Total Medicare Reimbursement Research Articles

Dwindling dollars: The inflation-adjusted decline of Medicare reimbursement in endocrine surgery (2003–2023)

Medicare determines reimbursement rates for medical services, often setting a benchmark that is followed by private insurers. Across various medical specialties, decreases in Medicare reimbursement have been observed. However, the extent of Medicare reimbursement for endocrine surgery remains unexplored. This study investigates the trajectory of reimbursement rates for endocrine surgical procedures. Data spanning 2003 to 2023 were gathered from the Physician Fee Schedule Look-Up Tool for 16 endocrine operations and procedures. Each operation's or procedure's relative value units and conversion factor, which accounts for geographic variation in relative value units, are determined annually by the Centers for Medicare and Medicaid Services. The total annual Medicare reimbursement for each operation or procedure was determined by multiplying procedure-specific relative value units with the conversion factor. Raw yearly percentage changes in reimbursement were computed and compared to changes in the general consumer price index. All data were then corrected for inflation. The compound annual growth rate for each procedure was calculated using inflation-adjusted data. From 2003 to 2023, the mean unadjusted percentage change for all queried procedures was+14.14% (standard deviation 0.28). During this same time, the consumer price index increased by 69.15% (P < .001). After adjusting for inflation, the mean total adjusted percentage change for all queried procedures over the entire study period was -31% (standard deviation 0.17). The adjusted average yearly compound annual growth rate was -1.93% (standard deviation 0.92). Only 1 procedure showed an increase in reimbursement (image-guided fine-needle aspiration,+32%). Inflation-adjusted Medicare reimbursement rates for endocrine surgical procedures have consistently declined. Stakeholders must address these trends to ensure access to quality surgical endocrine care in an evolving health care landscape.

Gender based disparities in Medicare physician reimbursement persist across years and specialty.

The gender pay gap is wide in medicine but the extent of this disparity across specialties and over time have not been elucidated. Here we evaluate differences in Medicare reimbursement between men and women physicians over time and by specialty, controlling for physician and practice characteristics. The Centers for Medicare & Medicaid Services Payment Data was used to determine total reimbursements and number of services submitted by physicians practicing in the US between 2013 and 2019. Data from the American Community Survey (ACS) were used to determine average income, unemployment rates, poverty rates, income, and educational attainment levels by zip code for each physician's practice location. Among the 3,831,504 physicians included in this analysis from 2013-2019, 2,712,545 (70.8%) were men and 1,118,859 (29.2%) were women. Overall, men received more in Medicare reimbursements ($58,815 ± $104,772 vs. $32,205 ± $60,556, p<0.001) and billed more services (864 ± 1,780 vs. 505 ± 1,007, p<0.001) compared to women. The median Medicare reimbursement for men decreased from 2013 to 2019 from $59,710 to $57,874, while the median Medicare reimbursement for women increased from $30,575 to $33,456. Men were reimbursed more than women across all specialties with the greatest disparity in procedure-heavy specialties. The specialties with the highest difference in median Medicare reimbursement between men and women were ophthalmology ($99,452), dermatology ($84,844), cardiology ($64,112), nephrology ($62,352), and pulmonary medicine ($47,399). In linear regression models controlling for calendar year, years of experience, total number of services, and ACS zip-code-level variables, men received a higher amount of Medicare reimbursement in all specialties, as compared to women (p<0.01 for all). The percentage of top earning men (range: 65.0%-99.5%) surpassed the proportion of men in each specialty (range: 46.1%-94.6%), except public health and preventive medicine. Women physicians continue to receive lower total Medicare reimbursements than men physicians, particularly in procedure-heavy specialties. Lower clinical volume and fewer procedural services among women physicians partially contribute to the disparities in reimbursement.

Current Medicare reimbursement for complex endovascular aortic repair is inadequate based on results from a multi-institutional cost analysis

