Medicare Physician Research Articles

Sitting at the Head Table and Leading Change: AMDA’s 2023 Policy Initiatives

Sitting at the Head Table and Leading Change: AMDA’s 2023 Policy Initiatives

Trends in Medicare utilization and reimbursement for hematology/oncology procedures.

e13641 Background: Medicare Part B pays for physician services such as office visits and procedures based on the Medicare Physician Fee Schedule which is re-evaluated annually to maintain budget neutrality. Moreover, national cancer-attributed medical care costs in 2015 were $183 billion and projected to increase 34% to $246 billion by 2030 (Green et al: J Clin Oncol, PMID: 31804856). The aim of this study is to evaluate trends in Medicare reimbursement for procedures in hematology/oncology between 2012-2022. Methods: The data analyzed were extracted from the Physician Fee Schedule Look-Up Tool. CPT Codes were obtained from the Medicare Coverage Database. The following CPT codes were extracted: antineoplastic chemotherapy administration (96405, 96406, 96401, 96409, 96411, 96413, 96415, 96416, 96417, 96420, 96422, 96423, 96425, 96440, 96446, 96450, 96542), antineoplastic hormone therapy administration (96402), non-chemotherapy infusion (96360, 96361, 96365, 96366, 96367, 96368, 96369, 96370, 96371, 96372, 96373, 96374, 96375, 96376 ), bone marrow sampling (38220, 38221, 38222), bone marrow harvest (38230, 38232) and bone marrow transplant (38240, 38241, 38242). Consumer Price Index (CPI) obtained from the U.S. Department of Labor's Bureau of Labor Statistics was used to adjust reimbursement rates for cumulative inflation to 2022 U.S. dollars. The T-test was used to compare the mean prices for each procedure. This research contains publicly available data and as such is exempt from the IRB according to the Institutional Review Board at LSU Health Sciences Center in New Orleans, Louisiana. Results: The procedure with the highest reimbursement rate in 2012 was bone marrow harvest and the procedure with the lowest reimbursement rate in the same year was antineoplastic hormone therapy administration. The procedure with the highest reimbursement rate in 2022 was bone marrow harvest. The procedure with the lowest reimbursement rate in 2022 was antineoplastic hormone therapy. All procedure reimbursement fell significantly (p value of <0.001) over the timer period studied. Conclusions: Between 2012 and 2022 the reimbursement rates for common hematology oncology services fell significantly when adjusted for inflation due to reforms in Medicare part B. [Table: see text]

COUNTY-LEVEL ANALYSIS OF EYE EXAM ACCESS AND UTILIZATION IN THE UNITED STATES

ABSTRACT Purpose The eye exam is a critical tool for the prevention, screening, and diagnosis of ocular and systemic conditions. In this study, we characterize county-level variation in eye exam access and utilization for Medicare patients in the United States. Methods This nationwide study uses the Medicare Physician & Other Practitioners – by Provider and Service dataset. We included all ophthalmologists and optometrists who performed eye exams on Medicare beneficiaries within a United States county in 2019. For every county where exams were performed, we calculated the number of practicing vision testing providers, percentage of providers classified as ophthalmologists, and the number of exams per 100 Medicare beneficiaries. Multiple linear regression was used to characterize associations between these variables and county characteristics, including measures of poverty, education, and income. Results In 2019, 28937,540 eye exams were performed by 46,000 providers in 2,291 U.S. counties. In the median county, 34.9 eye exams were provided per 100 Medicare beneficiaries. The average county had 20.1 exam providers, 16.5% of whom were ophthalmologists. There were a median 6.6 eye exam providers for every 10,000 Medicare beneficiaries in the average county. The average provider performed 517.8 exams. Regression showed counties with lower median household incomes, higher poverty rates, or fewer high-school graduates had fewer eye exam providers per 10,000 Medicare beneficiaries and fewer eye exams performed per 100 Medicare beneficiaries. Conclusions We find significant county-level variation in eye exam utilization and provider availability. This reflects broader, well-recognized trends in socioeconomic health disparities in the U.S.

Gender Differences in Reimbursement Among Orthopaedic Surgeons: A Cross-sectional Analysis of Medicare Claims.

