Reimbursement For Procedures Research Articles

Comparison of patients undergoing a two-stage sacral nerve stimulation procedure: is there a cost benefit for a single-stage procedure?

Sacral neurostimulation (SNS) involves a two-stage procedure to assess outcomes prior to permanent implantation. Stage 1 involves placement of a sacral lead that is externalized and tested for 2 weeks. Stage 2 is the implantation of a pulse generator in responders (≥ 50% improved). This study's purpose was to determine the overall response rate, costs of a two-staged versus single-stage approach, and explore predictors of a positive response. A prospective database of 145 patients undergoing SNS was analyzed. Demographics, history, and operative data were collected from the medical records. Cost data were collected from our institutions' reported average reimbursement for all stages of Interstim implantation and explantation in 2008. Wilcoxon rank test were used for analysis. Of 145 patients, 131 (90.3%) progressed to Stage 2 and 14 (9.7%) had removal. Explanted patients were older (mean 63 years) than implanted patients (56 years); however, this was not statistically significant. Total Medicare and Blue Cross/Blue Shield (BCBS) reimbursement for a two-stage procedure was calculated at $21,428/case and $26,968. Implanting the lead and generator as a single-stage would cost Medicare and BCBS $20,696 and $21,602, respectively. Since 9.7% were explanted, overall cost saving might be significant: a single-stage approach would yield savings of $3,655/case (BC/BS) over a two-stage approach (after the cost of explantation is factored in). The majority of patients tested with SNS would benefit from a single-stage procedure (90.3%). This would reduce operative and anesthesia risks, time lost from work, and burden on patients and providers.

When research is reconciled with care and ethics with science, reimbursement for clinical procedures can be linked to trial participation

When research is reconciled with care and ethics with science, reimbursement for clinical procedures can be linked to trial participation

Estimating medical expenditures spent on rule‐out diagnoses in Japan

According to the regulations concerning reimbursement rules for the uniform coverage scheme in Japan's health insurance system, rule-out diagnoses must be included in a health insurance claim (HIC) to ensure reimbursement for clinical procedures whose results show that a suspected disease is not present. However, estimations of disease-specific medical expenditure by conventional methods have not considered the information on rule-out diagnoses. To estimate disease-specific medical expenditure for rule-out diagnoses. Data were obtained from 169,622 outpatient HICs in May 2006 from corporate health insurance societies. We used the proportional distribution method to estimate medical expenditure for each of the major disease categories defined by the Classification of Diseases for the use of Social Insurance, which is based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. There were 442,010 diagnoses on the HICs, of which 20,330 (4.60%) were rule-out diagnoses. Rule-out diagnoses accounted for 8.5% of total medical expenditure. The proportion of medical expenditure spent on rule-out diagnoses varied across the major diseases categories, and it was estimated that more than one-third (36.9%) of the medical expenditure on neoplasm is spent on rule-out diagnoses. The existence of rule-out diagnoses affects the estimation of disease-specific medical expenditure. Therefore, the estimation of disease-specific medical expenditure and evaluation of prevention and treatment programmes should be improved by utilizing information on rule-out diagnoses.

Management of obstructive sleep apnea in Europe

Objectives In Europe, the services provided for the investigation and management of obstructive sleep apnoea (OSA) varies from country to country. The aim of this questionnaire-based study was to investigate the current status of diagnostic pathways and therapeutic approaches applied in the treatment of OSA in Europe, qualification requirements of physicians involved in diagnosis and treatment of OSA, and reimbursement of these services. Methods Two questionnaires were sent to 39 physicians in 22 countries in Europe. In order to standardize the responses, the questionnaire was accompanied by an example. Results Sleep centers from 21 countries (38 physicians) participated. A broad consistency among countries with respect to the following was found: pathways included referral to sleep physicians/sleep laboratories, necessity for objective diagnosis (primarily by polysomnography), use of polygraphic methods, analysis of polysomnography (PSG), indications for positive airway pressure (PAP) therapy, application of standard continuous PAP (CPAP) therapy (100% with an CPAP/APAP ratio of 2.24:1), and the need (90.5%) and management of follow-up. Differences were apparent in reimbursement of the diagnostic procedures and follow-up, in the procedures for PAP titration from home APAP titration with portable sleep apnea monitoring (38.1%) up to hospital monitoring with PSG and APAP (85.7%), and in the qualification requirements of sleep physicians. Conclusions Management of OSA in different European countries is similar except for reimbursement rules, qualification of sleep specialists and procedures for titration of the CPAP treatment. A European network (such as the one accomplished by the European Cooperation in Science and Technology [COST] B26 Action) could be helpful for implementing these findings into health-service research in order to standardize management in a cost effective perspective.