ObjectiveComplex endovascular juxta-, para- and suprarenal abdominal aortic aneurysm repair (comEVAR) is frequently accomplished with commercially available fenestrated (FEVAR) devices or off-label use of aortoiliac devices with parallel branch stents (chEVAR). We sought to evaluate the implantable vascular device costs incurred with these procedures as compared with standard Medicare reimbursement to determine the financial viability of comEVAR in the modern era. MethodsFive geographically distinct institutions with high-volume, complex aortic centers were included. Implantable aortoiliac and branch stent device cost data from 25 consecutive, recent, comEVAR in the treatment of juxta-, para-, and suprarenal aortic aneurysms at each center were analyzed. Cases of rupture, thoracic aneurysms, reinterventions, and physician-modified EVAR were excluded, as were ancillary costs from nonimplantable equipment. Data from all institutions were combined and stratified into an overall cost group and two, individual cost groups: FEVAR or chEVAR. These groups were compared, and each respective group was then compared with weighted Medicare reimbursement for Diagnosis-Related Group codes 268/269. Median device costs were obtained from an independent purchasing consortium of >3000 medical centers, yielding true median cost-to-institution data rather than speculative, administrative projections or estimates. ResultsA total of 125 cases were analyzed: 70 FEVAR and 53 chEVAR. Two cases of combined FEVAR/chEVAR were included in total cost analysis, but excluded from direct FEVAR vs chEVAR comparison. Median Medicare reimbursement was calculated as $35,755 per case. Combined average implantable device cost for all analyzed cases was $28,470 per case, or 80% of the median reimbursement ($28,470/$35,755). Average FEVAR device cost per case ($26,499) was significantly lower than average chEVAR cost per case ($32,122; P < .002). Device cost was 74% ($26,499/$35,755) of total reimbursement for FEVAR and 90% ($32,122/$35,755) for chEVAR. ConclusionsResults from this multi-institutional analysis show that implantable device cost alone represents the vast majority of weighted total Medicare reimbursement per case with comEVAR, and that chEVAR is significantly more costly than FEVAR. Inadequate Medicare reimbursement for these cases puts high-volume, high-complexity aortic centers at a distinct financial disadvantage. In the interest of optimizing patient care, these data suggest a reconsideration of previously established, outdated, Diagnosis-Related Group coding and Medicare reimbursement for comEVAR.

Care Ecosystem Collaborative Model and Health Care Costs in Medicare Beneficiaries With Dementia

Collaborative dementia care programs are effective in addressing the needs of patients with dementia and their caregivers. However, attempts to consider effects on health care spending have been limited, leaving a critical gap in the conversation around value-based dementia care. To determine the effect of participation in collaborative dementia care on total Medicare reimbursement costs compared with usual care. This was a prespecified secondary analysis of the Care Ecosystem trial, a 12-month, single-blind, parallel-group randomized clinical trial conducted from March 2015 to March 2018 at 2 academic medical centers in California and Nebraska. Participants were patients with dementia who were living in the community, aged 45 years or older, and had a primary caregiver and Medicare fee-for-service coverage for the duration of the trial. Telehealth dementia care program that entailed assignment to an unlicensed dementia care guide who provided caregiver support, standardized education, and connection to licensed dementia care specialists. Primary outcome was the sum of all Medicare claim payments during study enrollment, excluding Part D (drugs). Of the 780 patients in the Care Ecosystem trial, 460 (59.0%) were eligible for and included in this analysis. Patients had a median (IQR) age of 78 (72-84) years, and 256 (55.7%) identified as female. Participation in collaborative dementia care reduced the total cost of care by $3290 from 1 to 6 months postenrollment (95% CI, -$6149 to -$431; P = .02) and by $3027 from 7 to 12 months postenrollment (95% CI, -$5899 to -$154; P = .04), corresponding overall to a mean monthly cost reduction of $526 across 12 months. An evaluation of baseline predictors of greater cost reduction identified trends for recent emergency department visit (-$5944; 95% CI, -$10 336 to -$1553; interaction P = .07) and caregiver depression (-$6556; 95% CI, -$11 059 to -$2052; interaction P = .05). In this secondary analysis of a randomized clinical trial among Medicare beneficiaries with dementia, the Care Ecosystem model was associated with lower total cost of care compared with usual care. Collaborative dementia care programs are a cost-effective, high-value model for dementia care. ClinicalTrials.gov Identifier: NCT02213458.

Incidence and Reimbursement Trends for Facial Fracture Repair in the Elderly: A Medicare Analysis.

The aim was to describe incidence and reimbursement trends of surgical repair of facial fractures among the Medicare population. The annual procedure data from the Centers for Medicare and Medicaid Service National Part B Data File from 2000 to 2019 were queried. The total number of surgically corrected facial fractures increased from 10,148 in 2000 to 19,631 in 2019 in a linear pattern (r = 0.924). Specifically, nasal bone/septum fracture repairs increased the most by 200.6% (n = 4682 to n = 14,075), whereas operations for TMJ dislocations, malar/zygoma fractures, and alveolar ridge/mandibular fractures decreased by 27.9%, 12.3%, and 3.2%, respectively, between 2000 and 2019. Correspondingly, the total Medicare reimbursement rose from $2,574,317 in 2000 to $4,129,448 in 2019 (r = 0.895). However, the mean reimbursement for all procedures decreased from $376.63 to $210.35 (44.1% fall) over the same time after adjusting for inflation, with this trend holding for individual fracture types as well. Given the population's increasing age, there has been a significant increase in the number of surgical repairs of facial fractures in Medicare patients between 2000 and 2019. However, this is largely driven by an increase in nasal bone/septum closed reductions, with stagnant and, in some cases, declining incidence among other fracture repairs. The reason is unclear and may be related to an increase in nonoperative management or poor outcomes. Nevertheless, like other subfields within otolaryngology and medicine at large, payments have lagged far behind, which may play some role. 3 Laryngoscope, 134:659-665, 2024.

