Decrease In Reimbursement Research Articles

Trends in Surgeon Reimbursement for Primary Total Hip and Knee Joint Arthroplasty: An Analysis of 2,421,710 Medicare Part B Claims From 2017 to 2022.

Primary hip and knee total joint arthroplasties (TJAs) are among the most frequently performed orthopaedic surgeries in the United States, with demand projected to increase to two million cases per year by 2040. Despite the growing demand, previous studies have shown a declining value of Medicare surgeon reimbursements. Given recent inflationary trends, an updated analysis of the changing value of primary TJA reimbursement is necessary. This study examines surgeon reimbursement trends for primary TJA among Medicare patients from 2017 to 2022. We analyzed Medicare Part B claims data from the Centers for Medicare and Medicaid Services Medicare Physician & Other Practitioners database. Using Healthcare Common Procedure Coding System codes for primary TJA, we queried the database for procedures performed between 2017 and 2022. Yearly service counts and allowed Medicare reimbursements were examined. Reimbursement values were adjusted for inflation using the Consumer Price Index with all values converted to 2022 U.S. dollars. The study included 2,421,710 Medicare claims for primary TJA from 2017 to 2022. During this period, the volume of primary TJA increased by 2.9%. However, average reimbursement decreased by 4.2%, from $1,343 in 2017 to $1,286 in 2022. When adjusted for inflation, the decrease in reimbursement was more pronounced, falling by 19.6% from $1,600 to $1,286. Trends in reimbursement varied by procedure type and geographic region. Between 2017 and 2022, while the volume of primary TJA increased, Medicare surgeon reimbursement for these procedures decreased, with a markedly greater reduction when adjusted for inflation. These trends highlight the need for policy reforms to ensure sustainable reimbursement for surgeons performing primary TJA.

Trends in Medicare Reimbursement and Service Volume of Vitreoretinal Procedures: 2000 to 2021.

Purpose: To characterize trends in service volume and inflation-adjusted Medicare reimbursement of vitreoretinal procedures over the past 2 decades. Methods: Medicare Part B National Summary Data Files were accessed to identify the number of allowed services for vitreoretinal procedures. The Medicare Physician Fee Schedule was accessed to identify average annual national reimbursement rates. The Spearman correlation coefficient was used to evaluate time trends for each procedure. All analyses were conducted using Prism 9.5.1 software with 2-sided significance testing and statistical significance set at P ≤ .05. Results: From 2000 to 2021, the 2-tailed Spearman correlation showed that 20 of 38 procedures had statistically significant decreases in service volume over time. Intravitreal injections increased more than 1000-fold, from 2922 in 2000 to 3 444 500 injections in 2021 (ρ = 0.997; P < .001). Panretinal photocoagulation treatments declined from 104 865 to 48 533 procedures (ρ = -0.966; P = .003). Scleral buckling declined from 6502 to 587 procedures (ρ = -0.999; P < .001). Pars plana vitrectomy-associated procedures increased from 71 039 to 95 429 (ρ = 0.691; P < .001). From 2000 to 2021, the 2-tailed Spearman correlation showed that 29 of 38 procedures had statistically significant decreases in reimbursement over time. No procedure had a significant increase in payment. Conclusions: Vitreoretinal practice patterns have changed dramatically over the past 2 decades, with significant declines in inflation-adjusted Medicare reimbursement for most procedures. Awareness of service volume and reimbursement trends is vital to assessing economic viability and patient coverage under the current Medicare payment policies.

Trends in Medicare Utilization and Reimbursement of Tracheostomy From 2000 to 2022.