Inequalities involving women across orthopaedic subspecialties continue to be highlighted in the literature. Previous analyses exploring reimbursement differences between sexes have not controlled for confounding factors or have been limited by small sample sizes. Our study used Medicare data on a national sample of orthopaedic surgeons to better evaluate these disparities. This cross-sectional analysis used publicly available data from the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File. Using each provider's National Provider Identifier number, this data set was linked to the National Plan and Provider Enumeration System downloadable file and the 2019 National Provider Compare Database. Mean differences were calculated using the Welch t -test. Multivariate linear regression analysis was conducted to determine the effect of sex on total Medicare payments per physician, controlling for years in practice, practice diversity, clinical productivity, and subspecialty. Nineteen thousand six orthopaedic surgeons were included in our analysis. Of these providers, 1,058 were female (5.6%) and 17,948 were male (94.4%). Male orthopaedic surgeons billed an average of 19.40 unique billing codes per provider and female orthopaedic surgeons billed 14.4 per provider ( P < 0.001). Female orthopaedic surgeons billed an average of 1,245.5 services per physician while male orthopaedic surgeons billed 2,360.7 services per physician. The mean difference in payment between male and female orthopaedic surgeons was $59,748.7 ( P < 0.001). Multivariate linear regression showed that female sex was a significant predictor of lower total yearly Medicare reimbursement ( P < 0.001). These findings emphasize the need for additional efforts to help ensure reimbursement differences do not deter women from pursuing orthopaedics. Healthcare organizations should use this information to ensure equal salary negotiating power among their employees while additionally addressing potential biases and misconceptions related to referrals and surgeon aptitude, respectively.

Letter: Commentary: The Anatomy of Disvalued Codes: The 63047 and the 22633.

Letter: Commentary: The Anatomy of Disvalued Codes: The 63047 and the 22633.

Proximal Humerus Fractures in the Elderly U.S. Population: A Cross-Sectional Study of Treatment Trends and Comparison of Complication Rates after Joint Replacement, Open Reduction and Internal Fixation, and Non-Surgical Management.

Proximal humerus fracture (PHF) treatment remains challenging. Multiple therapy options exist, and the optimal choice of management has been increasingly discussed in the literature. The aim of this study was to (1) analyze trends in the propensity of proximal humerus fracture treatments and (2) compare complication rates after joint replacement, surgical repair, and non-surgical treatment in terms of mechanical complications, union failure, and infection rates. In this cross-sectional study, patients aged 65 years or older with proximal humerus fractures occurring between 1 January 2009 and 31 December 2019 were identified from Medicare physician service claims records. The Kaplan-Meier method with the Fine and Gray adjustment was used to calculate the cumulative incidence rates for malunion/nonunion, infection, and mechanical complications for the following treatment categories: shoulder arthroplasty, open reduction and internal fixation (ORIF), and non-surgical treatment, respectively. Semiparametric Cox regression was performed incorporating 23 demographic, clinical, and socioeconomic covariates to determine risk factors. Between 2009 through 2019, conservative procedures decreased by 0.9%. ORIF procedures decreased from 9.51% (95% CI: 8.7-10.4) to 6.95% (95% CI: 6.2-7.7), whereas shoulder arthroplasties rose from 1.99% (95% CI: 1.6-2.4), to 5.45% (95% CI: 4.8-6.2). PHFs managed through ORIF were associated with higher union failure rates compared to conservatively treated fractures (HR = 1.31, 95% CI: 1.15-1.5, p < 0.001). The risk of developing an infection was increased after joint replacement compared to ORIF (2.66% vs. 1.09%, HR = 2.09, 95% CI: 1.46-2.98, p < 0.001). Mechanical complications were more common after joint replacement (6.37% vs. 4.85%, HR = 1.66, 95% CI: 1.32-2.09, p < 0.001). Complication rates differed significantly across treatment modalities. This should be considered when choosing a management procedure. Vulnerable elderly patient cohorts could be identified, and the optimization of modifiable risk factors might lead to a decrease of complication rates in both surgically and non-surgically treated patients.

Comparing Trends in Medicare Reimbursement and Inflation within Plastic Surgery Subspecialties.

Over the past decade across multiple surgical specialties, Medicare reimbursement rates have remained stagnant, failing to keep pace with inflation. An internal comparison of subspecialties within plastic surgery has not yet been attempted. The goal of this study was to investigate the trends in reimbursement from 2010 to 2020 and compare across the subspecialties of plastic surgery. The Physician/Supplier Procedure Summary was used to extract the annual case volume for the top 80% most-billed CPT codes within plastic surgery. Codes were defined into the following subspecialties: microsurgery, craniofacial surgery, breast surgery, hand surgery, and general plastic surgery. The Medicare physician reimbursement was weighted by case volume. The growth rate and compound annual growth rate were calculated and compared against an inflation-adjusted reimbursement value. On average, inflation-adjusted growth in reimbursement for the procedures analyzed in this study was -13.5%. The largest decrease in growth rate was within the field of microsurgery (-19.2%), followed by craniofacial surgery (-17.6%). These subspecialties also had the lowest compound annual growth rate (-2.11% and -1.91%, respectively). For case volumes, microsurgery increased case volumes by an average of 3% per year, whereas craniofacial surgery increased case volumes by an average of 5% per year. After adjusting for inflation, all subspecialties had a decrease in growth rate. This was particularly evident in the fields of craniofacial surgery and microsurgery. Consequently, practice patterns and patient access may be negatively affected. Further advocacy and physician participation in reimbursement rate negotiation may be essential to adjust for variance and inflation.

