Trends in Medicare physician reimbursement and utilization for proximal humerus fixation and shoulder arthroplasty

Abstract

BackgroundFixation and arthroplasty remain the mainstays of surgical treatment of degenerative and traumatic shoulder pathology. They also constitute an appreciable sum of Medicare expenditure. With continued concern for declines in Medicare reimbursement across orthopedic surgery, it is important to understand how trends in reimbursement correlate with relative procedure volumes. Our aims were to describe temporal changes in procedure volumes, physician payment, and patient charges for proximal humerus open reduction internal fixation (ORIF) and shoulder arthroplasty. MethodsUsing Medicare's Physician Fee Schedules from 2012 to 2017, we examined procedure volumes, number of unique surgeons performing, actual submitted patient charges, and surgeon payments from 2012 to 2017 for six shoulder procedures: proximal humerus ORIF (CPT-23615), traumatic hemiarthroplasty (HEMI) (CPT-23616), degenerative HEMI (CPT-23470), primary total shoulder arthroplasty (TSA) (CPT-23472), partial TSA revision (humeral or glenoid component, CPT-23473), and total TSA revision (CPT-23474). The reimbursement ratio was calculated by dividing surgeon payment by patient charges. Growth rates of charges and payment were adjusted for inflation using annual consumer price index inflation rates over the same time period. ResultsThe total number of traumatic and degenerative HEMI cases fell over −60%. Similarly, the number of unique surgeons performing traumatic and degenerative HEMI fell over −53%. In contrast, the number of TSA procedures rose by +70%, whereas partial and total revision TSA rose by +62% and +88%, respectively. The number of unique surgeons rose +28% and over +73% for primary and revision TSA, respectively. There was a large gap (between 3.4 and 4.4 times) between submitted charges and surgeon payment for all years analyzed. After adjusting for inflation, Medicare payment to surgeons decreased for all types of surgery (−6% to −9%) other than ORIF, which increased +10%. Submitted patient charges during this period increased +14% and +9.7% for ORIF and revision TSA (total), respectively, but decreased by −6% for traumatic HEMI. The reimbursement ratio was ≤29% for all procedures analyzed across all years and fell the most for revision TSA (partial and total). ConclusionFrom 2012 to 2017, there was a sharp decline in the use of shoulder HEMI with a correspondingly high increase in TSA. After accounting for inflation, HEMI and TSA showed appreciable declines in surgeon payment over time, whereas ORIF was the only surgery with increased surgeon payment. Revision TSA saw the largest declines in the reimbursement rate. Physicians and health care policy makers must be aware of these trends to ensure both a sustainable payment infrastructure for surgeons as well as to maintain access to care for these procedures. Level of evidenceLevel III; Economic Study