Long-term Trends in Open vs Endoscopic Carpal Tunnel Release Among the Medicare Population in the United States.

Carpal tunnel release (CTR) surgery is the most common surgery billed to Medicare by hand surgeons. As such, the purpose of this study was to evaluate trends for CTR surgeries billed to Medicare from 2000 to 2020. The publicly available Medicare Part B National Summary File from 2000 to 2020 was queried. For both open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR), the number of procedures and total Medicare reimbursement were extracted. For year 2020, the specialty of the performing surgeon was recorded. Descriptive statistics were reported. A total of 3 429 471 CTR surgeries were performed in the Medicare population from 2000 to 2020. For these procedures, Medicare paid surgeons over $1.23 billion. During this period, there was a 101.8% increase in annual CTR procedures (91 130 in 2000, 183 911 in 2020). Further, annual volume of ECTR increased by 456.2%, and accounted for an increasing percentage of total CTR procedures (9.1% in 2012, 25.2% in 2020). The average adjusted Medicare reimbursement per procedure decreased by 1.5% for OCTR, and decreased by 11.6% for ECTR. In 2020, orthopedic surgeons performed 85.1% of CTR procedures. The volume of CTR surgeries among the Medicare population has increased from 2000 to 2020, and ECTR is accounting for a growing proportion of surgeries. When adjusted for inflation, average reimbursement has decreased, with a greater decrease among ECTR. Orthopedic surgeons perform most of such surgeries. These trends are important to assure adequate resource allocation as treating carpal tunnel becomes more common among the aging Medicare population.

Estimating revenue, costs, and operating margin of any hospital-based thoracic surgery practice using a novel financial model

ObjectiveThe study objective was to develop a generalizable financial model that estimates payor-specific reimbursements associated with anatomic lung resections for any hospital-based thoracic surgery practice. MethodsMedical records of patients who presented to the thoracic surgery clinic and eventually underwent an anatomic lung resection from January 2019 to December 2020 were reviewed. The volume of preoperative and postoperative studies, clinic visits, and outpatient referrals was measured. Neither subsequent studies nor procedures from outpatient referrals were captured. Diagnosis-related group, cost-to-charge ratios, Current Procedural Terminology Medicare payment data, and Private:Medicare and Medicaid:Medicare payment ratios were used to estimate payor-specific reimbursements and operating margin. ResultsA total of 111 patients met inclusion criteria and underwent 113 operations: 102 (90%) lobectomies, 7 (6%) segmentectomies, and 4 (4%) pneumonectomies. These patients underwent 554 total studies, received 60 referrals to other specialties, and had 626 total clinic visits. The total charges and Medicare reimbursement were $12.5 M and $2.7 M, respectively. After adjusting for a 41% Medicare, 2% Medicaid, and 57% Private payor mix, the total reimbursement was $4.7 M. With a 0.252 cost-to-charge ratio, total costs and operating income were $3.2 M and $1.5 M, respectively (ie, 33% operating margin). Average reimbursement per surgery by payor was $51k for Private, $29k for Medicare, and $23k for Medicaid. ConclusionsFor any hospital-based thoracic surgery practice, this novel financial model can calculate both overall and payor-specific reimbursements, costs, and operating margin across the full perioperative spectrum. By manipulating hospital name, hospital state, volume, and payor mix, any program can gain insights into their financial contributions and use the outputs to guide investment decisions.

Abstract 11144: Cardiac Imaging Procedural Volume and Reimbursement Among Medicare Beneficiaries During Covid-19 Pandemic: An Observational Study From 2018 to 2020

