A Medicare Physician Fee Schedule Analysis of Reimbursement Trends in Laryngology from 2000 to 2021

OBJECTIVE

The purpose of this study is to characterize Medicare reimbursement trends for laryngology procedures over the last two decades.

METHODS

This analysis used CMS' Physician Fee Schedule (PFS) Look-Up Tool to determine the reimbursement rate of 48 common laryngology procedures, which were divided into four groups based on their practice setting and clinical use: office-based, airway, voice disorders, and dysphagia. The PFS reports the physician service reimbursement for "facilities" and global reimbursement for "non-facilities". The annual reimbursement rate for each procedure was averaged across all localities and adjusted for inflation. The compound annual growth rate (CAGR) of each procedure's reimbursement was determined, and a weighted average of the CAGR for each group of procedures was calculated using each procedure's 2020 Medicare Part B utilization.

RESULTS

Reimbursement for laryngology procedure (CPT) codes has declined over the last two decades. In facilities, the weighted average CAGR for office-based procedures was -2.0%, for airway procedures was -2.2%, for voice disorders procedures was -1.4%, and for dysphagia procedures was -1.7%. In non-facilities, the weighted average CAGR for office-based procedures was -0.9%. The procedures in the other procedure groups did not have a corresponding non-facility reimbursement rate.

CONCLUSION

Like other otolaryngology subspecialties, inflation-adjusted reimbursements for common laryngology procedures have decreased substantially over the past two decades. Because of the large number of physician participants and patient enrollees in the Medicare programs, increased awareness and further research into the implications of these trends on patient care is necessary to ensure quality in the delivery of laryngology care.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:247-256, 2024.

Geospatial Distribution of Ambulatory Surgery Center Utilization for Otorhinolaryngologic Surgeries Among Medicare Patients From 2015 to 2019

Objective

To investigate the geographic clustering of ambulatory surgical center (ASC) utilization in otolaryngology to determine hot spot areas of high utilization and cold spot areas of low utilization and socioeconomic factors that correlate with these hot spots and cold spots.

Study Design

To develop a national epidemiologic study of ASC utilization in otolaryngology in the United States.

Setting

United States of America.

Methods

Multiple county-level national databases were reviewed including Center for Medicare Services (CMS) physician billing data, CMS Medicare demographic data, and US Census socioeconomic data. The analysis was conducted using the average of all Medicare billing information from 2015 to 2019. Whether a procedure was performed in an ASC was extracted from CMS data using the CMS definition of an ASC. The percentage ASC billing was calculated as the fraction of CMS payments that were performed in ASCs for the top ENT procedures. A Python-based script for database building and GeoDa, Moran's I clustering coefficient, and a 1-way analysis of variance was utilized to chart and analyze demographic, geographic, and socioeconomic trends.

Results

Hot spots of utilization, with an average ASC billing of 80.13%, were seen in Southern California, Florida, Mid-Atlantic, and clusters throughout the Deep South. Cold spot clusters, with an average ASC billing of 2.21%, were located in large swaths of New England, Ohio, and the Deep South with clusters bisecting the Midwest. Cold spots had a higher percentage of poverty and percent eligible for Medicaid.

Conclusion

ASC utilization is best used to improve cost-effectiveness and accessibility of care but what is seen is that ASC use is currently highest in cities in coastal areas which already have high levels of care access and are making the most proportional money compared to their rural counterparts.

Geriatric otorhinolaryngology: reasons for outpatient referrals from generalists to ENT specialists

PURPOSE

To determine the main symptoms leading to referral of geriatric patients from primary care to otorhinolaryngology.

METHODS

 Retrospective, observational study performed on patients aged 65 and older, referred from Primary Care to the Otorhinolaryngology and Head and Neck Surgery department of a tertiary centre during 2019 and 2020. Symptoms leading to otorhinolaryngological referral were categorized as "Oto-neurological symptoms", "Nasal symptoms", "Pharyngolaryngeal symptoms", "Other Head and Neck symptoms" and "Other Reasons". Data regarding age, gender and whether patients maintain follow-up or have been discharged was also collected.

RESULTS

 The study population included a total of 1304 patients (697 female; 607 male). Oto-neurological symptoms were found to be the most prevalent symptoms, with 65% of patients reporting oto-neurological symptoms as at least one of the reasons for referral. Hearing loss was the most commonly reported symptom, with an association found between this symptom and age (p < 0.001). Results also showed an association between the female gender and vertigo/dizziness (p < 0.001) and tinnitus (p = 0.007). An association between the male gender and nasal symptoms was also found (p = 0.018), particularly nasal obstruction (p = 0.003) and epistaxis (p = 0.028). No statistically significant associations were found among the pharyngolaryngeal group.