97 Burning a Hole in Our Pockets: 12 Year Trends of Medicare Reimbursement for Burn Procedures

Abstract Introduction Burn injuries cost the USA ~$976.6 million annually. Physician reimbursement has lagged despite years of lobbying by physician groups. The Centers for Medicare and Medicaid Services plan to cut physician reimbursement by 4.2% in 2023. Evaluating reimbursement data for hospital-based procedures is timely, including burn procedures. We hypothesized Medicare reimbursement trends for common burn procedures decreased from 2010-2022. Methods We obtained pricing data from the publicly-available Medicare Physician Fee Schedule Look-Up Tool for 26 Current Procedural Terminology (CPT) codes: “Burns–preparation of wound bed” (15002-15005), “Burns–split thickness skin graft” (15100-15101 &amp; 15120-15121), “Burns–skin substitute” (15271-15278), “Cultured epidermal autograft” (15150-15152 &amp; 15155-15157), and “Cell Suspension Epidermal Autograft” (15110-15111 &amp; 15115-15116). We calculated percent differences for reimbursement; compound annual growth rate (CAGR); and percent differences for work, facility, non-facility, and malpractice relative value units (RVUs). Analysis was conducted in R 4.1.2. Results The three largest reimbursement increases were for CPT codes 15272 (24.6%), 15155 (23.7%), and 15003 (10.9%); the three largest decreases were for 15121 (-16.8%), 15120 (-6.1%), and 15275 (-5.0%). The three largest CAGR increases were for CPT codes 15272 (2.2%), 15155 (1.8%), 15274 (0.9%), and 15003 (0.9%); the three smallest were for 15121 (-1.5%), 15120 (-0.5%), and 15275 (-0.5%). Table 1 shows trends of RVUs. Conclusions Our 12-year analysis of Medicare reimbursement trends for 26 burn procedures demonstrated an overall increase in hospital reimbursement and parallel net decrease in physician work RVUs. Reimbursements were increasingly allocated away from surgeons to facility fees and malpractice insurance. Cultured epidermal autograft to the head, neck, hands, and feet (15155) saw the largest increase in Medicare reimbursement with no change in direct physician reimbursement while split-thickness skin grafts to the head, neck, &amp; genitals (15120 &amp; 15121) showed decreased rates. Future work is needed to understand why these trends are occurring to advocate against physician reimbursement cuts. Applicability of Research to Practice Studies contributing to price transparency allow stakeholders to focus on why burn surgeons are receiving lower reimbursements.

Medicare Reimbursement Rates and Utilization Trends in Sacroiliac Joint Fusion.

Sacroiliac joint (SIJ) fusion is a surgical treatment option for SIJ pathology in select patients who have failed conservative management. More recently, minimally invasive surgical (MIS) techniques have been developed. This study aimed to determine the trends in procedure volume and reimbursement rates for SIJ fusion. Publicly available Medicare databases were assessed using the National Summary Data Files for 2010 to 2020. Files were organized according to current procedural terminology (CPT) codes. CPT codes specific to open and MIS SI joint fusion (27279 and 27280) were identified and tracked. To track surgeon reimbursements, the CMS Medicare Physician Fee Schedule Look-Up Tool was used to extract facility prices. Descriptive statistics and linear regression were used to evaluate trends in procedure volume, utilization, and reimbursement rates. Compound annual growth rates were calculated, and discrepancies in inflation were corrected for using the Consumer Price Index. A total of 33,963 SIJ fusions were conducted in the Medicare population between 2010 and 2020, with an overall increase in procedure volume of 2,350.9% from 318 cases in 2010 to 7,794 in 2020. Since the introduction of the 27279 CPT code in 2015, 8,806 cases (31.5%) have been open and 19,120 (68.5%) have been MIS. Surgeon reimbursement for open fusions increased nominally by 42.8% (inflation-adjusted increase of 20%) from $998 in 2010 to $1,425 in 2020. Meanwhile, reimbursement for MIS fusion experienced a nominal increase of 58.4% (inflation-adjusted increase of 44.9%) from $582 in 2015 to $922 in 2020. SIJ fusion volume in the Medicare population has increased substantially in the past 10 years, with MIS SIJ fusion accounting for most of the procedures since the introduction of the 27279 CPT code in 2015. Reimbursement rates for surgeons have also increased for both open and MIS procedures, even after adjusting for inflation.