Introduction: The COVID-19 pandemic has had major impacts on all healthcare services, including cardiac imaging. In this study, we investigate annual changes in cardiac imaging procedural volume and reimbursement among Medicare Beneficiaries (MB) from 2018 to 2020. Methods: We used the Center of Medicare and Medicaid Services database to identify a 100% sample of MB who underwent cardiac imaging procedures from 2018 to 2020. Using the Current Procedural Terminology (CPT) codes, we identified transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), stress echocardiogram, and nuclear stress test procedures. We examined each procedure’s total, inpatient (facility), and outpatient (non-facility) annual volumes per 1,000 MB. We also examined the total annual Medicare reimbursement per imaging type during that period. We compared annual changes in volumes and total reimbursement between two-time intervals: 2018-2019 and 2019-2020. Results: All annual cardiac imaging procedural volumes decreased significantly in 2020 compared to 2019 ( P&lt;0.001 ). The biggest change was observed in TEE, which decreased by 29.20%, followed by stress echocardiography (26.01%), nuclear stress test (22.96%), and TTE (10.68%). The decrease was more evident in the inpatient setting. Inpatient stress echocardiography decreased by 27.04% (vs 23.82% in the outpatient setting), nuclear stress test decreased by 24.82% (vs 20.66%), and TTE decreased by 11.03% (vs 9.58%). There was also a significant reduction in total annual reimbursement for all procedures in 2020 compared to 2019 ( P=0.0015 ). Stress echocardiogram, nuclear stress test, TEE, and TTE reimbursement decreased by 28.08%, 24.00%, 21.11%, and 15.79%, respectively. Conclusions: The COVID-19 pandemic was associated with a significant and abrupt reduction in annual cardiac imaging procedural volumes and total reimbursement among MB in both inpatient and outpatient settings.

Trends in Billing and Medicare Reimbursement for In-Office Cerumen Removal by Otolaryngologists and Other Providers.

To analyze trends in billing patterns, Medicare reimbursement, and practice-setting for otolaryngologists (ORLs) and other provider types performing in-office cerumen removal. This retrospective study included data on Medicare-billing providers from the Medicare Part B: Provider Utilization and Payment Datafiles (2012-2018). Number of providers performing in-office cerumen removal, total sums and medians for Medicare reimbursements and services, and services per patient were gathered along with geographic distributions. There have been near linear declines in number of general physicians and other provider types performing cerumen extractions with 42.6% and 40.7% declines, respectively, and near linear growth in number of ORLs and advanced practice providers (APPs) with 9.7% and 51.1% growth, respectively. At the median, general physicians, APPs, and other provider types have been billing for a similar and constant number of cerumen extractions per provider, while ORLs have seen a 10.6% increase. Total Medicare reimbursement to general physicians and other provider types has fallen 45.0% and 32.5%, respectively, and to ORLs and APPs has grown 16.9% and 103.4%, respectively. Compared to non-ORLs, ORLs tend to bill for cerumen extraction out of an urban setting rather than a rural setting (P < .001). General physicians and other provider types are increasingly referring cerumen disimpaction patients to ORL physicians and allowing APPs to perform these procedures, indicating a change in landscape of medical practice among these providers. General physicians may be filling a need in the rural setting, where there are fewer ORLs practicing.

Recent Trends in Medicare Utilization and Reimbursement for Spinal Cord Stimulators: 2000–2019

Spinal cord stimulators (SCS) allow spine surgeons to provide relief for patients who suffer from chronic pain due to several disorders, such as failed back surgery syndrome, complex regional pain syndrome, and neuropathy. Despite this, there remains a paucity of data regarding the utilization and reimbursement of SCS. Therefore, the purpose of this study is to evaluate the monetary and procedural trends of spinal cord stimulators among the Medicare database from 2000 to2019. Medicare Part B National Summary Data files, which are publicly available, were used. These files contain data from the years 2000-2019 on all services billed to Medicare within that time frame. Each service is given a Current Procedural Terminology (CPT) code and the number of times that service was performed, as well as the total physician Medicare charges and reimbursements for each service annually are included in that data set. The CPT codes for percutaneous and open placement of spinal cord stimulators were identified: 63650 and 63655, respectively. The total allowed services allowed charges and actual payments were isolated from the data set for each year for each CPT code. The total allowed charges and actual payments for the year were then divided by the total allowed services to find and trend the allowed charges and actual payment for each individual service performed for both percutaneous and open placement of spinal cord stimulators. There were 992,372 Medicare-approved total percutaneous spinal cord stimulator operations and 99,736 Medicare-approved total open spinal cord stimulator operations from 2000 to 2019. Medicare paid $1.02 billion (2019 U.S. dollars) in reimbursement to physicians for percutaneous spinal cord stimulator operations and nearly $145 million (2019 U.S. dollars) in reimbursement to physicians for open spinal cord stimulator operations. From the years 2000 to 2019, there was an average 21.9% increase annually in Medicare-approved percutaneous spinal stimulator placement operations and a 18.4% increase annually in Medicare-approved open spinal stimulator placement operations. During this time, there was also an average 8.7% increase annually in Medicare reimbursement per each percutaneous spinal stimulator placement operation and a 9.1% increase annually in Medicare reimbursement per each open spinal stimulator placement operation. The results of this study show that the number of percutaneous and open procedures have steadily increased from 2000 to 2019. Reimbursement per procedure has also increased steadily over this time. Identifying these trends is important to promote research into costs of these surgeries and ensure adequate resource allocation.

