Total Reimbursement Research Articles

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.

Impacts of unifying urban and rural residents’ medical insurance on the hospitalisation expenses of rural patients in eastern China: an interrupted time series analysis

ObjectivesThis study evaluated the impact of the Urban and Rural Residents’ Basic Medical Insurance scheme on hospitalisation expenses of rural patients in eastern China, which unified separate healthcare systems for...

Effects of Adalimumab Entering National Reimbursement on Medical Costs for Patients With Psoriasis: A 4-Year Single-Center Retrospective Study in China

Objective: Adalimumab (ADA) is expensive and rarely used among patients. However, its cost for moderate to severe chronic plaque psoriasis can now be reimbursed since its addition to the National Reimbursement Drug List (NRDL) in January 2020. Therefore, we conducted this study to estimate the medical cost of ADA and its influencing factors in patients with psoriasis using ADA and thus gain a better understanding of the effect of the NRDL adjustment in China. Methods: This retrospective study evaluated the medical cost of ADA before and after the addition of ADA to the NRDL (2018—2022) among 320 patients in a large professional dermatology specialty hospital. Descriptive analysis, Welch’s analysis of variance, and multiple regression analysis were used to evaluate the medical cost and influencing factors. Results: Before ADA was added to the NRDL, patients’ mean total cost and ADA cost were ¥24,243.56 ± 16,346.53 and ¥20,391.11 ± 14,440.69, respectively. After ADA became covered by the NRDL, the above 2 expenses decreased to ¥10,461.19 ± 7,554.66 and ¥8,775.27 ± 7,092.16, respectively. This significant decrease in the cost of ADA resulted in a significant 110.5-times increase in ADA use. Statistically significant differences were found in the total cost, patient type (outpatient/inpatient), insurance status (yes/no), reimbursement status (before/after), and age. Medical insurance reimbursement (P < 0.001, β = -0.468, before reimbursement = 1, after reimbursement = 2) was the most significant influencing factor, followed by patient type (P = 0.018, β = -0.215, outpatient = 1, inpatient = 2) and age (P = 0.0046, β = -0.174). Conclusion: Medical insurance reimbursement is the most important factor affecting patients’ total cost of ADA by reducing the economic burden, enhancing the availability of ADA, and stimulating the need for treatment.

Patient-specific Risk Factors Increase Episode of Care Costs After Lumbar Decompression.

Retrospective cohort analysis. To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression. Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression. Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05. A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (β = $324.70, P < 0.001), comorbid depression (β = $4368.30, P = 0.037), revision procedures (β = $6538.43, P =0.012), increased hospital length of stay (per day) (β = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (β = $14,417.42, P = 0.001), incidence of a complication (β = $8178.07, P < 0.001), and readmission (β = $18,734.24, P < 0.001) within 90 days. Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.

Estimated reimbursement impact of COVID-19 on emergency physicians.

The delivery and financing of health care services were altered in unprecedented ways by COVID-19 and subsequent policy responses. We estimated reimbursement losses to emergency physicians in 2020 compared to 2019 related to shifting acute care utilization during COVID-19. This was an observational analysis of the Clinical Emergency Department Registry (CEDR) and the Nationwide Emergency Department Sample (NEDS). Study sample included all ED visits from a sample of 214 emergency department (ED) sites in the CEDR in 2019 and 2020 as well as all ED visits in the NEDS in 2019. We identified level of service billing code for evaluation and management (E&M) services, insurance payer, and geographic location of ED visits across sites in the CEDR and linked these to fee schedules to estimate total professional reimbursement across sites. Our primary analysis was to estimate reimbursement in 2020 compared to 2019 across the CEDR sites. In our secondary analysis, we linked sites in the CEDR to those in NEDS to estimate nationwide reimbursement. Total E&M reimbursement for emergency physicians in the CEDR was $1.6 billion in 2019 and $1.3 billion in 2020, reflecting a 19.7% decline year over year ($308 million loss). In our secondary analysis, we estimate nationwide losses of $6.6 billion, a -19.4% decline year over year. If emergency physicians had received maximum allowable federal relief funds via CARES Act Phases 1 to 3 (2% of 2019 revenue) this would sum to $680 million (2% of the $34 billion) or 10.3% of the estimated $6.6 billion pandemic-related losses. Our analyses provide an estimate of the scale of economic impacts of the COVID-19 pandemic. These findings warrant consideration for policymaker relief and future redesign of emergency care financing. Ultimately, the COVID-19 pandemic likely expanded known cracks in the financing of health care into steep fault lines.