Ophthalmologist Turnover in the United States: Analysis of Workforce Changes from 2014 through 2021

Physician turnover is costly to health care systems and affects patient experience due to discontinuity of care. This study aimed to assess the frequency of turnover by ophthalmologists and identify physician and practice characteristics associated with turnover. Retrospective cross-sectional study. Actively practicing United States ophthalmologists included in the Centers for Medicare and Medicaid Services Physician Compare and Physician and Other Supplier Public Use File between 2014 and2021. We collected data for each ophthalmologist that was associated with practice/institution and then calculated the rate of turnover both annually in each year window and cumulatively as the total proportion from 2014 to 2021. Multivariable logistic regression analysis was used to identify physician and practice characteristics associated with turnover. We also evaluated turnover characteristics surrounding the Coronavirus disease 2019 (COVID-19) pandemic. Ophthalmologist turnover, defined as a change of an ophthalmologist's National Provider Identifier practice affiliation from one year to the next. Of 13 264 ophthalmologists affiliated with 3306 unique practices, 34.1% separated from at least 1 practice between 2014 and 2021. Annual turnover ranged from 3.7% (2017) to 19.4% (2018), with an average rate of 9.4%. Factors associated with increased turnover included solo practice (adjusted odds ratio [aOR], 9.59), university affiliation (aOR, 1.55), practice location in the Northeast (aOR, 1.39), and practice size of 2 to 4 members (aOR, 1.21; P < 0.05 for all). Factors associated with decreased turnover included male gender (aOR, 0.87) and more than 5 years of practice: 6 to 10 years (aOR, 0.63), 11 to 19 years (aOR, 0.54), 20 to 29 years (aOR, 0.36), and ≥ 30 years (aOR, 0.18; P < 0.05 for all). In the initial year (2020) of the COVID-19 pandemic, annual turnover increased from 7.8% to 11.0%, then decreased to 8.7% in the postvaccine period (2021). One-third of United States ophthalmologists separated from at least 1 practice from 2014 through 2021. Turnover patterns differed by various physician and practice characteristics, which may be used to develop future strategies for workforce stability. Because administrative data cannot solely determine reasons for turnover, further investigation is warranted given the potential clinical and financial implications. Proprietary or commercial disclosure may be found after the references.

D107. Head and Neck Cancer Reconstruction and Relative Disincentives to Surgical Reconstruction

PURPOSE: The incidence of head and neck cancers (HNC) is rising as HPV becomes the dominant disease etiologic factor. Financial support for HNC care is critical for ensuring equitable access to care. Examining non-profit support, reimbursement rates and hospital-associated costs for HNC patients relative to other patients requiring complex reconstruction may reveal possible care disparities. METHODS: Reimbursement data from HNC and breast cancer (BC) reconstructive procedures was abstracted from the Centers for Medicare and Medicaid Services Physician Fee Schedule Look-Up Tool. Patient-level data for 2015 to 2017 was acquired from the New York State Department of Health. Inflation-adjusted reimbursement values from 2012 to 2021 were compared using Student’s t-test. Wilcoxon-Mann-Whitney tests were used for inter-group analyses. Analysis was completed in R Studio (v1. 3.1). RESULTS: Procedure reimbursements for free and pedicled flaps indicate that HNC reconstruction procedures are reimbursed significantly lower than both breast and extremity reconstruction (p < 0.01). New York State inpatient data indicates that HNC procedure recipients are more likely to have public insurance, generate higher hospital costs and require longer lengths of stay than patients hospitalized for BC procedures (p < 0.01). CONCLUSION: Reimbursements for HNC reconstructive procedures are significantly lower than BC and extremity reconstructive procedures of comparable work effort. HNC patients are more likely to be publicly insured and have longer lengths of stay than patients undergoing breast reconstruction. The large discrepancy in reimbursement may financially disincentivize investment in care for HNC patients and limit future access to care in this vulnerable and growing patient population.

MP07-10 BEFORE AND AFTER THE BAN: NATIONAL INCIDENCES OF TRANSVAGINAL MESH PLACEMENT AND REMOVAL FOR PELVIC ORGAN PROLAPSE

You have accessJournal of UrologyCME1 Apr 2023MP07-10 BEFORE AND AFTER THE BAN: NATIONAL INCIDENCES OF TRANSVAGINAL MESH PLACEMENT AND REMOVAL FOR PELVIC ORGAN PROLAPSE Elie Kaplan-Marans, Mariela Martinez, Arshia Sandozi, Jeffrey Lee, Dhaval Jivanji, Karis Buford, and Allison Polland Elie Kaplan-MaransElie Kaplan-Marans More articles by this author , Mariela MartinezMariela Martinez More articles by this author , Arshia SandoziArshia Sandozi More articles by this author , Jeffrey LeeJeffrey Lee More articles by this author , Dhaval JivanjiDhaval Jivanji More articles by this author , Karis BufordKaris Buford More articles by this author , and Allison PollandAllison Polland More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In April 2019, the Food and Drug Administration (FDA) banned manufacturers from selling and distributing mesh for transvaginal repair of pelvic organ prolapse (POP). We assessed national incidences of transvaginal mesh placement and revision or removal for POP before and after the ban. METHODS: The Medicare Physician and Other Practitioners database was queried for all transvaginal mesh placements and revisions or removals for POP between 2013 and 2020 using CPT codes 57267 and 57295, respectively. Linear regression was performed with statistical significance set to 95% confidence intervals. RESULTS: A total of 51,234 mesh placements and 15,854 mesh revisions or removals were identified. As shown in the Figure 1, there was a significant and gradual downward trend in utilization of both procedures during the study period, without precipitous changes after the ban (mesh placement, R2=0.97, p<0.001; mesh revisions or removals, R2=0.97, p<0.001). From 2013 to 2020, mesh placement decreased from 10,397 to 2,813 cases (370%) and mesh revision or removal decreased from 2,975 to 1,091 cases (270%). Despite the FDA ban, transvaginal mesh placement for POP was still performed in 2020 (2,813 cases). CONCLUSIONS: There was not a precipitous decline in the use of transvaginal mesh for prolapse after the 2019 ban. Utilization has instead gradually decreased since the original FDA notification in 2011. Physicians may now be using the remaining stock of transvaginal mesh or other types of mesh that are off-label for prolapse repair. It is important to discuss the risks and benefits of using transvaginal mesh as well as the FDA notification and ban with patients prior to prolapse surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e88 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elie Kaplan-Marans More articles by this author Mariela Martinez More articles by this author Arshia Sandozi More articles by this author Jeffrey Lee More articles by this author Dhaval Jivanji More articles by this author Karis Buford More articles by this author Allison Polland More articles by this author Expand All Advertisement PDF downloadLoading ...