Atherosclerotic Renal Artery Stenosis, the Oculostenotic Reflex, and Therapeutic Nihilism

Fifteen years ago, Topol and Nissen1 described the oculostenotic reflex as an “irresistible temptation … to perform angioplasty on any significant residual stenosis,” highlighting a widely held misperception that an angiographically severe stenosis must cause ischemia and that revascularization results in clinical benefit. Although quantitative angiography improves the accuracy of stenosis severity, it does not improve the accuracy of diagnosing ischemia. In fact, more than one third of angiographically severe coronary stenoses are hemodynamically insignificant by fractional flow reserve (FFR), and FFR results are highly correlated with findings of ischemia by myocardial perfusion imaging.2 Similarly, angiographic renal artery stenosis (RAS) severity correlates poorly with hemodynamic significance.3 Article see p 537 Five randomized trials4–8 demonstrated that a strategy of renal revascularization based on the oculostenotic reflex was not associated with improvement in blood pressure or renal function or reduction in clinical events compared to medical therapy alone. These results lead some to recommend a nihilistic approach …

Invited commentary

Invited commentary

Cost-effectiveness of ranibizumab for the treatment of neovascular age-related macular degeneration in germany: Model analysis from the perspective of germany's statutory health insurance system

Background: In clinical trials, ranibizumab has been associated with stabilization and even improvement of visual acuity among patients with neovascular agerelated macular degeneration (AMD), but its use is also associated with considerable costs. Objective: The aim of this work was to compare ranibizumab with best supportive care or photodynamic therapy (PDT) for AMD by means of economic costutility and cost-effectiveness analysis from the perspective of Germany's Statutory Health Insurance System. Methods: Visual acuity data from the Anti-VEGF (vascular endothelial growth factor) Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD (ANCHOR) and Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD (MARINA) studies were applied, based on a ranibizumab dose of 0.5 mg. A Markov model simulated visual acuity and costs over 10 years (discounted at 3%). The base-case analysis assumed 5 injections per year over 2 years. Treatment costs were based on year-2008 euros (using German prices) and recommendations for procedure reimbursement from a public health insurance perspective. To assess cost-effectiveness, costs per year of legal blindness avoided (ie, vision-year gained [VYG]) and per quality-adjusted life-year (QALY) were calculated. The model assumed each patient's affected eye had better sight than the other eye, and the 2 comparators against which ranibizumab treatment was assessed were best supportive care and PDT. The robustness of the results was investigated in a univariate sensitivity analysis of all relevant parameters and a multivariate probabilistic sensitivity analysis. The multivariate 95% CIs for incremental cost-effectiveness ratios were obtained by conducting 1000 Monte Carlo simulations. Results: Compared with best supportive care, costs per VYG for ranibizumab were €6767 in occult choroidal neovascularization (CNV) and €6020 in minimally classic CNV. In classic CNV, costs were €5734/VYG for ranibizumab compared with supportive care and €778/VYG for ranibizumab compared with PDT. Costs per QALY for ranibizumab treatment for occult, minimally classic CNV, and classic CNV were €22,320, €22,538, and €25,036, respectively, and €3294 for classic CNV compared with PDT. Results were sensitive to the cost of blindness, injection frequency, and duration. The multivariate 95% CIs for the incremental costeffectiveness ratios were €14,438 to €41,110/QALY for occult CNV, €13,463 to €43,614/QALY for minimally classic CNV, and €15,634 to €51,106/QALY for classic CNV. Conclusion: In this model analysis using costs and clinical trial data from Germany, ranibizumab appeared to be a cost-effective treatment option for all angiographic subtypes of neovascular AMD, from the perspective of Germany's Statutory Health Insurance System.