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.

Gender disparities in industry compensation and research payments among neurointerventional surgeons in the USA

BackgroundThe purpose of this study is to examine the presence of gender disparity represented by industry payments and research funding within the field of interventional neuroradiology.MethodsPayment information was collected using...

Ophthalmology Operation Note Encoding with Open-Source Machine Learning and Natural Language Processing

Introduction: Accurate assignment of procedural codes has important medico-legal, academic, and economic purposes for healthcare providers. Procedural coding requires accurate documentation and exhaustive manual labour to interpret complex operation notes. Ophthalmology operation notes are highly specialised making the process time-consuming and challenging to implement. This study aimed to develop natural language processing (NLP) models trained by medical professionals to assign procedural codes based on the surgical report. The automation and accuracy of these models can reduce burden on healthcare providers and generate reimbursements that reflect the operation performed. Methods: A retrospective analysis of ophthalmological operation notes from two metropolitan hospitals over a 12-month period was conducted. Procedural codes according to the Medicare Benefits Schedule (MBS) were applied. XGBoost, decision tree, Bidirectional Encoder Representations from Transformers (BERT) and logistic regression models were developed for classification experiments. Experiments involved both multi-label and binary classification, and the best performing model was used on the holdout test dataset. Results: There were 1,000 operation notes included in the study. Following manual review, the five most common procedures were cataract surgery (374 cases), vitrectomy (298 cases), laser therapy (149 cases), trabeculectomy (56 cases), and intravitreal injections (49 cases). Across the entire dataset, current coding was correct in 53.9% of cases. The BERT model had the highest classification accuracy (88.0%) in the multi-label classification on these five procedures. The total reimbursement achieved by the machine learning algorithm was $184,689.45 ($923.45 per case) compared with the gold standard of $214,527.50 ($1,072.64 per case). Conclusion: Our study demonstrates accurate classification of ophthalmic operation notes into MBS coding categories with NLP technology. Combining human and machine-led approaches involves using NLP to screen operation notes to code procedures, with human review for further scrutiny. This technology can allow the assignment of correct MBS codes with greater accuracy. Further research and application in this area can facilitate accurate logging of unit activity, leading to reimbursements for healthcare providers. Increased accuracy of procedural coding can play an important role in training and education, study of disease epidemiology and improve research ways to optimise patient outcomes.

Are Foot & Ankle Surgeons Being Adequately Compensated for Ankle Fractures? – An Analysis of Relative Value Units

The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons – National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

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.

Assessment of Patterns of Atherectomy Use.

Background Atherectomy has become the fastest growing catheter-based peripheral vascular intervention performed in the United States, and overuse has been linked to increased reimbursement, but the patterns of use have not been well characterized. Methods and Results We used Blue Cross Blue Shield of Michigan Preferred Provider Organization and Medicare fee-for-service professional claims data from the Michigan Value Collaborative for patients undergoing office-based laboratory atherectomy in 2019 to calculate provider-specific rates of atherectomy use, reimbursement, number of vessels treated, and number of atherectomies per patient. We also calculated the rate that each provider converted a new patient visit to an endovascular procedure within 90 days. Correlations between parameters were assessed with simple linear regression. Providers completing ≥20 office-based laboratory atherectomies and ≥20 new patient evaluations during the study period were included. A total of 59 providers performing 4060 office-based laboratory atherectomies were included. Median professional reimbursement per procedure was $4671.56 (interquartile range [IQR], $2403.09-$7723.19) from Blue Cross Blue Shield of Michigan and $14 854.49 (IQR, $9414.80-$18 816.33) from Medicare, whereas total professional reimbursement from both payers ranged from $2452 to $6 880 402 per year. Median 90-day conversion rate was 5.0% (IQR, 2.5%-10.0%), whereas the median provider-level average number of vessels treated per patient was 1.20 (IQR, 1.13-1.31) and the median provider-level average number of treatments per patient was 1.38 (IQR, 1.26-1.63). Total annual reimbursement for each provider was directly correlated with new patient-procedure conversion rate (R2=0.47; P<0.001), mean number of vessels treated per patient (R2=0.31; P<0.001), and mean number of treatments per patient (R2=0.33; P<0.001). Conclusions A minority of providers perform most procedures and are reimbursed substantially more per procedure compared with most providers. Procedural conversion rate, number of vessels, and number of treatments per patient represent potential policy levers to curb overuse.