CONCLUSIONS

 This retrospective observational study allowed for a better understanding of the type of otorhinolaryngological symptoms affecting elderly patients and driving otorhinolaryngology evaluation, cementing hearing loss as one of the major complaints among older adults and allowing for a better preparation by otorhinolaryngologists for the changing needs of this subset of the population.

Frailty Is Superior to Age for Predicting Readmission, Prolonged Length of Stay, and Wound Infection in Elective Otology Procedures

OBJECTIVE

To determine the predictive ability of the 5-point modified frailty index relative to age in elective otology patients.

STUDY DESIGN

Retrospective database analysis.

SETTING

Multicenter, national database of surgical patients.

PATIENTS

We selected all elective surgical patients who received tympanoplasty, tympanomastoidectomy, mastoidectomy, revision mastoidectomy, and cochlear implant procedures from 2016 to 2019 from the National Surgical Quality Improvement database.

INTERVENTIONS

Therapeutic.

MAIN OUTCOME MEASURES

Readmission rates, discharge disposition, reoperation rates, and extended length of hospital stay.

RESULTS

Utilizing receiver operating characteristics with area under the curve (AUC) analysis, nonrobust status was determined to be a superior predictor relative to age of readmission (AUC = 0.628 [p < 0.001] versus AUC = 0.567 [p = 0.047], respectively) and open wound infection relative to age (AUC = 0.636 [p = 0.024] versus AUC = 0.619 [p = 0.048], respectively). Nonrobust otology patients were more likely to have dyspnea at rest and an American Society of Anesthesiology score higher than 2 before surgery (odds ratios, 13.304 [95% confidence interval, 2.947-60.056; p < 0.001] and 7.841 [95% confidence interval, 7.064-8.704; p < 0.001], respectively).

CONCLUSION

Nonrobust status was found to be a useful predictor of readmission and prolonged length of stay in patients undergoing elective otology procedures, which generally have low complication rate. Given the aging population and corresponding increase in otology disease, it is important to use age-independent risk stratification measures. Frailty may provide a useful risk stratification tool to select surgical candidates within the aging population.

An Analysis of Otolaryngology's NIH Research Funding Compared to Other Specialties

OBJECTIVE

To compare NIH funding in the field of Otolaryngology to other medical and surgical specialties between 2009 and 2019.

METHODS

Data was collected from the NIH RePORTER database on funding dollars received by each specialty from 2009 to 2019. Along with data on total active physicians per specialty using the Physician Specialty Data Book, comparisons were drawn between Otolaryngology and other medical and surgical specialties with regards to trends in total funding and NIH funding dollars per physician. The distributions of grant funding, within Otolaryngology from various NIH institutes among principal investigators, organizations, and subspecialties were further explored.

RESULTS

There were 3810 grants (1147 unique projects) for a total of $1 276 198 555 funded by the NIH to Otolaryngology departments from 2009 to 2019. Statistically insignificant funding increases (P > .05) caused otolaryngology to fall from first to fourth in funding among studied specialties. The National Institute on Deafness and Other Communication Disorders funded 57% of all unique projects, and 57.2% of all unique NIH projects were otology related. Most projects were basic science related. The top 10 principal investigators obtained 22.3% of the total NIH funding for Otolaryngology. The top 3 organizations over the studied period comprised 26.55% of the total funding, generating a combined 729 grants. Among principal investigators, 63.0% had a PhD degree, 25.3% had an MD, and 9.6% had an MD/PhD.

CONCLUSION AND RELEVANCE

NIH funding in Otolaryngology has remained stable and is highly concentrated among a small number of organizations, geographic regions, and principal investigators. Recent initiatives by academic communities have sought to address funding disparities by incorporating diversity and inclusion into clinician-scientist pipelines. We urge our colleagues to strive toward identification of the factors that contribute to successful acquisition of funding and implementation of a more conducive institutional infrastructure to produce research.

Rhinology Medicare reimbursements have not been keeping up with inflation

BACKGROUND

Studies have suggested that physicians are steadily being paid less per Medicare service over time based on inflation-adjusted dollars. The objective of this study was to determine whether this phenomenon was true for rhinologic procedures.

METHODS

This study was a retrospective analysis of the 2000-2021 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule investigating fees for in-office endoscopies (Current Procedural Terminology [CPT] codes 31231-31238), in-office balloon ostial dilation (CPTs 31295-31298), in-facility low-relative value unit (RVU) surgeries (<10 work RVUs [wRVUs]; CPTs 31239-31288 and 61782), and in-facility high-RVU surgeries (>10 wRVUs; CPTs 31290-31294). Total number of and reimbursements for these services was obtained from yearly National Part B Summary Datafiles.