To analyze the utilization and reimbursement for tracheostomy. Retrospective Cross-Sectional Study. Centers for Medicare & Medicaid Services (CMS) Medicare Provider Utilization and Payment Data (2013 and 2021) and Part B Medicare Fee-For-Service National Summary Data (2000-2022). Utilization, payment, and specialty breakdown were analyzed for planned tracheostomy (Current Procedural Terminology [CPT] codes 31600, 31601, 31610) and emergency tracheostomy (CPT codes 31603, 31605). From 2000 to 2022, there was a 48.9% decrease (40,754-20,812) in number of planned tracheostomies and a 75.3% decrease (3277-811) in number of emergency tracheostomies, leading to an overall decrease of 51%. Similarly, there was a 59.3% inflation-adjusted decrease ($13.4-$5.5 million) in total reimbursement for planned tracheostomies and an 82.1% inflation-adjusted decrease ($1.1 million-$205 thousand) in total reimbursement for emergency tracheostomies. There was a 20.3% inflation-adjusted decrease ($329-$262) in reimbursement per planned tracheostomy and a 27.7% inflation-adjusted decrease ($349-$252) in reimbursement per emergency tracheostomy. In our sample of 280 high-volume tracheostomy providers in 2021 (28.2% otolaryngology, 28.2% general surgery, 14.6% thoracic surgery, 14.3% pulmonary disease, 6.4% critical care), the average provider performed 15.8 tracheostomies and was reimbursed $5362. Despite significant declines in tracheostomy utilization and reimbursement, understanding trends for these lifesaving procedures are critical for otolaryngologists and other providers in delivering high-quality care, and can be used by surgeons, hospital systems, and policymakers to guide future health care legislation.

Trends in Medicare Utilization and Reimbursement for Traumatic Brain Injury: 2003–2021

Traumatic brain injury (TBI) is a significant public health issue among Medicare beneficiaries, with many specialties reporting consistent annual decreases in utilization and reimbursement. This study investigates the trends in Medicare utilization and rates of reimbursement for neurosurgical procedures related to TBI from 2003 to 2021, aiming to provide insights into the economic aspects of TBI care. Utilizing the Medicare Part B National Summary Data files, we analyzed 14 neurosurgical procedures over the 18-year period, assessing the changes in procedural volume and mean reimbursement per procedure, adjusted for inflation to the 2021 USD using the Consumer Price Index. From 2003 to 2021, TBI-related neurosurgical interventions showed a total percent change of −15.39% in procedural volume and −3.11% in inflation-adjusted mean reimbursement per procedure. Linear regression analyses indicated a significant downward trend in the overall procedural volume (p &lt; 0.001) but no significant trend in the inflation-adjusted mean reimbursement rates (p = 0.585). Subgroup analyses did not reveal significant changes in the reimbursement rates for decompressive craniotomy/craniectomy, cranioplasty, intracranial pressure management, and traumatic fracture/penetration procedures. Our study indicates a significant decrease in neurosurgical TBI procedural volumes, while reimbursement rates remained stable when adjusted for inflation, highlighting the need for policy adjustments to ensure adequate resources for TBI care.

American Thyroid Association Policy Statement: Impact of Changes in Fine Needle Aspiration Biopsy Reimbursement on Clinical Care of Patients with Thyroid Nodules in the United States.

Introduction: The Clinical Affairs Committee of the American Thyroid Association has developed this statement to describe recent changes in the billing and coding of ultrasound-guided fine needle aspiration procedures of thyroid nodules, and to raise awareness of the adverse consequences that have arisen as a result. Review: A reduction in payment of ultrasound-guided fine needle aspiration procedures was enacted by the Centers for Medicare and Medicaid Services in 2019. The Clinical Affairs Committee has sought to examine the effects of the change in reimbursement on the care of patients with thyroid diseases. Summary: The historical background of the changes in payment structure for ultrasound-guided fine needle aspiration of thyroid nodules is discussed. The years 2019 and 2020 saw a significant decline in claims for ultrasound-guided fine needle aspiration procedures, concomitant with a shift in the performance of these procedures away from non-facility outpatient settings and a rise in costs to the health care system. Conclusion: Several negative consequences of the decrease in reimbursement for ultrasound-guided fine needle aspiration of thyroid nodules have arisen. This has led to significant concern among clinicians who care for patients with thyroid diseases regarding delays in patient access to care and diagnosis, and a diminished pool of qualified thyroid specialists to perform these procedures in the future.