Medicare Payments to Hospitals and Physicians for Total Hip and Knee Arthroplasty Declined From 2009 to 2019

BackgroundRecent research has reported hospital payments for total hip arthroplasty (THA) and knee arthroplasty (TKA) from commercial payers to be increasing, despite increasing price pressure from the increasing scale and scope of alternative reimbursement schemes. Therefore, the primary objective of this study was to analyze the recent trends in Medicare payments to hospitals and surgeons for primary THA and TKA. MethodsThe primary data source for this study was the Medicare Provider Analysis and Review Limited Data Set (MEDPAR) for the years 2009, 2014, and 2019. A total of 331,721 patients undergoing primary elective THA and 742,476 patients undergoing primary elective TKA were included. Total Medicare payments and total hospital reimbursements, which included Medicare payments and patient copayments, were calculated. Physician fees were obtained from the Medicare physician fee schedule (MPFS) look-up tool. All financial data were inflation-adjusted. Patient comorbidities were identified as a measure of health status. The data were stratified by year and analyzed using descriptive statistics. ResultsFrom 2009 to 2019, inflation-adjusted Medicare payments declined by 11.5% and total hospital reimbursements (Medicare payments plus copayments) declined by 6.5% for THA, while Medicare payments declined by 13.4%, and total hospital reimbursements declined by 7.7% for TKA. Over the same period, surgeons’ fees declined by 13.1% for THA and 18.9% for TKA. ConclusionFrom 2009 to 2019, Medicare payments to hospitals and physicians declined markedly. Physician payments decreased faster than hospital payments. These results may have implications for the future viability of performing THA and TKA on Medicare patients.

S1491 Gender Gap in Total CMS Reimbursements for Gastroenterologists: A Medicare Claims Analysis

Introduction: Despite increased demand for gastroenterology services, in 2017 only 17.6% of gastroenterologists were women. On average, physicians receive approximately 19% of their income from treating Medicare patients. The aim of this study was to evaluate the total amount of CMS reimbursements for gastroenterologists and identify any differences between male and female providers after adjusting for multiple factors previously identified to affect differences in salary. Methods: The CMS Physician and Other Supplier Public Use File (POSPUF) Database displays Part B claims organized by provider. For each unique NPI registered under “Gastroenterology” the total standardized amount reimbursed by Medicare was extracted for 2019. One univariate and one multivariate-adjusted linear regression model were used to analyze gender and CMS reimbursement. Reimbursement amounts greater than 97.5 percentile and less than 2.5 perdentile were excluded. The multivariate model evaluated gender after adjusting for region, practice setting, number of services performed, average complexity and age of Medicare beneficiaries, and physician experience. Results: For 2019, there were 2577 female and 11215 male gastroenterologists. Men had higher median total payments ($94416.28 vs $56014.14), higher median total services (1047 vs 633) and higher median unique HCPCS codes billed (39 vs 32). Men also had higher median years of experience since graduation (28 vs 17). Of the 13,792 gastroenterologists billing to Medicare in 2019, 13,500 (97.9%) had data regarding number of years of experience (2503 females, 10997 males). This subset was used for the linear regression models. The univariate unadjusted model demonstrated that female gastroenterologists received less total CMS reimbursement than their male counterparts (log b = −0.42 [−0.46 to −0.39]). After adjusting for region, practice setting, number of services performed, average complexity and age of Medicare beneficiaries, and number of years of physician experience, female gastroenterologists still received less CMS payments (log b = −0.15 [−0.18 to −0.12]). Conclusion: Much of the discussion regarding gender pay gaps can be subjective. However, even after adjustment for multiple factors, female gastroenterologists are receiving less CMS payments, which can comprise a significant portion of their annual income. Further objective data is warranted to provide a more accurate understanding of reimbursement inequity and help drive change from a national level to address gender-pay gaps.

Influence of medical comorbidity and surgical indication on total elbow arthroplasty cost of care.