MP19-02 IMPACT OF PRIVATE EQUITY ACQUISITION ON UROLOGIC PROCEDURAL VOLUME

You have accessJournal of UrologyCME1 Apr 2023MP19-02 IMPACT OF PRIVATE EQUITY ACQUISITION ON UROLOGIC PROCEDURAL VOLUME Shyam Patnaik, Danielle Sharbaugh, Michael Stencel, Cameron Jones, Stephen Kisty, Divya Nateson, Charlotte Stahlfeld, Sarah Erpenbeck, Cailey Guercio, Mia Alcorn, Jonathan Yabes, Bruce Jacobs, and Benjamin Davies Shyam PatnaikShyam Patnaik More articles by this author , Danielle SharbaughDanielle Sharbaugh More articles by this author , Michael StencelMichael Stencel More articles by this author , Cameron JonesCameron Jones More articles by this author , Stephen KistyStephen Kisty More articles by this author , Divya NatesonDivya Nateson More articles by this author , Charlotte StahlfeldCharlotte Stahlfeld More articles by this author , Sarah ErpenbeckSarah Erpenbeck More articles by this author , Cailey GuercioCailey Guercio More articles by this author , Mia AlcornMia Alcorn More articles by this author , Jonathan YabesJonathan Yabes More articles by this author , Bruce JacobsBruce Jacobs More articles by this author , and Benjamin DaviesBenjamin Davies More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003244.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Private equity firms have been increasing investment in urology in recent years. Despite the changing ownership model in urology private practice, the effect of these acquisitions on urologic practice and procedural volume has yet to be determined. We sought to investigate the impact on procedural volume in a variety of urologic procedures before and after private equity acquisition. METHODS: Private equity acquisitions of urology practices were identified via the existing literature, which utilized a compilation of financial databases cataloguing both public and private transactions. Yearly office visit and procedure volume by provider was extracted from the publicly available “Medicare Physician & Other Practitioners by Provider and Service” dataset from 2013-2019. The most commonly billed procedures were chosen for analysis: post-void residual (PVR), cystometrogram (CMG), uroflow, cystoscopy, prostate biopsy, extracorporeal shock-wave lithotripsy (ESWL), and ureteroscopy. Mixed regression model and sensitivity analyses were conducted. RESULTS: 1,564,853 office visits and 867,216 procedures were analyzed over a 5-year period. Using mixed model analysis, the number of cystoscopies, PVRs, ESWL, and ureteroscopies per physician-year showed no statistically significant change after private equity acquisition (Table 1). Prostate biopsy and complex CMG showed statistically significant increases by an average of 2.06 and 6.88 procedures per physician-year respectively after private equity. Complex uroflow had a significant decrease by an average of 13.5 procedures per physician-year after acquisition. The average number of each urologic procedure per 100 visits remained stable from before private equity acquisition to after acquisition. In terms of the average number of new patient visits, the observed trends for 30-, 45-, and 60- minute visits per 100 visits remained stable from before to after private equity acquisition. CONCLUSIONS: In this study we demonstrate the impact of private equity ownership on urologic practices before and after acquisition. We found that both prostate biopsy and complex CMG procedures rates increased significantly since private equity acquisition. The fiscal impact of these changes has yet to be determined. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e264 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shyam Patnaik More articles by this author Danielle Sharbaugh More articles by this author Michael Stencel More articles by this author Cameron Jones More articles by this author Stephen Kisty More articles by this author Divya Nateson More articles by this author Charlotte Stahlfeld More articles by this author Sarah Erpenbeck More articles by this author Cailey Guercio More articles by this author Mia Alcorn More articles by this author Jonathan Yabes More articles by this author Bruce Jacobs More articles by this author Benjamin Davies More articles by this author Expand All Advertisement PDF downloadLoading ...