Health Care Reform for Children: Views From the Academic Pediatric Association

N ational public opinion polls indicate that a majority of Americans favor expanding the federal government’s role in regulating health care to ensure coverage for all Americans. Polls conducted prior to the recently enacted Patient Protection and Affordable Care Act indicate that an increasing number of Americans were not satisfied with the proposed health care reforms. National physician surveys indicate that most physicians also believe that a larger portion of the population should have health insurance coverage and favor expanding the government’s involvement to achieve this. A majority of physicians, across a spectrum of specialties, believe they have a fiduciary obligation to address health policy issues as part of their professional responsibility and report that they would be willing to accept limits on reimbursement for expensive drugs and procedures to achieve expanded access to basic health care. Although state-administered programs such as the Children’s Health Insurance Program Reauthorization Act currently ensure partial coverage for children through 2013, proposed health care reforms could alter pediatric coverage through alternative coverage options, such as exchange plans, or by increasing dependent coverage through reforms aimed at increasing parental coverage. Although national polls indicate that a majority of physicians tend to agree on the general direction in which health care reform should move, the views of pediatricians have not been reported separately. Children are a vulnerable group of patients, who, unlike many other stakeholders

Potential financial impact of restriction in “never event” and periprocedural hospital-acquired condition reimbursement at a tertiary neurosurgical center: a single-institution prospective study

The Centers for Medicare and Medicaid Services (CMS) have moved to limit hospital augmentation of diagnosis-related group billing for "never events" (adverse events that are serious, largely preventable, and of concern to the public and health care providers for the purpose of public accountability) and certain hospital-acquired conditions (HACs). Similar restrictions may be applied to physician billing. The financial impact of these restrictions may fall on academic medical centers, which commonly have populations of complex patients with a higher risk of HACs. The authors sought to quantify the potential financial impact of restrictions in never events and periprocedural HAC billing on a tertiary neurosurgery facility. Operative cases treated between January 2008 and June 2008 were reviewed after searching a prospectively maintained database of perioperative complications. The authors assessed cases in which there was a 6-month lag time to allow for completion of hospital and physician billing. They speculated that other payers would soon adopt the present CMS restrictions and that procedure-related HACs would be expanded to cover common neurosurgery procedures. To evaluate the impact on physician billing and to directly contrast physician and hospital billing impact, the authors focused on periprocedural HACs, as opposed to entire admission HACs. Billing records were compiled and a comparison was made between individual event data and simultaneous cumulative net revenue and net receipts. The authors assessed the impact of the present regulations, expansion of CMS restrictions to other payers, and expansion to rehospitalization and entire hospitalization case billing due to HACs and never events. A total of 1289 procedures were completed during the examined period. Twenty-five procedures (2%) involved patients in whom HACs developed; all were wound infections. Twenty-nine secondary procedures were required for this cohort. Length of stay was significantly higher in patients with HACs than in those without (11.6 +/- 11.5 vs 5.9 +/- 7.0 days, respectively). Fifteen patients required readmission due to HACs. Following present never event and HAC restrictions, hospital and physician billing was minimally affected (never event billing as percent total receipts was 0.007% for hospitals and 0% for physicians). Nonpayment for rehospitalization and reoperation for HACs by CMS and private payers yielded greater financial impact (CMS only, percentage of total receipts: 0.14% hospital, 0.2% physician; all payers: 1.56% hospital, 3.0% physician). Eliminating reimbursement for index procedures yielded profound reductions (CMS only as percentage of total receipts: 0.62% hospital, 0.8% physician; all payers: 5.73% hospital, 8.9% physician). The authors found potentially significant reductions in physician and facility billing. The expansion of never event and HACs reimbursement nonpayment may have a substantial financial impact on tertiary care facilities. The elimination of never events and reduction in HACs in current medical practices are worthy goals. However, overzealous application of HACs restrictions may remove from tertiary centers the incentive to treat high-risk patients.