The Decline of Medicare Reimbursement in Anatomic Pathology

Abstract Introduction/Objective Lack of an annual inflationary update for physician reimbursement from the Centers for Medicare &amp; Medicaid Services (CMS) jeopardizes access to anatomic pathology services at healthcare institutions nationwide. The effects of recent inflationary trends on anatomic pathology physician reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2004 to 2024 for anatomic pathology procedures. Methods/Case Report The Physician Fee Schedule Look-Up Tool from the CMS was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the Consumer Price Index and reported in 2024 US dollars. The average annual and total percent change in reimbursement were calculated for included procedures. The compound annual growth rate (CAGR) was calculated using 2024 and 2000 inflation-adjusted monetary data. Results (if a Case Study enter NA) Prior to adjusting for inflation, the average physician reimbursement increased by 9.7% from 2004 to 2024 for all included anatomic pathology CPT codes. After adjusting for inflation, the average physician reimbursement decreased by 34.2% for included CPT codes. The greatest decrease in reimbursement observed from 2004 to 2024 was for outside slide consultation at 60.5% ($330.12 to $130.49), followed by pathology consultation during surgery at 59.0% ($83.54 to $34.29). The average CAGR was -2.19%. Conclusion Our study demonstrates that Medicare physician reimbursement for common anatomic pathology procedures is declining annually at an unsustainable rate. This downward trend necessitates policy action to prevent access barriers to quality anatomic pathology care nationwide, especially for Medicare beneficiaries.

The Decline of Medicare Reimbursement in Clinical Pathology

Abstract Introduction/Objective Access to clinical pathology services nationwide is threatened by the lack of an annual inflationary update for physician reimbursement from the Centers for Medicare &amp; Medicaid Services (CMS). Most recently, the 2024 Medicare Physician Fee Schedule (MPFS) implemented an overall 2.0% reduction in pathology reimbursement. The effects of recent inflationary trends on clinical pathology physician reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2004 to 2024 for clinical pathology procedures. Methods/Case Report The Physician Fee Schedule Look-Up Tool from the CMS was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the Consumer Price Index and reported in 2024 US dollars. The average annual and total percent change in reimbursement were calculated for included procedures. A subset analysis was conducted to assess physician pathology clinical consultation services average annual and total percent change in reimbursement pre- and post- 2022 MPFS Update. The compound annual growth rate (CAGR) was calculated using 2024 and 2000 inflation- adjusted monetary data. Results (if a Case Study enter NA) Prior to adjusting for inflation, the average physician reimbursement decreased by 6.8% from 2004 to 2024 for included clinical pathology CPT codes. After adjusting for inflation, the average physician reimbursement decreased by 44.0% for included CPT codes. The greatest decrease in reimbursement observed from 2004 to 2024 was for flow cytometry interpretation, 2-8 minutes at 69.5% ($114.44 to $34.95) followed by flow cytometry interpretation, 9-15 minutes at 57.8% ($142.77 to $60.25) and flow cytometry interpretation, &amp;gt;16 minutes at 56.6% ($188.05 to $81.55). The average CAGR was -2.86%. Prior to adjusting for inflation, the average physician reimbursement for clinical pathology consultation services pre-2022 decreased by 0.9%, and when adjusted for inflation, decreased by 30.0%. Post-2022 MPFS revision, the average physician reimbursement for clinical pathology consultation services decreased by 3.5%, and when adjusted for inflation, decreased by 12.2%. The average CAGR pre-2022 was -2.0% and post-2022 was -4.3%. Conclusion Medicare physician reimbursement for common clinical pathology procedures is decreasing at an untenable rate annually. It is critical that policymakers understand these trends to ensure continued access to quality clinical pathology care at healthcare institutions.

Trends in Reimbursement for All Billable Total Joint Replacement Procedures: An Analysis of the Medicare Part B Database from 2013-2021