MP54-14 MENTAL HEALTH ILLNESS IN PATIENTS WITH NON-MUSCLE INVASIVE BLADDER CANCER. DOES BCG PLAY A ROLE?

You have accessJournal of UrologyCME1 Apr 2023MP54-14 MENTAL HEALTH ILLNESS IN PATIENTS WITH NON-MUSCLE INVASIVE BLADDER CANCER. DOES BCG PLAY A ROLE? Valentina Grajales, Zhigang Duan, Wei Shen Tan, Roberto Contieri, Hui Zhao, Sharon Giordano, Stephen B. Williams, and Ashish M. Kamat Valentina GrajalesValentina Grajales More articles by this author , Zhigang DuanZhigang Duan More articles by this author , Wei Shen TanWei Shen Tan More articles by this author , Roberto ContieriRoberto Contieri More articles by this author , Hui ZhaoHui Zhao More articles by this author , Sharon GiordanoSharon Giordano More articles by this author , Stephen B. WilliamsStephen B. Williams More articles by this author , and Ashish M. KamatAshish M. Kamat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003307.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Up to a third of cancer patients experience a mental health condition during their cancer treatment; Bacillus Calmette-Guerin (BCG) has been shown to be neuroprotective. Herein, we assess the incidence of mental health illness (MHI) in non-muscle invasive bladder cancer (NMIBC) patients and the impact of intravesical BCG on the development of non-neurodegenerative MHI. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data set, we identified 30,991 patients diagnosed with NMIBC between 2005-2017. MHI diagnosis and BCG treatment were identified using ICD9/ICD10 diagnosis codes and HCPCS codes from Medicare inpatient, outpatient, and physician claims. We excluded developmental, organic, and neurodegenerative MHI. Descriptive statistics were done using the Pearson’s chi-square test for categorical variables. RESULTS: A total of 27.0% of patients (N=8,367) received at least an induction course of BCG. Pre-existing MHI was present in 15.9% (N=4,928) of patients 1 year prior to bladder cancer diagnosis. These patients had lower rates of induction BCG (23.0% VS 27.8%, p<0.001). Excluding pre-existing MHI, 43.7% (N=11,377) of patients developed MHI after their bladder cancer diagnosis. Both female and older patients had higher rates of developing MHI (p<0.001), Table 1. Patients without pre-existing MHI treated with at least an induction course of BCG (N=7,233) had a lower MHI development rate than those who did not receive BCG (41.5% VS 44.5%, p<0.001). CONCLUSIONS: Patients with NMIBC are at high risk of developing MHI after diagnosis especially elderly and female patients. Patients who received at least induction BCG treatment had lower rates of developing de novo MHI, however, those with pre-existing MHI were less likely to receive BCG. Source of Funding: This research was supported by the Wayne B. Duddlesten Professorship in Cancer Research © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e759 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Valentina Grajales More articles by this author Zhigang Duan More articles by this author Wei Shen Tan More articles by this author Roberto Contieri More articles by this author Hui Zhao More articles by this author Sharon Giordano More articles by this author Stephen B. Williams More articles by this author Ashish M. Kamat More articles by this author Expand All Advertisement PDF downloadLoading ...

The NP's role in increasing RVU values.

The NP's role in increasing RVU values.

115 State-to-State Variation in Medicaid and Medicare Reimbursement: Implications for Healthcare Access Among Vulnerable Populations

INTRODUCTION: Medicaid and Medicare are social insurance programs providing coverage for specific populations, namely low-income and aged individuals. While Medicare is a federally indexed health insurance program, Medicaid is largely administered by individual states resulting in varying policies and practices. METHODS: Maximum allowed physician reimbursement fees for twenty common neurosurgical codes were obtained from the 2022 Medicare Physician Fee Schedule and individual state Medicaid Fee-for-Service Schedules. The Medicaid-Medicare Index (MMI), which measures Medicaid reimbursement as a fraction of Medicare allowed amounts, was calculated for each procedure across 49 states and the District of Columbia. MMI &lt;1 or &gt;1 indicates that Medicaid reimburses less than or greater than Medicare, respectively. The proportion of providers accepting new Medicaid patients and total Medicaid enrollment were compared across states as a function of MMI. RESULTS: Maximum allowed amounts for Medicare reimbursement (CV = 0.09) were less variable than Medicaid (CV = 0.26, p &lt; 0.01). The average national MMI was 0.79 with a range of 0.37 in NY/NJ to 1.43 in NE. The largest absolute disparity was observed for intracranial aneurysm clipping in NY, where the maximum Medicaid reimbursement is $3,496.52 less than that of Medicare. Higher MMI was associated with a significantly larger proportion of providers accepting new Medicaid patients (R2 = 0.43, p &lt; 0.01). Moreover, MMI varied inversely with the number of Medicaid beneficiaries (R2 = 0.12, p = 0.01). CONCLUSIONS: Medicaid reimbursement varies drastically between states reflecting the disparate methods of fee calculation. Lower reimbursement is associated with more limited provider enrollment, especially in states with a greater number of beneficiaries. While more limited access to Medicaid-accepting neurosurgeons may contribute to poorer outcomes, this is an issue that warrants further exploration.