Movement toward providing value-based musculoskeletal care requires understanding the cost associated with surgical care as well as the drivers of these costs. The aim of this study was to investigate the effect of common medical comorbidities and specific total elbow arthroplasty (TEA) indications on reimbursement costs throughout the 90-day TEA episode of care. The secondary aim was to identify the drivers of these costs. Administrative health claims for patients who underwent orthopedic intervention between 2010 and 2020 were queried using specific disease classification and procedural terminology codes from a commercially available national database of 53 million patients. Patients with commercial insurance were divided into various cohorts determined by different surgical indications and medical comorbidities. The reimbursement costs of the surgical encounter, 89-day postoperative period, and total 90-day period in each cohort were evaluated. The cost drivers for the 89-day postoperative period were also determined. Analyses were performed using descriptive statistics and the Kruskal-Wallis test for comparison. A total of 378 patients who underwent TEA were identified. The mean reimbursement cost of the surgical encounter ($13,393±$8314) did not differ significantly based on patient factors. The mean reimbursement cost of the 89-day postoperative period ($4232±$2343) differed significantly when stratified by surgical indication (P<.0001) or by medical comorbidity (P<.0001). The indication of rheumatoid arthritis ($4864±$1136) and the comorbidity of chronic kidney disease ($5873±$1165) had the most expensive postoperative period. In addition, the total 90-day reimbursement cost ($16,982±$4132) differed significantly when stratified by surgical indication (P=.00083) or by medical comorbidity (P<.0001), with the indication of acute fracture ($18,870±$3971) and the comorbidity of chronic pulmonary disease ($19,194±$3829) showing the highest total 90-day cost. Inpatient costs related to readmissions represented 38% of the total reimbursement cost. The overall readmission rate was 5.0%, and the mean readmission cost was $16,296. TEA reimbursements are significantly influenced by surgical indications and medical comorbidities during the postoperative period and the total 90-day episode of care. As the United States transitions to delivering value-based health care, the need for surgeons and policy makers to understand treatment costs associated with different patient-level factors will expand.

Open Debridement Alone Versus Open Debridement With Tendon Repair for Lateral Epicondylitis: A Comparison of Complications and 5-Year Reoperation Rates From a Large Insurance Database.

Background:Open debridement (OD) of the extensor carpi radialis brevis tendon, both with and without repair to the lateral epicondyle, are effective treatments for recalcitrant lateral epicondylitis. However, few comparative studies exist within the literature.Purpose:To (1) compare the 5-year reoperation rates of patients who underwent OD alone versus OD with tendon repair (ODR) and (2) identify the 90-day adverse event rates, total same-day reimbursement amounts, and national usage trends for these 2 procedures from 2010 to 2019.Study Design:Cohort study; Level of evidence, 3.Methods:The PearlDiver MUExtr database was reviewed for patients diagnosed with lateral epicondylitis who underwent OD alone and ODR or reattachment between January 2010 and December 2019. These patients were stratified into 2 cohorts: the OD cohort and ODR cohort. The 5-year reoperation rates were assessed and compared, and the incidence of 90-day postoperative complications and risk factors were identified. The number of ODs and ODRs performed each year and the mean same-day reimbursement amounts (in US$) for both procedures were assessed.Results:Overall, 41,932 lateral epicondylitis patients who underwent debridement were identified, with 17,139 OD patients and 24,793 ODR patients. There were no significant changes in the proportion of OD versus ODR procedures performed during the study period (P = .18). A significantly higher incidence of hematoma was seen after OD compared with ODR (0.19% vs 0.12%; P = .04), but ODR had a significantly lower 5-year reoperation rate than OD (2.8% vs 3.9%; P = .006), with an absolute risk reduction of 1.1% and a number needed to treat of 91. Finally, ODR ($1683.17 ± $12.15) had a higher mean same-day reimbursement than OD ($1479.05 ± $15.78) (P = .001).Conclusion:Both OD and ODR had low complication rates. The 5-year reoperation rates were low for both procedures, but they were significantly higher for OD. Over the 10-year study period, there were no significant changes in the relative percentages of OD versus ODR performed. ODR had a significantly higher mean same-day reimbursement.