Decreases in Radiation Oncology Medicare Reimbursement Over Time: Analysis by Billing Code

Radiation oncology (RO) has seen declines in Medicare reimbursement (MCR). However, there are no recent studies analyzing the contributions of specific billing codes to overall RO reimbursement. We compared total MCR for specific Healthcare Common Procedure Coding System (HCPCS) codes in 2019 with MCR for those codes in 2010 and 2015, corrected for inflation, to see how the same basket of RO services in 2019 would have been reimbursed in 2010 and 2015 (adjusted MCR). The Centers for Medicare & Medicaid Services Physician/Supplier Procedure Summary database was used to obtain MCR data for RO HCPCS codes in 2010, 2015, and 2019. For each code, the total allowed charge was divided by the number of submitted claims to calculate the average MCR per claim in 2010, 2015, and 2019. The 2019 billing frequency for each code was then multiplied by the inflation-adjusted average MCR for those codes in 2010 and 2015 to determine what the MCR would have been in 2010 and 2015 using 2019 dollars and utilization rates. Results were compared with actual 2019 MCR to calculate the projected difference. Total inflation-adjusted RO MCR was $2281 million (M), $1991 M, and $1848 M in 2010, 2015, and 2019 respectively. This represents a cut of $433 M (19%) and $143 M (7%) from 2010 and 2015, respectively, to 2019. After utilization adjustment, total reimbursement was $2534 M, $2034 M, and $1848 M for 2010, 2015, and 2019, respectively, representing a cut of $686 M (27%) and $186 M (9%) from 2010 and 2015, respectively, to 2019. Intensity modulated radiation therapy (IMRT) treatment delivery and planning accounted for $917 M (36%), $670 M (33%), and $573 M (31%) of the adjusted MCR in 2010, 2015, and 2019, respectively. Medicare reimbursement decreased substantially from 2010 to 2019. A decline in IMRT treatment reimbursement was the primary driver of MCR decline. When considering further cuts, policymakers should consider these trends and their consequences for health care quality and access.

Association Between Radiation Oncologist Density and Medicare Spending

The accessibility of radiation oncology services impacts the likelihood of radiation therapy receipt during cancer care. The density of radiation oncologists (ROs) varies nationally, impacting the geographic access to radiation therapy. We aimed to assess the relationship between RO density and Medicare spending to better evaluate this impact of this relationship.We used the Physician and Other Supplier Public Use File from the Centers for Medicare & Medicaid Services to ascertain the total Medicare reimbursements to each provider marked as a "Radiation Oncologist" for the year 2017. We then placed each radiation oncologist within a Hospital Referral Region (HRR), designed by the Dartmouth Atlas to represent regional healthcare markets for tertiary medical care, using a publicly available zip code-to-HRR crosswalk from the Dartmouth Atlas. We summed the total Medicare reimbursements to ROs in each HRR and compared this to the total Medicare reimbursements (part A+B) in each HRR for the year 2017, as reported by the Dartmouth Atlas group. After winsorization of the top and bottom 2% of HRRs by RO density, linear regression was used to evaluate the relationship between RO density and percentage of Medicare expenditure on RO. Modeling without a constant was used as in an HRR without an RO, there can be no RO services billed.We identified 4,533 ROs in the United States that received a total of $1.38 billion in Medicare reimbursements in 2017. This represented 0.5% of total Medicare reimbursements in 2017. There were 17.0 ROs per 100,000 Medicare enrollees in the US in 2017. On an HRR level, there was an average of 15.4 ROs per 100,000 Medicare enrollees (range 0 - 139.4, standard deviation 10.6). On linear regression, there was a positive relationship between the percentage of Medicare spending on RO and the number of ROs per 100,000 Medicare enrollees: for every additional RO per 100,000 Medicare enrollees, an additional 0.027% (95% CI = 0.025% - 0.030%; P < 0.001) of Medicare expenditures in a given HRR were spent on RO.Using density of RO by HRR as a proxy for access to care, this analysis suggests that with increasing access to care, an increasing proportion of Medicare dollars are spent on RO services at the HRR level.

Decreases in Radiation Oncology Medicare Reimbursement Over Time: Analysis by Billing Code

Decreases in Radiation Oncology Medicare Reimbursement Over Time: Analysis by Billing Code

Comprehensive analysis of trends in Medicare utilization and reimbursement in Physical Medicine & Rehabilitation: 2012 to 2017.