Costs and reimbursement gaps after implementation of third-generation left ventricular assist devices

The purpose of this study was to compare and contrast total hospital costs and subsequent reimbursement of implementing a new program using a third-generation left ventricular assist device (LVAD) in Norway. Between July 2005 and March 2008, the total costs of treatment for 9 patients were examined. Costs were calculated for three periods-the pre-implantation LVAD phase, the LVAD implantation phase and the post-implantation LVAD phase-as well as for total hospital care. Patient-specific costs were obtained prospectively from patient records and included personnel resources, medication, blood products, blood chemistry and microbiology, imaging, and procedure costs including operating room costs. Overhead costs were registered retrospectively and allocated to the specific patient by pre-defined allocation keys. Finally, patient-specific costs and overhead costs were aggregated into total patient costs. The average total patient cost in 2007 U.S. dollars was $735,342 and the median was $613,087 (range $342,581 to $1,256,026). The mean length of stay was 77 days (range 40 to 127 days). For the LVAD implantation phase, the mean cost was $457,795 and median cost was $458,611 (range $246,239 to $677,680). The mean length of stay for the LVAD implantation phase was 55 days (range 25 to 125 days). The diagnosis-related group (DRG) reimbursement (2007) was $143,192. There is significant discrepancy between actual hospital costs and the current Norwegian DRG reimbursement for the LVAD procedure. This discrepancy can be partly explained by excessive costs related to the introduction of a new program with new technology. Costly innovations should be considered in price setting of reimbursement for novel technology.

Interventional Nephrology: Core Curriculum 2009

Interventional Nephrology: Core Curriculum 2009

Reimbursement Trends for Outpatient Interventional Radiology Procedures: Comparison of Hospital and Freestanding Physician Office Sites of Service

The aim of this study was to compare trends in reimbursement rates between hospital outpatient departments and freestanding physician offices for commonly performed interventional radiology procedures from 2006 through 2010. Using final rules data from the 2006 and 2008 Hospital Outpatient Prospective Payment System for Medicare and Medicare Physician Fee Schedule, reimbursement rates were calculated for a sample of procedures commonly performed by interventional radiologists in the outpatient setting. Hospital and freestanding reimbursement rates for 2006, 2008, and 2010 (projected) were adjusted for inflation to 2008 dollars and weighted by relative procedure frequency using Medicare Part B claims data. Reimbursements for the entire sample of procedures were compared year to year, by site of service, and by payment system. Individual procedure reimbursements were also trended. In 2006, reimbursements for the entire procedure sample were 6% less in hospital outpatient departments than in freestanding offices. In 2008 and 2010, they are projected to be 3% and 23% greater, respectively, in hospital outpatient departments than in freestanding offices. Over the 4-year interval, reimbursements are projected to fall by 36% in freestanding offices and by 16% in hospital outpatient departments. Reimbursements to hospitals for facility costs are projected to decrease by 14%. Reimbursements to physicians for work done in hospital outpatient departments are projected to decrease by 23%. Substantial reductions in calculated outpatient interventional radiology practice expenses being phased in between 2006 and 2010 under the Medicare Physician Fee Schedule seem to be dramatically reducing reimbursements for interventional procedures performed on outpatients, especially in freestanding offices. The impact of these practice expense reductions on interventional radiology seems to far outweigh that of the Deficit Reduction Act and other recent Medicare reimbursement changes.

Downstream Hospital Charges Generated From Endoscopic Ultrasound Procedures Are Greater Than Those From Colonoscopies

Endoscopic ultrasound is a clinically valuable endoscopic platform, although a potential barrier to its widespread use is the modest reimbursement to the hospital, compared with that of standard endoscopy. However, the downstream procedures generated by endoscopic ultrasound findings might offset its modest procedural reimbursement for a hospital or health care system. We compared the number of hospital procedures that resulted from endoscopic ultrasound findings with those from colonoscopy findings and also compared the downstream hospital charges generated by endoscopic ultrasounds with those from colonoscopies. We retrospectively reviewed data from 920 consecutive endoscopic ultrasounds and 920 consecutive colonoscopies performed at University Hospital in Cincinnati, Ohio to determine the downstream procedures generated within 18 months of the index procedure. Total hospital charges were determined for the index procedures, as well as all downstream surgeries, endoscopic procedures, and radiation therapy, chemotherapy, and interventional radiology procedures. Endoscopic ultrasounds led to a greater number of downstream procedures than colonoscopies (198 vs 34). Hospital charges for downstream procedures that arose from endoscopic ultrasounds were 2.63-fold greater than those of colonoscopies ($4,068,115 vs $1,546,291). Hospital charges that resulted from the 920 index endoscopic ultrasounds were 1.34-fold greater than those of the index colonoscopies ($3,194,715 vs $2,381,745). Thus, the total hospital charges (index procedures plus downstream procedures) that arose from endoscopic ultrasounds were 1.85-fold greater than those of colonoscopies ($7,262,830 vs $3,928,036). Endoscopic ultrasounds generate greater downstream hospital charges than colonoscopies. These downstream charges attenuate the higher procedure-related charges of colonoscopy for a hospital.