RESULTS

Between 2000 and 2021, adjusted reimbursements for low- and high-wRVU rhinologic surgeries decreased by 50.0% and 36.1%, respectively. The average compound annual growth rate (CAGR) decrease was 3.3% and 2.1%, respectively. Excluding a 48.3% unadjusted reimbursement increase between 2000 and 2004, endoscopies saw an adjusted reimbursement decrease of 29.4% from 2004 onward, an average CAGR of -2.1%. From 2011 onward, balloon ostial dilations saw a decrease in adjusted reimbursement of 43.8%, an average CAGR of -6.0%. Nevertheless, after inflation adjustment, National Part B data reveal that Medicare paid more, in total, for these procedures in 2019 than in 2000 due to increasing utilization.

CONCLUSION

Medicare reimbursements are complex, adjusted yearly, and undergo constant federal scrutiny due to the increasing costs of health care. These results suggest that, in terms of real dollars, rhinologic procedures have seen a large gradual decrease in Medicare reimbursement, which is important information for policymakers and surgeons alike.

Trends in Medicare Reimbursement for Otology Procedures From 2000 to 2020

OBJECTIVE

The purpose of this study is to investigate the Medicare reimbursement trends for otologic procedures from 2000 to 2020.

STUDY DESIGN

Retrospective data analysis using the Physician Fee Schedule Look-Up tool from the Centers for Medicare and Medicaid services.

SETTING

Facility performed procedures of the auditory system.

PATIENTS

Medicare beneficiaries from 2000 to 2020.

INTERVENTIONS

Selected otologic current procedural terminology codes and their respective year-to-year reimbursement data.

MAIN OUTCOME MEASURES

Assessment of trends in financial reimbursement.

RESULTS

After adjusting for inflation, the total average reimbursement for all procedures saw an average decrease of -21.2% from 2000 to 2020. The average adjusted percent change per year was -1.3% indicating a slow decline in reimbursement over the study period. There was a difference between the adjusted and unadjusted percent change in reimbursement rate during the study period (-21% versus 20.4%, respectively; p < 0.001). Linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2000 to 2020 with an R-squared value of 0.85 indicating a decline in reimbursement over time.

CONCLUSIONS

After adjusting all data for inflation, there has been a reduction in the average Medicare reimbursement for otology procedures from 2000 to 2020. Compared with previous reimbursement studies on the whole field of otolaryngology, otology has a less severe decline in reimbursement. Knowledge of these reimbursement trends is critical for otologic surgeons and leaders within the field to develop more sustainable reimbursement plans.

Unique Challenges for Otolaryngology Patients During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has drastically altered health care delivery and utilization. The field of otolaryngology in particular has faced distinct challenges and an increased risk of transmission as day-to-day procedures involve intimate contact with a highly infectious upper respiratory mucosa. While the difficulties for physicians have been thoroughly discussed, the unique challenges of patients have yet to be considered. In this article, we present challenges for patients of otolaryngology that warrant thoughtful consideration and propose solutions to address these challenges to maintain patient-centered care both during and in the aftermath of the COVID-19 pandemic.

Medicare Reimbursement Trends for Facility Performed Otolaryngology Procedures: 2000-2019

OBJECTIVE

There is a paucity of data regarding financial trends for procedural reimbursements in otolaryngology. The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for the 20 most commonly billed otolaryngology procedures from 2000 to 2019.

STUDY DESIGN

Analysis of physician reimbursement.

METHODS

The American Academy of Otolaryngology-Head and Neck Surgery database was queried to determine the 20 most performed otolaryngology procedures. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services was utilized to assess each of the top 20 most utilized Current Procedural Terminology (CPT) codes in otolaryngology, and reimbursement data was extracted. All monetary data was adjusted for inflation to 2019 U.S. dollars using changes to consumer price index. Average annual and total percentage change in reimbursement were calculated based on adjusted values for all included procedures.

RESULTS

After adjusting for inflation, the average reimbursement for the total 20 procedures decreased by 37.63% from 2000 to 2019. The greatest single mean decrease was seen in CPT code 61782 for stereotaxis procedures on the skull, meninges, and brain (-59.96%), whereas the smallest mean decrease was in CPT code 30520 for septoplasty (-1.50%). From 2000 to 2019, the adjusted reimbursement rate for the combined procedures decreased by an average of 2.33% each year.