Introduction Total joint arthroplasty (TJA) remains highly prevalent, nearly rivaling the prevalence of other challenging conditions such as heart failure. Annually, there are over 790,000 total knee replacements and more than 450,000 hip replacements performed in the United States. As the demand for TJAs steadily increases, issues related to access, and quality have become increasingly pronounced. Despite the significant annual rise in volume of surgeries, there exists a notable gap pertaining to the epidemiology and reimbursement rates of TJAs within the United States. Methods Publicly available data from the Centers for Medicare &amp; Medicaid Services Database was extracted. The dataset was queried to retrieve information on all TJA procedures spanning the years 2013 to 2021. Demographic and reimbursement variables were also analyzed. Furthermore, a regional analysis was performed, categorizing the data based on the United States Census regions. All monetary values in the analyses were adjusted for inflation and statistical significance was indicated by p&lt;0.05. Results From 2013-2021 there was an overall significant increase in total beneficiaries coupled by a significant decrease in Medicare reimbursement over the same time period. Total shoulder arthroplasties had the greatest increase in beneficiaries (124.42%) and greatest decline in Medicare reimbursement (-51.23%). When stratified by region, the Northeast had the greatest mean Medicare reimbursement and the South had the greatest total beneficiaries, with reimbursement significantly declining across all regions. Conclusion With an aging United States population, the number of individuals requiring joint arthroplasty procedures is only expected to increase. The results of this study demonstrate an overall decline in reimbursement rates for TJAs coupled with increasing numbers of procedures. This may contribute to increasing strain on orthopedic surgeons and it is crucial to address the factors contributing to these trends. Future studies may seek to further clarify potential implications of this unsustainable trend and explore potential solutions.

State Variation in Medicare Reimbursement for the Top 100 Cardiothoracic Surgery Procedures, 2013-2022.

Objective We analyzed changes in reimbursement rates for cardiothoracic surgery procedures from 2013 to 2022 to identify interstate variance andcompare changes in reimbursement between procedural groups. Methods The Center for Medicare and Medicaid Services database was analyzed to find the 100 highest-grossing cardiothoracic surgery CPT codes from 2013 to 2022. Medicare Administrative Contractor codes were utilized to identify reimbursement for each state. The payments were adjusted for inflation utilizing the consumer price index. Procedures were weighted according to revenue, and an average yearly, inflation-adjusted percent change in reimbursement was generated for each U.S. state. Procedural groups were compared using single-factor ANOVA and post-hoc tests. Results Since 2013, the inflation-adjusted Medicare reimbursement for the top cardiothoracic surgery procedures for all U.S. states and territories decreased by a yearly average of 2.67%. Puerto Rico (-0.33%), Louisiana (-1.84%), and Alabama (-1.85%) showed the smallest change. Illinois (-3.62%), Kansas (-3.40%), and Wyoming (-3.22%) had the greatest decrease in reimbursement throughout the observed period. Pacemaker and defibrillator (mean: -20.85), valvular (-22.07%), and coronary artery bypass graft(CABG) surgery (-21.99%) procedural groups demonstrated significant differences between valvular (p=0.01) or CABG (p=0.02) and pacemaker and defibrillator. Conclusions Our study confirms that reimbursement patterns vary by geographical area. Second, geographic variation suggests an incentive for physicians to practice in states with higher Medicare reimbursement. Certain procedural groups have been affected more than others. New lobbying strategies may be needed to mitigate diminishing reimbursement so that quality of care is not impacted for Medicare beneficiaries in low reimbursement states.

Outsourcing Practice Processes

In recent years we have witnessed the steady erosion of physicians’ incomes. Lately there has been a decrease in reimbursements and an increase in overhead costs, resulting in a further decrease in physicians’ incomes. Few options appear to be available, but raising our fees is not a viable alternative. However, we can identify ways to decrease overhead costs by becoming more efficient and productive without compromising patient care, patient satisfaction, online reputation management, and staff morale. This article discusses the concept of outsourcing various activities in the office, thus reducing overhead costs.