Financial impact of breast reconstruction on an academic surgical practice.

The financial reimbursement for breast reconstruction is perceived to be low. The authors evaluated the financial impact of providing breast reconstruction for an academic medical practice and health care system. The authors examined the billing records for 97 patients undergoing postmastectomy breast reconstruction in 2006 at the University of Michigan. Professional net revenue was calculated by applying actual collection rates to procedural charges. Facility revenue was calculated by applying actual collection rates to charges from inpatient care and the operating room. The payer mix was 70.1 percent private insurance, 22.7 percent health maintenance organization, 3.1 percent Medicare, 2.1 percent Medicaid, and 2.0 percent uninsured. The professional revenue and costs allocated to breast reconstruction were $242,078 and $177,411, respectively [net profit of $64,667 (27 percent)]. Health system facility revenue and costs were $1,109,678 and $943,892, respectively [net profit of $165,786 (15 percent)]. Physician reimbursement by surgical time was highest for delayed tissue expander placement ($1977.70/hour in the operating room) and lowest for immediate transverse rectus abdominis myocutaneous (TRAM) flaps ($327/hour in the operating room). The facility received the greatest average direct margin on TRAM flaps ($3471) and lost money on latissimus dorsi flaps (-$398 margin). Postmastectomy breast reconstruction at this academic medical center is fiscally advantageous for both the surgical department and the health care system. However, reimbursement varies dramatically by type and timing of reconstructive procedure. Although immediate postmastectomy reconstructions with TRAM flaps provide superior aesthetic results with the greatest amount of patient satisfaction, poor physician reimbursement for these labor-intensive procedures may limit the ability of surgeons to provide these services because of poor financial return.

Current trends in coronary revascularization

The options for coronary revascularization broadened in recent years with the introduction of bare-metal stents in the 1990s and drug-eluting stents in 2003. Since then, the rates of percutaneous coronary intervention (PCI) have increased whereas the use of coronary artery bypass grafting (CABG) has decreased. Although historically there have been disparities in the use of revascularization procedures in women, the elderly, and nonwhite patients, there is some evidence to suggest these gaps have narrowed in recent years. In any given clinical circumstance, there is ongoing debate as to whether PCI or CABG is the more appropriate revascularization method depending on coronary anatomy, ventricular function, and associated conditions. Also, trends in coronary revascularization are potentially influenced by emerging clinical evidence and new technologies, national guidelines and appropriateness criteria, procedure reimbursement, and changes in the population being treated. Accordingly, it is unclear whether the trend in increased use of PCI versus CABG will continue.

Physician Reimbursement for General Surgical Procedures in the Last Century: 1906–2006

Physician Reimbursement for General Surgical Procedures in the Last Century: 1906–2006

Chronic Kidney Disease in the United States

In the past decade, a crisis in nephrology has slowly emerged in the areas of both clinical care and public policy. In 2003, the Council of American Kidney Societies (CAKS) identified 19 barriers to improved patient outcomes in chronic kidney disease (CKD). Site visits and in-depth telephone interviews were conducted with 15 nephrologists focusing on current issues with identifying and treating patients with CKD. The qualitative analyses were considered in the context of CAKS-identified barriers to assess the present state of nephrology care and provide a foundation for a more detailed quantitative CKD project potential implications for advancing nephrology-related health policy. Despite new evidence-based therapies to slow, stop, or reverse the progression of CKD to ESRD as well as premature cardiovascular disease, major systemic barriers continue to limit the implementation of this body of evidence at the level of the nephrology practice. Key factors include under- or uninsurance, unstructured medical care systems, and lack of enabling public policies. The crisis of nephrology is embedded within the unresolved duress of the ability to provide quality early intervention juxtaposed upon inadequate reimbursement for clinical care and procedures, unfunded mandates for information technology systems, and organizational inconsistencies between nephrology and other specialties. We believe now is the time for the renal community and related stakeholders to unite in an effort to address the clinical, financial, and public policy issues that will enable the delivery of appropriate CKD care to this vulnerable patient population.