CONCLUSION

Medicare reimbursement for included procedures has decreased from 2000 to 2019. Increased awareness and consideration of these trends will be important for policy makers, hospitals, and surgeons in order to assure continued access to meaningful otolaryngology care in the United States.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:496-501, 2021.

Presentation and Outcomes of Elderly Patients Undergoing Head and Neck Surgeries: A National Perspective

Objectives

To examine clinical profile and outcomes of elderly patients (65-90 years) undergoing head and neck surgeries in the United States.

Study Design

A retrospective cross-sectional analysis.

Setting

The Nationwide Readmissions Database, 2010 to 2015.

Subjects and Methods

Adult (≥18 years) patients who underwent head and neck surgeries. Analysis included χ2 test and logistic analysis.

Results

A total of 113,602 and 32,580 patients <65 and ≥65 years old, respectively, were included. Patients ≥65 years old were more likely to have multiple comorbidities (62.8% vs 32.6%, P < .001) and to present with head and neck cancer (19.8% vs 11.4%, P < .001). The most common comorbidity was diabetes (21.0%). The most common cancer types by site were mouth (29.12%), thyroid (28.08%), and nonmelanoma skin cancer (13.22%). The percentage of geriatric patients who underwent head and neck surgeries increased from 21.8% in 2010 to 25.0% in 2015 ( P < .001). A total of 5450 (16.85%) patients developed postoperative complications, and the most common complications were pulmonary related (10.55%), bleeding (6.96%), acute renal failure (6.01%), and infection (3.97%). Blood transfusion was required in 3.53% of the patients. Readmission prevalence was 0.32%, and mortality risk was twice as likely (odds ratio, 2.05; 95% confidence interval, 1.77-2.38; P < .001). Independent risk factors of mortality were older age, multiple comorbidities, type of surgery, blood transfusion, and tracheostomy ( P < .05, each).

Conclusion

Elderly patients currently represent 25% of patients admitted for head and neck surgery. This population should be provided with a different level of care due to a higher risk of complications and mortality.

Is type 1 tympanoplasty effective in elderly patients? Comparison of fascia and perichondrium grafts

Background: Tympanoplasty is regularly performed in various ages but data about the procedure in elderly is insufficient. Objectives: To compare the success rates and hearing outcomes of fascia and perichondrium grafts used for tympanoplasty in patients >65 years and to evaluate the prognostic factors affecting the success of tympanoplasty. Methods: Reviewing records of 49 elderly patients underwent tympanoplasty, two groups were constituted: perichondrium (25 patients) and fascia (24 patients) groups. Ages, genders, perforation sides, type and location of perforation, graft success rates, functional success rates and air-bone gap (ABG) gains were compared. Results: Overall graft success rate was 85.7%. After a mean follow-up of 23.3 ± 8.32 months, overall mean ABG gain was 11.33 ± 8.42 dB. Overall median postoperative ABG value (9 dB) was significantly lower compared to the median preoperative value (24 dB) (p < .001). Graft success rate was higher in perichondrium group (96%) compared to fascia group (75%) (p = .04). Functional success rate did not significantly differ between perichondrium (68%) and fascia groups (62.5%) (p = .68). Conclusion and significance: Tympanoplasty is an effective procedure with a graft success rate of 85.7% in elderly. Both fascia and perichondrium are suitable materials; however, perichondrium had higher success rate.

A Critical Analysis of Medicare Claims for Otolaryngology Procedures

OBJECTIVE

This study was performed to outline and analyze the overall Medicare landscape with respect to otolaryngologists and beneficiaries, services, and reimbursements.

METHODS

This is a retrospective analysis of publicly available Medicare utilization and payment data for all otolaryngologists in facility and nonfacility practice settings who provided services to Medicare beneficiaries between January 1, 2012, and December 31, 2016.

RESULTS

In 2016, a total of $701,195,375 was distributed to 8572 otolaryngology physician providers for 815 unique Healthcare Common Procedure Coding System codes for 13,942,536 procedure claims. Of specialty care, otolaryngology ranks 20th among 54 subspecialties for total Medicare payments. The average number of services coded per provider was 1627. The average otolaryngologist was paid $81,800.67. Thirty-two percent of otolaryngologists did not receive reimbursement for services from Medicare in 2016.

DISCUSSION

In 2016, the most significant contributors to Medicare payments to otolaryngologists were large-scale, low-cost events that are relatively short procedures done in clinic. Utilization of nasal endoscopy was up trending from 2012 to 2016. Some of the Current Procedural Terminology codes with the greatest discrepancies between submitted charge and Medicare payment among nonfacility otolaryngology providers are more involved than simple office procedures.