Medicare billing and utilization trends in vascular surgery

ObjectiveWithin the past decade, Medicare Part B reimbursements for various surgical procedures have been declining, whereas health care expenses continue to increase. As a result, hospitals may increase service charges to offset losses in revenue, which may disproportionately affect underinsured patients. Our analysis aimed to characterize Medicare billing and utilization trends across common vascular surgical procedures. MethodsThe 2017 to 2021 Medicare Physician and Other Practitioners by Provider and Service dataset was queried for Current Procedural Terminology (CPT) codes for common vascular surgery procedures. The average charges, reimbursements, charge-to-reimbursement ratios, and service counts were calculated for the most common interventions performed by vascular surgeons. Data was stratified by care setting, facility (inpatient and outpatient hospital) vs non-facility locations. All monetary values were adjusted to the 2021 United States dollars to account for inflation. ResultsFor facility settings, the mean charge billed to Medicare Part B increased from $3708 to $3952 (6.6%) from 2017 to 2021, with the average charge-to-reimbursement ratio increasing from 7.2 to 8.6. There were 17 of the 19 facility procedures that had a decline in reimbursements, decreasing from an average of $558 to $499 (−10.4%). Stab phlebectomy had the largest individual decrease in facility reimbursement (−53.5%), followed by above-knee amputation (−11.3%) and below-knee amputation (−11.0%). Both non-facility charges (−10.8%) and reimbursements (−12.2%) declined over the study period. Procedural utilization remained stable from 2017 to 2019. Tibial and femoral-popliteal atherectomy had increases of 45.9% and 33.7%, respectively, in overall procedural utilization when performed in non-facility settings from 2017 to 2019. ConclusionsOur analysis of vascular surgery procedures billed to Medicare Part B from 2017 to 2021 demonstrates an increase in charges, a decline in reimbursements, and a resultant increase in charge-to-reimbursement ratios for facility care settings. In contrast, non-facility charges have decreased in the face of declining reimbursements. These markups in submitted charges in facility locations may serve as an additional barrier to accessing care for patients who are underinsured.

Regional differences in reimbursement, volume, and patient characteristics exist for rotator cuff repairs: a temporal analysis from 2013 to 2021

Prior studies have demonstrated declining reimbursement and changing procedural utilization across multiple orthopedic subspecialties, yet a comprehensive examination of this has not been performed for rotator cuff repair, particularly at a geographic level. The purpose of this study was to evaluate changes in reimbursement, utilization, and patient populations for open and arthroscopic rotator cuff repairs (RCR) from 2013 to 2021 at a national and regional level. The Medicare Physician and Other Practitioners database from years 2013 to 2021 were queried to extract all episodes of open chronic RCR, open acute RCR, and arthroscopic RCR. Utilization was measured as procedural volume per 10,000 Medicare beneficiaries. Inflation-adjusted reimbursement, utilization, surgeon information, and patient characteristics were extracted for each procedure for each year. Data was stratified geographically based on US Census regions and rural-urban commuting codes. Kruskal-Wallis tests and linear regressions were performed to compare geographical areas. Between 2013 and 2021, arthroscopic RCR utilization increased by 9.4% (11.0/10,000 to 12.0/10,000), while open chronic RCR utilization decreased by 58.8% (2.0/10,000 to 0.8/10,000). During that time, average inflation-adjusted reimbursement declined by 10.0% and 11.3% for arthroscopic and open chronic RCR, respectively. The increase in utilization and decrease in reimbursement was greatest in the Midwest. In 2021, arthroscopic RCR utilization was 12.0/10,000, while average reimbursement for was $846.87, nationally. Utilization was highest in the South (14.5/10,000) and lowest in the Northeast (8.1/10,000) (p<0.001). Alternatively, reimbursement was highest in the Northeast ($904.60) and lowest in the South ($830.80) (p<0.001). The proportion of patients who were male, Medicaid eligible, or non-White was highest in the West (p<0.001). Patients in the West also had the fewest comorbidities. Increased patient comorbidities, when controlling patient demographics, was associated with lower reimbursement nationally and within the Northeast (p<0.001). Geographical discrepancies in rotator cuff repair utilization and reimbursement exist. The South consistently demonstrates the highest utilization of RCR, while also having the lowest reimbursement. Alternatively, the Northeast has the lowest utilization but the highest reimbursement. Increased patient population comorbidities were associated with reduced RCR reimbursement for surgeons in the Northeast, but not in other regions.

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

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

Utilization and reimbursement of diagnostic cerebral angiograms: A Medicare trends analysis from 2013 to 2020.

