15%, respectively. There was not a significant difference over time in number of patient visits performed annually per provider according to provider type. The increase in number of APP vs physician providers was significantly greater for every procedure except for balloon sinus dilation and tympanostomy tube placement. Conclusion Due to increasing numbers, APPs are accounting for more patient visits and procedures over time. The physician workforce and the numbers of procedures performed per physician have remained relatively stable from 2012 to 2017. Increasing complexity of patients seen and a broader range of procedures offered by work-experienced or postgraduate-trained APPs may further improve access to health care in the face of possible physician shortages.
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Affiliation(s)
- Marshall Ge
- Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Jee-hong Kim
- Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Stephanie Shintani Smith
- Department of Otolaryngology–Head and Neck Surgery, McGaw School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Julianna Paul
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Christine Park
- Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Peiyi Su
- Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Elisabeth H. Ference
- Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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