Intentional Structured Opioid Monitoring Protocol: Responsible and Viable Opioid Deprescribing

INTRODUCTION Primary care providers are increasingly called to address the problem of treatment of non-malignant chronic pain with opioids, particularly in low resource areas. An Intentional Structured Opioid Management Protocol (ISOMP) is a primary care-based program shown to significantly decrease opioid burden. The development of sustainable programs that improve opioid-related outcomes is especially important in these low resource areas. METHODS A retrospective electronic health record review was conducted for financial data and billing practices for a cohort engaged in the ISOMP between 2011 and 2014. Data was analyzed for sustainability within macroscopic practice-wide and microscopic daily scopes. Further analysis was conducted on the implications of patients maintained on (Group A) and weaned from (Group B) opioids. Data was analyzed with STATA software. RESULTS ISOMP demonstrated decreased patient encounters numbers (-7.38%), increased total work relative value unit (RVU) (+7.73%), reduced no-show visits (-12.14%), and increased total reimbursement (+13.06%). Group A had fewer encounters (-6.41%) and increased work RVU (+42.95%). Group B had fewer encounters (-24.04%) but decreased work RVU (-17.56%). Significant decreases in encounters (-44.99%) and work RVUs (-47.39%) were seen after discontinuation of opioids. CONCLUSIONS Besides its previously documented opioid discontinuation rate, the ISOMP model was associated with fewer visits and better visit compli-ance. Sustainability was proven as neither global practice nor daily productivity was negatively impacted. Time-based coding for Group A offset losses seen in Group B productivity with savings directly related to speed of opioid wean

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.

Interrupted time series analysis for the impact of integrated medical insurance on direct hospitalization expense of catastrophic illness

In 2016, China initiated the merge of the urban resident basic medical insurance scheme and new rural cooperative medical scheme into one unified health insurance scheme: the urban and rural resident basic medical insurance. This study investigates the impact of integrated insurance on the direct hospitalization cost of inpatients with catastrophic illnesses. An interrupted time series analysis was conducted based on a sample of 6174 inpatients with catastrophic illness from January 2014 to December 2018. The factors surveyed included per capita total inpatient expense, out-of-pocket expense, and reimbursement ratio. Univariate analysis indicated that after the implementation of the unified urban and rural medical insurance, the reimbursed expense increased from 9398 to 13,842 Yuan (P < 0.001), average reimbursement ratio increased from 0.57 to 0.59 (P < 0.05). Expenses on both western and traditional medicines increased, although the proportion of medicine expense decreased after the integration. Interrupted time series analysis showed that per capita total inpatient expense and per capita out-of-pocket expense increased but showed a gradually decreasing trend after the integration. After the integration of urban and rural medical insurance, the average reimbursement ratio increased slightly, which had limited effect on the alleviation of patients’ financial burden. Furthermore, the integration effect on inpatient expense is offset by increased out-of-pocket medical expense due to suspected supplier-induced demand.

Utilization Trends of Total Ankle Arthroplasty and Ankle Fusion for Tibiotalar Osteoarthritis: A Nationwide Analysis of the United States Population.

Introduction: Studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) are sparse. The purpose of this study was to use a nationwide administrative claims database to compare baseline demographics between TAA and ankle arthrodesis and to determine whether patients who had a TAA have increased rates of: (1) utilization, (2) in-hospital length of stay (LOS), and (3) costs of care. Methods: PearlDiver, a nationwide claims database was queried from 2005 to December 2013 for all patients who underwent primary TAA or AF for the treatment of osteoarthritis of the ankle and foot. Baseline demographics of age, sex, geographic distribution, and the prevalence of comorbidities comprising the Elixhauser comorbidity index (ECI) were compared between patients who had TAA and AF. Linear regression was used to compare differences in utilization and in-hospital LOS between the 2 cohorts during the study interval. Annual charges and reimbursement rates for TAA were assessed during the study period. A P value less than .05 was considered to be statistically significant. Results: A total of 21 433 patients undergoing primary TAA (n = 7126) and AF (n = 14 307) were included. Patients undergoing TAA had significantly greater ECI driven by arrythmias, congestive heart failure, diabetes mellitus, electrolyte/fluid disorders, iron deficiency anemia than patients undergoing AF (P < .001). From 2005 to 2013, TAA utilization increased from 21.5% to 49.4% of procedures (P < .0001). There was reduced in-hospital LOS over the time interval for patients with TAA compared with AF (2.15 days vs. 3.11 days, P < .0001). Total ankle arthroplasty reimbursements remained stable while charges per patient increased significantly from $40 203.48 in 2005 to doubling by the end of 2013 to $86 208.59 (P < .0001). Conclusion: This study demonstrated increased use of TAA compared to AF showing decreased in-hospital LOS and increased cost of care with stagnant reimbursement rates.Level of Evidence: Level III.