There is an absence of literature describing Medicare utilization by physiatrists, despite their key role in treating Medicare enrollees with qualifying disabilities and common neuromusculoskeletal conditions. To analyze Medicare data regarding physiatrists and their beneficiaries, services, and reimbursement, as well as trends in utilization and geographic distribution. Retrospective analysis of publicly available Centers for Medicare & Medicaid Services data for Medicare beneficiaries receiving physiatric services from 2012 to 2017. After adjustment for inflation, variables assessed for changes over time included provider and beneficiary demographics, total Medicare reimbursement, and the number of services provided, subsequently separated by drug and medical service metrics. Lorenz curves and Gini coefficients were computed to study reimbursement inequality. Choropleth maps were generated to assess geographic differences in physician density and reimbursement, both by state and ZIP code. The number of physiatrists utilizing Medicare increased from 7230 to 7895 from 2012 to 2017, whereas the average number of unique beneficiaries per clinician remained constant (307 vs. 310; p=.51). The beneficiaries' mean hierarchical conditions category (HCC) health risk score, normalized to 1.0 for the average beneficiary, increased significantly from 2012 to 2017 (1.72 vs. 1.80; p < .01). The mean Medicare reimbursement per physiatrist decreased significantly from 2012 to 2017 ($131,960 vs. $117,623; p < .001), whereas the mean number of services remained constant (3243 vs. 3077; p=.132). Botulinum toxin and baclofen injections were the two most reimbursed drug-related services. Gini coefficients ranged from 0.52 to 0.53 for 2012 to 2017, suggesting moderate reimbursement inequality, with the 75th percentile receiving on average two times the median. Both physician density and top earners were concentrated in urban and metropolitan areas. Despite rising health care costs and the increasing medical complexity of physiatrists' beneficiaries, Medicare payments have decreased over time. These trends are relevant to both providers and policymakers, particularly in light of unequal geographic distribution of physiatrists across the country.

PD03-08 THE INTRODUCTION AND UPTAKE OF UROLIFT: A STUDY OF INDUSTRY PAYMENTS AND REIMBURSEMENT PATTERNS (2015-2018)

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making I (PD03)1 Sep 2021PD03-08 THE INTRODUCTION AND UPTAKE OF UROLIFT: A STUDY OF INDUSTRY PAYMENTS AND REIMBURSEMENT PATTERNS (2015-2018) Evan Garden, Nir Tomer, Micah Levy, Devki Shukla, Alexander Small, and Michael Palese Evan GardenEvan Garden More articles by this author , Nir TomerNir Tomer More articles by this author , Micah LevyMicah Levy More articles by this author , Devki ShuklaDevki Shukla More articles by this author , Alexander SmallAlexander Small More articles by this author , and Michael PaleseMichael Palese More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001967.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostatic urethral lift (UroLift, NeoTract Inc., Pleasanton, CA) is a minimally invasive procedure for benign prostatic hyperplasia (BPH). It was approved in 2013 and utilization has since increased dramatically. We sought to describe UroLift’s uptake and to explore any relationship between industry payments from NeoTract to physicians with rates of UroLift utilization. METHODS: Using the CMS Provider Utilization and Payment Database (2015-2018), all UroLift cases were identified for providers who performed >10 procedures annually (CPT Codes 52441, 52442). Providers who performed <10 of procedures are excluded from the database. These data were merged with Sunshine Act-reported payment data from NeoTract for each physician over the same interval. Differences in case volume and total Medicare reimbursement were evaluated based on receipt of payments. Spearman's rank correlation was used to test for association between payment amount and annual case volume. RESULTS: Medicare spending for UroLift increased more than 28-fold (2015-2018: $777,742.83 to $22,118,346.10), while mean annual reimbursement for providers rose by 11.6% (2015-2018: $33,814.91 to $37,744.62). For the 1,168 providers included, median industry payment was $243.50 (IQR: $45-$1,173). 171 providers received no payment. On average, this group performed fewer cases compared to providers who received industry payments (18.49 vs. 22.86, p<0.001). They also had lower annual reimbursement totals ($20,815.64 vs. $41,251.12, p<0.001). The fraction of providers who received no payment increased yearly (2015-2018: 4.35% to 16.55%). There was a small-but-significant correlation between industry payment amount and annual total Medicare reimbursement (R = 0.254, p<0.01) (Figure 1). CONCLUSIONS: Since its introduction, UroLift has seen a rapid uptake among urologists. Physician utilization of UroLift correlated positively with Sunshine Act-reported industry payments in a small-but-significant way. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e45-e46 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Evan Garden More articles by this author Nir Tomer More articles by this author Micah Levy More articles by this author Devki Shukla More articles by this author Alexander Small More articles by this author Michael Palese More articles by this author Expand All Advertisement Loading ...