Increasing life expectancy has caused growing concern about maintaining viable neurointerventional practices due to altered Medicare payment structures. This study analyzes the financial trends of three common diagnostic tests for cerebrovascular disease: cerebral digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). Medicare Part B National Summary Data files from 2013 to 2020 were queried by Current Procedural Terminology (CPT) codes for DSA (36221-36228), CTA (70496, 70498), and MRA (70544-70547, 70549). Inflation-adjusted charges and reimbursement were calculated using the U.S. City Average Consumer Price Index for Medical Services. Regression analysis was performed on charges, reimbursement, and volume. A total of 1,519,245 diagnostic procedures were conducted between 2013 and 2020 (782,370 angiograms, 246,603 CTAs, and 490,272 MRAs). A total of $41.005 million was reimbursed by Medicare in 2020 for these diagnostic procedures. The annual percent change in volume for all procedures was -2.90%. From 2013 to 2020, inflation-adjusted: Medicare total physician reimbursement decreased for cerebral angiograms (-4.12%, p = 0.007), CTAs (-2.77%, p = 0.458), and MRAs (-9.06%, p < 0.001). Procedural volume billed to Medicare decreased for cerebral angiograms (-4.63%, p = 0.007) and MRAs (-2.94%, p = 0.0.81) and increased for CTAs (+3.15%, p = 0.004). The greatest increase in Medicare reimbursement (+66.75%) came from CPT code 36224, "place catheter carotid artery", and the greatest decrease in Medicare reimbursement (-8.66%) came from CPT code 36226, "place catheter vertebral artery." This study provides an analysis of Medicare reimbursement trends for routine cerebrovascular angiogram techniques. The findings highlight a decline in Medicare reimbursements for neurointerventionalists.

Trends of Medicare reimbursement rates for gender affirmation procedures.

While nearly 1 in 5 Americans receives health insurance coverage through Medicare, literature suggests that Medicare reimbursement is lagging behind inflation for many plastic surgery procedures. This article evaluates trends in Medicare reimbursement for gender affirmation procedures. The most common gender affirmation procedures performed at an urban academic medical center were identified in this cross-sectional study (level 4 evidence). Five nongender surgery codes were evaluated for reference. A standardized formula utilizing relative value units (RVUs) was used to calculate monetary data. Differences in reimbursement between 2014 and 2021 were calculated for each procedure. The main outcome was inflation-adjusted difference of charges from 2014 to 2021. Between 2014 and 2021, Medicare reimbursement for gender affirmation procedures had an inflation-unadjusted average change of -0.09% (vs +5.63% for the selected nongender codes) and an inflation-adjusted change of -10.03% (vs -5.54% for the selected nongender codes). Trends in reimbursement varied by category of gender-affirming procedure. The overall average compound annual growth rate had a change of -0.99% (vs -0.53% for the selected nongender codes). The average changes in work, facility, and malpractice RVUs were -1.05%, +9.52%, and -0.93%, respectively. Gender surgeons and patients should be aware that the decrease in reimbursement may affect access to gender-affirming care. Our study is one of the first evaluating the reimbursement rates associated with the full spectrum of gender affirmation surgery. However, our study is limited by its cross-sectional nature. From 2014 to 2021, Medicare reimbursement for gender affirmation procedures lagged inflation.

Comparing Changes in Medicare Reimbursement for Radiation Oncology and Medical Oncology (2010-2020)