What Is the Prevalence of Clinically Important Findings Among Incidentally Found Osseous Lesions?

Patients with incidentally found musculoskeletal lesions are regularly referred to orthopaedic oncology. Most orthopaedic oncologists understand that many incidental findings are nonaggressive and can be managed nonoperatively. However, the prevalence of clinically important lesions (defined as those indicated for biopsy or treatment, and those found to be malignant) remains unknown. Missing clinically important lesions can result in harm to patients, but needless surveillance may exacerbate patient anxiety about their diagnosis and accrue low-value costs to the payor. (1) What percentage of patients with incidentally discovered osseous lesions referred to orthopaedic oncology had lesions that were clinically important, defined as those receiving biopsy or treatment or those found to be malignant? (2) Using standardized Medicare reimbursements as a surrogate for payor expense, what is the value of reimbursements accruing to the hospital system for the imaging of incidentally found osseous lesions performed during the initial workup period and during the surveillance period, if indicated? This was a retrospective study of patients referred to orthopaedic oncology for incidentally found osseous lesions at two large academic hospital systems. Medical records were queried for the word "incidental," and matches were confirmed by manual review. Patients evaluated at Indiana University Health between January 1, 2014, and December 31, 2020, and those evaluated at University Hospitals between January 1, 2017, and December 31, 2020, were included. All patients were evaluated and treated by the two senior authors of this study and no others were included. Our search identified 625 patients. Sixteen percent (97 of 625) of patients were excluded because their lesions were not incidentally found, and 12% (78 of 625) were excluded because the incidental findings were not bone lesions. Another 4% (24 of 625) were excluded because they had received workup or treatment by an outside orthopaedic oncologist, and 2% (10 of 625) were excluded for missing information. A total of 416 patients were available for preliminary analysis. Among these patients, 33% (136 of 416) were indicated for surveillance. The primary indication for surveillance included lesions with a benign appearance on imaging and low clinical suspicion of malignancy or fracture. A total of 33% (45 of 136) of these patients had less than 12 months of follow-up and were excluded from further analysis. No minimum follow-up criteria were applied to patients not indicated for surveillance because this would artificially inflate our estimated rate of clinically important findings. A total of 371 patients were included in the final study group. Notes from all clinical encounters with orthopaedic and nonorthopaedic providers were screened for our endpoints (biopsy, treatment, or malignancy). Indications for biopsy included lesions with aggressive features, lesions with nonspecific imaging characteristics and a clinical picture concerning for malignancy, and lesion changes seen on imaging during the surveillance period. Indications for treatment included lesions with increased risk of fracture or deformity, certain malignancies, and pathologic fracture. Diagnoses were determined using biopsy results if available or the documented opinion of the consulting orthopaedic oncologist. Imaging reimbursements were obtained from the Medicare Physician Fee Schedule for 2022. Because imaging charges vary across institutions and reimbursements vary across payors, this method was chosen to enhance the comparability of our findings across multiple health systems and studies. Seven percent (26 of 371) of incidental findings were determined to be clinically important, as previously defined. Five percent (20 of 371) of lesions underwent tissue biopsy, and 2% (eight of 371) received surgical intervention. Fewer than 2% (six of 371) of lesions were malignant. Serial imaging changed the treatment of 1% (two of 136) of the patients, corresponding to a rate of one in 47 person-years. Median reimbursements to work up the incidental findings analyzed was USD 219 (interquartile range USD 0 to 404), with a range of USD 0 to 890. Among patients indicated for surveillance, the median annual reimbursement was USD 78 (IQR USD 0 to 389), with a range of USD 0 to 2706. The prevalence of clinically important findings among patients referred to orthopaedic oncology for incidentally found osseous lesions is modest. The likelihood of surveillance resulting in a change of management was low, but the median reimbursements associated with following these lesions was also low. We conclude that after appropriate risk stratification by orthopaedic oncology, incidental lesions are rarely clinically important, and judicious follow-up with serial imaging can be performed without incurring high costs. Level III, therapeutic study.

Are Cervical Disc Arthroplasty Medicare Reimbursement Trends Sustainable?