Medicare Physician Fee Reimbursement for Revision Total Knee Arthroplasty Has Not Kept Up with Inflation from 2002 to 2019.

As orthopaedic physician fees continue to come under scrutiny by the U.S. Centers for Medicare & Medicaid Services (CMS), there is a continued need to evaluate trends in reimbursement rates across contemporary time intervals. Although substantially lower work relative value units (RVUs) have been previously demonstrated for septic revision total knee arthroplasty (TKA) compared with aseptic revisions, to our knowledge, there has been no corresponding analysis comparing total physician fees. Therefore, the purpose of our study was to analyze temporal trends in Medicare physician fees for septic and aseptic revision TKAs. Current Procedural Terminology (CPT) codes related to septic 1-stage and 2-stage revision TKAs and aseptic revision TKAs were categorized. From 2002 to 2019, the facility rates of physician fees associated with each CPT code were obtained from the CMS Physician Fee Schedule Look-Up Tool. Monetary data from Medicare Administrative Contractors at 85 locations were used to calculate nationally representative means. All total physician fee values were adjusted for inflation and were translated to 2019 U.S. dollars using Consumer Price Index data from the U.S. Bureau of Labor Statistics. Cumulative annual percentage changes and compound annual growth rates (CAGRs) were computed utilizing adjusted physician fee data. After adjusting for inflation, the total mean Medicare reimbursement (and standard deviation) for aseptic revision TKA decreased 24.83% ± 3.65% for 2-component revision and 24.21% ± 3.68% for 1-component revision. The mean septic revision TKA total Medicare reimbursement declined 23.29% ± 3.73% for explantation and 33.47% ± 3.24% for reimplantation. Both the dollar amount (p < 0.0001) and the percentage (p < 0.0001) of the total Medicare reimbursement decline for septic revision TKA were significantly greater than the decline for aseptic revision TKA. Septic revision TKAs have been devalued at a rate greater than their aseptic counterparts over the past 2 decades. Coupled with our findings, the increased resource utilization of septic revision TKAs may result in financial barriers for physicians and subsequently may reduce access to care for patients with periprosthetic joint infections. The devaluation of revision TKAs may result in reduced patient access to infection management at facilities unable to bear the financial burden of these procedures.

Salary Disparities in Academic Urogynecology: Despite Increased Transparency, Men Still Earn More Than Women.

To understand the compensation differences between male and female academic urogynecologists at public institutions. Urogynecologists at public universities with publicly available salary data as of June 2019 were eligible for the study. We collected characteristics, including sex, additional advanced degrees, years of training, board certification, leadership roles, number of authored scientific publications, and total National Institutes of Health funding projects and number of registered clinical trials for which the physician was a principal or co-investigator. We also collected total number of Medicare beneficiaries treated and total Medicare reimbursement as reported by the Centers for Medicare & Medicaid Services. We used linear regression to adjust for potential confounders. We identified 85 academic urogynecologists at 29 public state academic institutions with available salary data eligible for inclusion in the study. Males were more likely to be an associate or a full professor (81%) compared with females (55%) and were more likely to serve as department chair, vice chair, or division director (59%) compared with females (30%). The mean annual salary was significantly higher among males ($323,227 ± $97,338) than females ($268,990 ± $72,311, P = 0.004). After adjusting for academic rank and leadership roles and years since residency, the discrepancy persisted, with females compensated on average $37,955 less annually. Salaries are higher for male urogynecologists than female urogynecologists, even when accounting for variables such as academic rank and leadership roles. Physician compensation is complex; the differences observed may be due to variables that are not captured in this study. Nevertheless, the magnitude of disparity found in our study warrants further critical assessment of potential biases within the field.

Supporting Caring Efficacy in Nurses through Standardization of Communication

Background: Patient satisfaction scores are one of the measurements of performance and quality of care. Hospitals are facing up to two percent reward or penalty of their total Medicare reimbursement based on the results of clinical processes and patient experience measures. Local Problem: The staff addressed the lack of standardized care experience behaviors to facilitate and enhance nurse communication. Methods: Lewin’s change theory is the theoretical framework used for this project. Intervention: Behavior standards were developed and implemented on a 50-bed medical-surgical unit from August25 to November25, 2020, to support caring efficacy in nurses through standardization of communication. Results: Forty-eight nurses participated in this quality improvement project. A statistically significant difference was found between the pre-and post-Caring Efficacy Scale (CES) scores after the implementation of the behavior standard sp &lt; .0001 (p = 3.8475E-10). Conclusion: The use of standardized behavior standards was an effective intervention to improve the nursing communication process. The intervention can be easily replicated and sustained in a strategic care experience program, while ensuring better patient outcomes and strategically improving nurse and patient satisfaction. Key Words: Behavior Standards; HCAHPS Scores; Nursing Communication; Patient Satisfaction

Clinical utility of 18F-FDG-PET/CT in staging localized breast cancer prior to initiating preoperative systemic therapy.