A recent study found that radiation oncology (RO) has seen significant declines in Medicare reimbursement (MCR) from 2010-2019. While it is presumed that other cancer subspecialties have seen decreasing MCR, to our knowledge, there are no studies directly comparing changes in MCR between RO and other oncology subspecialties. In this study, we analyze changes in MCR from 2010-2020 for both RO and medical oncology. We hypothesized that the declines in MCR will be similar between the two fields. The publicly available Physician/Supplier Procedure Summary (PSPS) database was used for all years from 2010-2020. All reimbursement for providers with primary provider codes 92 (RO) and 83 and 90 (heme/onc and medical oncology, respectively) were analyzed. For the 150 most highly-reimbursed HCPCS codes for each specialty in 2010, the total allowed charge for each code was corrected for inflation and then divided by the number of submitted claims to calculate average MCR per code for each year. For each code and each specialty, the 2020 billing frequency was multiplied by the calculated average reimbursement per claim in a given year to calculate what the reimbursement would have been in that year using 2020 dollars and utilization rates (projected reimbursement). The projected reimbursement was summed for all HCPCS codes in each year for each specialty to calculate an aggregate MCR for that specialty for that year. This aggregate MCR was then compared with the actual 2020 reimbursement for that basket of codes to calculate the change in MCR over time. Both medical and radiation oncology saw decreases in projected vs. actual MCR from 2010-2020 for this basket of services (Table). Adjusting for inflation and utilization, RO MCR declined by $0.7 billion (B) (-29.0%) from 2010 to 2020 and by $0.2B (-10.5%) from 2015 to 2020 while medical oncology MCR declined by $0.8B (-14.7%) from 2010-2020 and by $0.4B (-6.6%) from 2015-2020. The average decrease per year in projected vs. actual reimbursement for RO was 2.9% (2010 to 2015) and 1.05% (2015 to 2020) and for medical oncology was 1.5% (2010-2015) and 0.7% (2015-2020), respectively. Adjusting for inflation, Medicare reimbursement for a large array of services has declined for both medical oncology and RO from 2010 - 2020. Contrary to our hypothesis, RO reported a 97% greater relative decline in reimbursement compared with medical oncology from 2010 - 2020. Significant decreases in reimbursement to both fields and their potential implications on patient care and access to care should be considered by policymakers while shifting towards an episode-based Alternative Payment Model and when considering further cuts to Medicare reimbursement.

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

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. 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. 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). 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.

Trends in Medicare Reimbursement for Interventional Radiology Procedures: 2007-2020.

Declining physician reimbursement has been occurring across multiple specialties due to changes in Medicare legislation, including theDeficit Reduction Omnibus Reconciliation Act (DRA),the Balanced Budget Act, and the Sustainable Growth Rate. The purpose of this study was to evaluate trends in Medicare reimbursement rates for various procedural classes in interventional radiology from 2007 to 2020. Common interventional radiology procedures were selected across multiple procedural classes: gastrointestinal, biliary, urinary, fallopian dilatation, other injection/change/removal, iliac vascular, femoral/popliteal vascular, tibial/peroneal vascular, hepatobiliary, and vascular emergency. The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for current procedural terminology (CPT) codes to extract reimbursement data. All monetary data were adjusted for inflation using the United States consumer price index (CPI). The compound annual growth rate (CAGR) and average annual change in reimbursement were calculated based on these adjusted trends. Aside from urinary and vascular emergency procedures, all other procedural classes experienced decreases in inflation-adjusted Medicare reimbursement from 2007 to 2020. The greatest mean decrease in reimbursement rates was observed in biliary procedures (-$21.25), while the largest mean increase in reimbursement rates was observed in vascular emergency procedures ($3.23). All procedures with increases in reimbursement rates and 36.8% of procedures with decreases in reimbursement rates have a CPT code change between 2007 and 2020. After accounting for inflation, reimbursement rates were shown to decline for all procedural classes except for urinary and vascular emergencies. Congressional policies, such as the Deficit Reduction Act (DRA) and the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015, may clarify some of these trends.

Pronounced State-Level Disparities in Prescription of Cannabinoids to Medicaid Patients