Reimbursement of long-term postplacement costs after endovascular abdominal aortic aneurysm repair

Postplacement cost of surveillance and secondary procedures over 5 years increases the global cost of endovascular aortic aneurysm repair (EVAR) by nearly 50%. This study identified and assessed the reimbursement received for long-term postplacement costs after EVAR. Between December 1995 and June 2007, 360 patients underwent EVAR at a single institution. The reimbursement collected from charges of postplacement surveillance and secondary procedures related to the aneurysmal disease was evaluated and compared against the actual costs. All amounts were converted to year 2007 dollars. To minimize costs associated with the early learning curve, the initial 50 EVAR patients between December 1995 and 1998 were excluded. Patients with <1 year follow-up were also excluded. Data are expressed as mean +/- standard error. The mean follow up after EVAR for 152 patients was 38.8 +/- 1.8 months. Medicare, capitated insurance, and commercial insurance provided coverage for 85 (56.0%), 49 (32.2%), and 18 (11.8%) patients, respectively. The cumulative 5-year postplacement reimbursement received per patient was $9792 meeting 81.4% of the cumulative cost of $12,027 for a net loss of $2235 per patient. Although 123 (80.9%) patients without secondary procedures generated a 5-year cumulative gain of $1830 per patient, 29 (19.1%) patients with secondary procedures averaged a 5-year cumulative loss of $9378 per patient. The average reimbursement rate over the 5-year period was 35.8% +/- 0.6%, with the lowest reimbursement rate seen in patients with Medicare at 31.6% +/- 0.7%. Current reimbursement is not sufficient to meet the costs associated with long-term surveillance and needed secondary procedures after EVAR. Inadequate reimbursement of costs associated with secondary procedures was the primary driver for the net institutional loss. Reimbursement for outpatient radiological procedures generated a modest surplus.

Public Health Reporting: The United States Perspective

The release of 2 landmark reports by the Institute of Medicine titled, "To Err Is Human: Building a Safer Health System" and "Crossing the Quality Chasm" were instrumental in the identification of safety and quality issues. Since their release, federal and state programs of public reporting of performance measures have attempted to close the quality gap of care that is inappropriate, not timely, or lacking an evidence base. Cardiac surgery has long been the focus of public scrutiny, and now, as we move from an era of managed care to public reporting, reimbursement for cardiac surgery procedures will be tied to performance. However, the question is whether public reporting and pay for performance will ultimately improve the quality of patient care, safety, and provide the consumer with enough information to make surgeon and institutional choices. Will the cost and focus of achieving perfection with performance standards overshadow any real improvement in clinical outcomes?

Financial Incentives for Lumbar Surgery: A Critical Analysis of Physician Reimbursement for Decompression and Fusion Procedures

Retrospective case-control study/economic analysis. To determine the treatment times required for isolated lumbar decompressions and for combined decompression and instrumented fusion procedures to compare the relative reimbursements for each type of operation as a function of time expenditure by the surgeon. Under current Medicare fee schedules, the payment for a fusion procedure is higher than of an isolated decompression. It has been recently suggested in the lay press that the greater reimbursement for a lumbar arthrodesis may inappropriately influence the manner in which surgeons elect to treat lumbar degenerative conditions, resulting in what they believe to be a substantial number of unnecessary spinal fusions. A consecutive series of 50 single-level decompression cases performed by single surgeon were retrospectively analyzed and compared with an equivalent cohort of subjects who underwent single-level decompression and instrumented posterolateral fusion with autogenous iliac crest bone grafting. The operative reports, office charts, and billing records were reviewed to determine the total clinical time invested by the surgeon and the Medicare reimbursement for each surgery. Relative to the corresponding values of the decompression group, combined decompression and fusion procedures were associated with a longer mean surgical time (134.6 min vs. 47.3 min, P<0.0001), a greater number of postoperative visits (1.0 vs. 3.2, P<0.0001), a higher mean total clinical time expenditure (186.6 min vs. 62.2 min, P<0.0001), and a lower mean dollars received per minute of surgeon time ($12.51 vs. $15.51, P<0.001). These findings challenge the assertion that spine surgeons have an undue financial incentive to recommend a combined decompression and instrumented fusion procedure over an isolated decompression to patients with symptomatic lumbar degeneration, especially when considering the greater time, effort, and risk characteristic of this more complex operation.