563 Background: 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET/CT) is recommended as an optional study in current National Comprehensive Cancer Network (NCCN) guidelines after computerized tomography and bone scan (CTBS) in patients with stage IIA-IIIC breast cancer. We evaluated our experience with use of PET/CT in this setting prior to beginning primary systemic therapy (PST) before planned surgery. Methods: We performed medical record abstractions to identify all adult female patients with clinical stage IIA to IIIC breast cancer diagnosed at Montefiore Medical Center from January 1, 2014 to January 1, 2019 who underwent PET/CT. We calculated the proportion of patients upstaged after PET/CT, stratified by their initial clinical stages and use of PST, and examined the cost and radiation exposure associated with PET/CT compared with CTBS. Results: 227 patients with 230 breast cancers (bilateral disease in 3) met the study inclusion criteria. PET/CT was the only staging done in 195 patients (86%); 32 patients had PET/CT based on suspicious findings from prior CTBS. Among these 195 patients with 196 breast cancers (bilateral disease in 1) that had PET/CT as the only staging done, the overall upstaging rate for regional nodal and/or distant metastasis was 37% (73/196), including 24% for stage IIA (9/38), 39% for IIB (31/79), 54% for IIIA (22/41), 27% for IIIB (8/30), and 37% for IIIC (3/8). The overall upstaging rate to stage IV was 14% (27/196), including 0% for stage IIA, 13% for IIB (10/79), 22% for IIIA (9/41), 17% for IIIB (5/30), and 37% for IIIC (3/8). The sensitivity and specificity of PET/CT in detecting distant metastasis was 100% and 94%, respectively. Our institution's total Medicare reimbursement rate of PET/CT is $1604.37 whereas CTBS is $1679.94. Radiation dose for PET/CT is 14 mSv whereas CTBS is 21 mSv. Conclusions: Approximately 37% of patients with clinical stage IIA-IIIC breast cancer who underwent PET/CT prior to PST showed more extensive disease, including 23% with more extensive regional nodal metastases and 14% with distant metastasis. Given the high detection rate, comparable cost, lower radiation dose and greater convenience, PET/CT should be considered as an alternative to CTBS rather than “optional” after CTBS, especially in patients who require an efficient and expeditious work up prior to initiating PST.

PUK7 THE EFFECT OF PRETRANSPLANT DIALYSIS MODALITIES ON POSTTRANSPLANT HEALTH SERVICES UTILIZATION AND MEDICARE REIMBURSEMENT: A PROPENSITY-MATCHED COMPARISON

Medicare total expenditure on End-stage renal disease (ESRD) in 2015 was estimated to be $33.9 billion accounting for more than 7% of total Medicare expenditure. To our knowledge, no previous propensity score-matched study was conducted to compare the effect of pretransplant dialysis modalities no posttransplant healthcare services utilization and Medicare expenditure. To compare post-TX healthcare services utilization and Medicare reimbursement between pretransplant peritoneal and hemodialysis for adults with ESRD in the US. A propensity-matched retrospective study of renal recipients between January 2007 and December 2011, following ≥60 days of maintenance dialysis. All the data were obtained from the USRDS for the period 2006 to 2012. Adults who received either kidney or kidney/pancreas, with ≥6 months of pre-TX history were included. Patients with other organ transplants, two or more prior renal TXs, and missing data were excluded. Per-person-per-year (PPPY) and mean differences (M-Diff.) were calculated using multivariate regression analyses models. All the dollar values were adjusted to the 2018 inflation rate. A total of 19,612 renal recipients (9,806 pairs) were included. No difference in follow-up (HD=36.51 vs PD=36.08 months, p-value =0.0807). Nearly, 50% of recipients had 2-18 months of pretransplant dialysis. The 6-year total Medicare reimbursement for healthcare services use was $1.728 billion. Inpatient services accounted for 42%; physician fees, 30%; prescription medications, 12%; outpatient visits, 10%; and dialysis sessions, around 4%. Patients in the HD group had significantly higher PPPY number of and reimbursement on medications, inpatient events, and number of and reimbursement on home health visits. The PPPY total Medicare expenditure indicated that each HD recipient imposes a significantly higher total expenditure (M-Diff. =$1,134.50, p-value <.0001) compared to PD recipients. Our findings indicated that hemodialysis recipients’ utilization of and reimbursement on healthcare services impose a significant expense to Medicare compare to peritoneal dialysis patients.