Introduction: Dronabinol is approved in the USA for chemotherapy-induced nausea as well as vomiting and HIV-induced anorexia, while cannabidiol is primarily approved for childhood epileptic disorders Lennox-Gastaut and Dravet syndrome. The use pattern for these prescription cannabinoids in the USA is unknown. This study examined Medicaid claims for two FDA-approved prescription cannabinoids, dronabinol and cannabidiol, approved in 1985 and 2018, respectively, from 2016–2020 to better understand the pharmacoepidemiologic trends and distribution of these drugs in US Medicaid amidst the increasing use of non-pharmaceutical formulations of cannabis. Methods: The longitudinal study analyzed Medicaid prescription claims that were calculated by extracting the prescriptions on a state level from 2016 to 2020 for two cannabinoids, dronabinol and cannabidiol, where outcomes over each year were calculated. Outcomes were (1) the number of prescriptions for each state corrected for the number of Medicaid enrollees and (2) dronabinol and cannabidiol spending. Spending refers to the amount reimbursed by the state Medicaid program. Results: Dronabinol prescriptions per state decreased by 25.3% from 2016 to 2020, while cannabidiol prescriptions increased by 16,272.99% from 2018 to 2020. The spending on these drugs parallels that of their prescription trend with a 66.3% decrease in reimbursement for dronabinol ($5.7 million in 2020), whereas cannabidiol increased by +26,582.0% ($233.3 million in 2020). Dronabinol prescriptions, when corrected for the number of enrollees, in Connecticut were 136.4 times larger than in New Mexico, and seventeen states had zero prescriptions. Idaho’s prescriptions of cannabidiol (27.8/10,000 enrollees) were significantly elevated relative to the national average and were 15.4-fold higher than Washington, DC (1.8/10K enrollees). Conclusions: The prescriptions of pharmaceutical-grade tetrahydrocannabinol decreased while those of cannabidiol increased. This study also identified pronounced state-level variation in cannabinoid prescribing to Medicaid patients. State formularies and prescription drug list variation may contribute to the drug reimbursements in Medicaid, though further research is needed to identify the health policy or pharmacoeconomic origins of these disparities.

MP39-08 CHANGES IN MEDICARE REIMBURSEMENT FOR TOP UROLOGY PROCEDURES BY STATE 2011-2022

You have accessJournal of UrologyCME1 Apr 2023MP39-08 CHANGES IN MEDICARE REIMBURSEMENT FOR TOP UROLOGY PROCEDURES BY STATE 2011-2022 Nathaniel Kimball, Alexander Dorius, Carson Bateman, and Pranav Sharma Nathaniel KimballNathaniel Kimball More articles by this author , Alexander DoriusAlexander Dorius More articles by this author , Carson BatemanCarson Bateman More articles by this author , and Pranav SharmaPranav Sharma More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Medicare enrollment has increased steadily since 2006, increasing the demand for urological procedures for Medicare beneficiaries. Previous studies on Medicare reimbursement have lacked state-by-state analysis. In this study, we analyzed reimbursement rates for the 100 most common urology procedures from 2011 to 2022, identifying which states and territories showed the greatest change. METHODS: The Center for Medicare and Medicaid Services’ Physician Fee Schedule database was analyzed to find the 100 most common urology Current Procedural Terminology codes. Medicare Administrative Contractor localities were used to identify varying facility-based reimbursement for each state or territory. Yearly reimbursement was adjusted for inflation by utilizing the consumer price index. The representation for each procedure was weighted according to frequency. Lastly, a percent change in reimbursement was generated for each U.S. state or territory. RESULTS: Over the twelve-year period, the inflation-adjusted Medicare reimbursement for the top urological procedures for all U.S. states and territories decreased annually by an average of 3.81%. Puerto Rico (-2.80%), New York (-3.33%), Washington (-3.51%), Maryland (-3.57%), and Louisiana (-3.58%) showed the smallest yearly precent change. Illinois (-4.27%), Idaho (-4.09%), Mississippi (-4.07%), Kansas (-4.06%), and Indiana (-4.05%) showed the greatest annual decrease in reimbursement. Total decrease in reimbursement from 2011-2022 ranged from -33.6% to -51.24%. The Figure 1 below showcases the average yearly percent change by state or territory. CONCLUSIONS: Medicare reimbursement for urological procedures decreased from 2011-2022. Our study suggests that specific areas have more or less favorable reimbursement rates than others. Because of the increasing number of adults covered by Medicare, urologists face mounting pressure to advocate for greater reimbursement for the procedures they perform. There remains incentive for physicians to practice in states with higher Medicare reimbursement versus more unfavorable areas. Continued advocacy should be taken to resolve diminishing reimbursement for urology procedures so quality of care is not impacted for Medicare beneficiaries. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e537 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathaniel Kimball More articles by this author Alexander Dorius More articles by this author Carson Bateman More articles by this author Pranav Sharma More articles by this author Expand All Advertisement PDF downloadLoading ...