IMPLICATIONS FOR PRACTICE

It is increasingly valuable for physicians to know factors that affect reimbursement for procedures and operations in different settings and to be aware of the trends in variation in their specialty. Otolaryngologists should communicate with policy makers in efforts toward sustainable reimbursement models.

Aging in the United States: Opportunities and Challenges for Otolaryngology-Head and Neck Surgery

The number of Americans over the age of 65 has been growing much faster than the overall population's growth rate. These changes can be largely attributed to the improvement in life expectancy. This demographic shift yields a unique and exciting opportunity to provide both expedient and cost-efficient care to a growing patient population.

The admission patterns of octogenerians nonagenerians and centenarians to the Department of Otoloaryngology

Life expectancy in Israel has risen by almost 6 years during the last 25 years, and the proportion of people 65 years of age or older is expected to reach 12 % of the total population by 2020. A substantial increase in the workload for Otolaryngologists and Head and Neck surgeons is anticipated. Our goal was to characterize the admissions of patients 80 years of age and older to the Department of Otolaryngology, Head and Neck Surgery in a tertiary medical center. The study group included all patients 80 years of age and older who were admitted to the Department of OTOHNS in our institute between 2009 and 2013. There were two control groups for comparison divided by age; one group 40-59 years old and the other group 60-79 years old. There were 385 admissions of 317 patients aged 80-103 years (4.2 % of overall admissions). Over the study period, admissions of patients over 80 years increased on average by 3 % per annum (p = 0.4), and those patients over 90 years old by 52 % per annum (p < 0.001). The most common indication was HN malignancy (28.8 %) followed by otologic disorders (22.0 %). Of the overall 158 operations conducted, 131 patients (82.9 %) underwent elective procedures (mainly oncology) and 27 patients (17.1 %) underwent emergent procedures. The distribution of the reasons for admission of the patients older than 80 years is surprisingly different from that of the "younger" patients. With life expectancy rising, our study predicts a workload increase mainly in the HN oncologic and otologic services.

Why do Geriatric Patients Visit Otorhinolaryngology?

The number and proportion of people more than 65 years old in the population are increasing with the rise in life expectancy. This study was designed to investigate the otolarygologic needs and visits of geriatric patients. We conducted a retrospective study that included all patients ≥65 years of age who visited the otolaryngology department between 8 a.m. and 4 p.m. during 1 year. Age, gender, main complaint, and clinical diagnosis were noted on a chart and analyzed. In 2012, a total of 19,875 patients attended the otolaryngology department between 8 a.m. and 4 p.m., of whom 418 (2.1%) were aged ≥65 years. The most common complaints were ear and hearing disorders (24.2%), epistaxis (15.3%), balance disorders (15.1%), pharyngotonsillar pathologies (14.8%), and head and facial trauma (9.6%). This study shows that the changing patient population will change the type and frequencies of pathologies seen in general otolaryngology practices. Geriatric patients need a targeted approach to their diseases because they have special issues unique to their population.

Comparison of old (75-79 years) to very old (80+ years) hospitalized otorhinolaryngology patients

BACKGROUND

The aim was to determine the patients' characteristics, comorbidity, and inpatient treatment features of very old otorhinolaryngology patients (80+ years) compared to old patients (75-79 years).

METHODS

A single-center cohort study in a tertiary and university care center was performed with 144 old and 143 very old patients who were hospitalized in 2012. Predictors for differences between old and very old patients were analyzed univariately and multivariately using regression models.

RESULTS

Ear (30 %) and nose/paranasal sinus (23 %) diseases were the most frequent reasons for hospitalization. Baseline and disease characteristics were not different between the two groups of elderly patients. Duration of hospitalization was no longer in very old patients (p = 0.827). Mobility (p = 0.017), dietary intake (p = 0.017), and having hearing aid (p < 0.0001) were independent comorbidity predictors in very old patients compared to old patients. Polymedication was found less frequently in very old patients (p = 0.017). To take cardiovascular drugs (p = 0.009) or psychotherapeutic drugs (p = 0.045) were independent permanent medication predictors in very old patients compared to old patients. About half of the patients received a surgical treatment (52 %) and the other half a conservative treatment (48 %). The very old patients received significantly more often an antibiotic treatment (p < 0.0001). Complication rates for surgical cases and non-surgical cases were not different (p = 0.686 and p = 0.524, respectively).

CONCLUSIONS

Although comorbidity continues to increase in hospitalized very old compared to old otorhinolaryngology patients, most of the disease, treatment and treatment related complication characteristics seem not to change significantly from old to very old patients.