Cervical disc arthroplasty (CDA) was originally approved by the US Food and Drug Administration (FDA) in 2007 as a motion-sparing procedure to treat cervical degenerative disc disease. Since then, promising results from randomized control trials have led to increasing popularity. However, data discussing monetary trends are limited. The aim of this study was to determine how utilization, hospital charges, and Medicare physician reimbursement for CDA have changed over time. In this retrospective cohort study, International Classification of Diseases procedure codes were used to identify all patients who underwent CDA from 2007 to 2017 in the National Inpatient Sample database. The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was queried for primary CDA using current procedural terminology codes to determine Medicare physician reimbursement from 2009 to 2021. Nominal monetary values were adjusted for inflation using the Consumer Price Index and inflation-adjusted data reported in 2021 US dollars. A total of 33,079 weighted patients who underwent CDA were included for analysis. CDA utilization increased by 183% from 2007 to 2017, with Medicare beneficiary utilization increasing 149%. Inflation-adjusted total hospital charges for CDA increased by 22.4%. However, inflation-adjusted Medicare physician reimbursement fell by 1.20% per year, demonstrating a total decrease of 12.9%, starting at $1928 in 2009 and declining to $1679 in 2021. While utilization and total hospital charges for CDA continue to rise, Medicare physician reimbursement has not shown the same trend. In fact, inflation-adjusted reimbursement has seen a steady decline since FDA approval in 2007. If this trend persists, it may become unsustainable for physicians to continue offering CDA to Medicare patients. As disproportionate increases in hospital charges incentivize a transition to outpatient CDA, stricter patient selection criteria associated with outpatient procedures may create health care disparities for Medicare patients and those with higher comorbidity burden. This study shows the decreasing reimbursement trends for CDA, which may disproportionately affect Medicare patients and those with increased comorbidities.

Is Surgical Repair With Nerve Allograft More Cost-Effective Than Non-Surgical Management for Persistent Trigeminal Neuropathy? Initial Assessment With Markov Model

Persistent trigeminal neuropathy (PTN) is associated with high rates of depression, loss of work, and decreased quality of life (QoL). Nerve allograft repair can achieve functional sensory recovery in a predictable manner; however, it bears significant upfront costs. In patients suffering from PTN, is surgical repair with allogeneic nerve graft, when compared to non-surgical therapy, a more cost-effective treatment option? A Markov model was constructed with TreeAge Pro Healthcare 2022 (TreeAge Software, Massachusetts) to estimate the direct and indirect costs for PTN. The model ran for 40years with 1-year-cycles on a 40-year-old model patient with persistent inferior alveolar or lingual nerve injury (S0 to S2+) at 3months without signs of improvement, and without dysesthesia or neuropathic pain (NPP). The 2 treatment arms were surgery with nerve allograft versus non-surgical management. There were 3 disease states, functional sensory recovery (S3 to S4), hypoesthesia/anesthesia (S0 to S2+), and NPP. Direct surgical costs were calculated using the 2022 Medicare Physician Fee Schedule and verified with standard institutional billing practices. Non-surgical treatment direct costs (follow-up, specialist referral, medications, imaging) and indirect costs (QoL, loss of employment) were determined from historical data and the literature. Direct surgical costs for allograft repair were $13,291. State-specific direct costs for hypoesthesia/anesthesia were $2,127.84 per year, and $3,168.24 for NPP per year. State-specific indirect costs included decreased labor force participation, absenteeism, and decreased QoL. Surgical treatment with nerve allograft was more effective and had a lower long-term cost. The incremental cost-effectiveness ratio was -10,751.94, indicating surgical treatment should be utilized based on efficiency and cost. With a willingness-to-pay threshold of $50,000, the net monetary benefits of surgical treatment are $1,158,339 compared to $830,654 for non-surgical treatment. With a standard threshold incremental cost-effectiveness ratio of 50,000, the sensitivity analysis shows that surgical treatment would remain the preferred choice based on efficiency even if surgical costs were doubled. Despite high initial costs of surgical treatment with nerve allograft for PTN, surgical intervention with nerve allograft is a more cost-effective treatment option when compared to non-surgical therapy.

Cost-Effectiveness Analysis of Open Versus Endovascular Revascularization for Chronic Mesenteric Ischemia

Recent studies have shown a trend supporting endovascular revascularization (ER) in the treatment of chronic mesenteric ischemia (CMI). However, few studies have compared the cost effectiveness of ER and open revascularization (OR) for this indication. The purpose of this study is to conduct a cost-effectiveness analysis comparing open versus ER for CMI. We built a Markov model with Monte Carlo microsimulation using transition probabilities and utilities from existing literature for CMI patients undergoing OR versus ER. Costs were derived from the hospital perspective using the 2020 Medicare Physician Fee Schedule. The model randomized 20,000 patients to either OR or ER and allowed for 1 subsequent reintervention with 3 other intervening health states: alive, alive with complications, and dead. Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a 5-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness. OR cost $4,532 for 1.03 QALYs while ER cost $5,092 for 1.21 QALYs, leading to an ICER of $3,037 per QALY gained in the ER arm. This ICER was less than our willingness to pay threshold of $100,000. Sensitivity analysis demonstrated that our model was most sensitive to costs, mortality, and patency rates after OR and ER. Probabilistic sensitivity analysis demonstrated ER would be considered cost effective 99% of iterations. This study found that while 5-year costs for ER were greater than OR, ER afforded greater QALYs than OR. Although ER is associated with lower long-term patency and higher rates of reintervention, it appears to be more cost effective than OR for the treatment of CMI.