Trends in Neurosurgical Practice Size: Increased Consolidation 2014-2019

The Decline of Small Practice in Colorectal Surgery: Practice Consolidation From 2015-2022

INTRODUCTION

Physicians have gravitated toward larger group practice arrangements in recent years. However, consolidation trends in colorectal surgery have yet to be well described. Our objective was to assess current trends in practice consolidation within colorectal surgery and evaluate underlying demographic trends including age, gender, and geography.

METHODS

We performed a retrospective cross-sectional study using the Center for Medicare Services National Downloadable File from 2015 to 2022. Colorectal surgeons were categorized by practice size and by region, gender, and age.

RESULTS

From 2015 to 2022, the number of colorectal surgeons in the United States increased from 1369 to 1621 (+18.4%), while the practices with which they were affiliated remained relatively stable (693-721, +4.0%). The proportion of colorectal surgeons in groups of 1-2 members fell from 18.9% to 10.7%. Conversely, those in groups of 500+ members grew from 26.5% to 45.2% (linear trend P < 0.001). The midwest region demonstrated the highest degree of consolidation. Affiliations with group practices of 500+ members saw large increases from both female and male surgeons (+148.9% and +86.9%, respectively). New surgeons joining the field since 2015 overwhelmingly practice in larger groups (5.3% in groups of 1-2, 50.1% in groups of 500+).

CONCLUSIONS

Colorectal surgeons are shifting toward larger practice affiliations. Although this change is happening across all demographic groups, it appears unevenly distributed across geography, gender, and age. New surgeons are preferentially joining large group practices.

The Risks and Benefits of Physician Practice Acquisition and Consolidation: A Narrative Review of Peer-Reviewed Publications Between 2009 and 2022 in the United States

The objective of this narrative review was to assess current literature regarding acquisition and consolidation of physician practices in the United States (US). The acquisition and consolidation of physician practices is a trend affecting patient care, quality of services, healthcare economics and the daily practice of physicians. As practices are acquired by fellow physician groups, private equity investors and entities such as hospitals or large healthcare systems, it is important to better understand the underlying forces driving these transactions and their effects. This is a narrative review of peer-reviewed publications to determine what current literature has covered regarding the acquisition and consolidation of physician practices in the US regarding risks and benefits of this trend. Sources included the SCOPUS, Medline- PUBMED and Web of Science databases. Peer reviewed publications from 2009 to 2022 were included for initial review and curation for relevance using the search terms "physician" and "practice" with either "acquisition" or "consolidation". Synthesis conducted after narrowing down of relevant articles did not use quantitative measurements, but instead examined overall trends, as well as risk and benefits of ongoing acquisition and consolidation in a narrative format. Journal articles focused on physician consolidation in the US often reported increases in physician numbers with decreases in numbers of individual practices. Private equity quantitative analyses reported rapidly accelerating acquisitions driven by these investors, and vertical integration scholarly work reported frequent geographic consolidation of nearby practitioners. Risks associated with these transactions included such items as decreased physician autonomy and higher cost of care. Benefits included practice stability, improved negotiation with insurers and improved access to resources.

Trends in Medicare Reimbursements for Commonly Performed Laryngeal Procedures from 2000 to 2021

OBJECTIVE

Numerous studies among different specialties have suggested that inflation-adjusted Medicare reimbursements have steadily declined in the last few decades. The objective of this study is to investigate whether this is true within the field of laryngology.

STUDY DESIGN

Retrospective Cross-Sectional Study.

SETTING

Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule.

METHODS

2000-2021 fees for laryngeal surgeries (Current Procedural Terminology [CPT] codes 31530, 31531, 31535, 31536, 31540, 31541, 31545, 31546, 31551-31554, 31560, 31561, 31570), and laryngectomies (CPTs 31360, 31365, 31367, 31368, 31370, 31375, 31380, 31382, 31390, 31395) were gathered. United States consumer price index (CPI) was used to adjust all gathered data for inflation to 2021 US dollars.

RESULTS

During the study period, unadjusted reimbursement for non-facility and facility laryngeal surgeries decreased an average of 6.1% and 6.6%, respectively. When adjusting for inflation, non-facility and facility laryngeal surgeries saw an average decrease of 17.8% (p < 0.001) and 28.5% (p < 0.001), respectively. Unadjusted reimbursement for facility laryngectomies saw an average increase of 40.2%, correlating to an inflation-adjusted decline of 8.9% (p < 0.001). Among laryngeal procedures overall, there was an average nominal increase of 17.0%, correlating to a 20.3% inflation-adjusted decline.

CONCLUSION

In terms of inflation-adjusted dollars, reimbursements for laryngeal procedures have seen a large decrease in the last two decades. Understanding reimbursement trends is critical for sustainability of otolaryngology practices, and can be used by surgeons, hospital systems, and policymakers to guide future healthcare legislation.

Consolidation trends in vascular surgery

BACKGROUND

Practice consolidation by vertical and horizontal integration is a growing trend in surgery. Practice consolidation has not been previously examined in vascular surgery.

METHODS

The Medicare Provider Enrollment, Chain, and Ownership System data were used to identify vascular providers and vascular surgery practices in the United States in 2015 and 2020. Practices were categorized as solo (1 surgeon), small (2), medium (3-5), and large (≥6). The number of providers and the number of practices in each size group were determined. The Hirfendahl-Hirshman index (HHI), a measure of market consolidation, was calculated. Provider count, practice size, and HHI were additionally analyzed by urban and rural regions. All values were calculated for each time point and compared.

RESULTS

Vascular providers increased in number from 2929 to 3154 (7.7%) from 2015 to 2020. The number of practices decreased from 1351 to 1090 (19.3%). The number of large practices increased by 49.4%; the number of small or solo practices decreased by 42.1%. The mean HHI increased from 0.486 in 2015 to 0.498 in 2020. Both urban and rural regions had a decrease in solo practices (43.3% and 2.3%, respectively) and an increase in HHI (from 0.499 to 0.509 and 0.793 to 0.818, respectively). All changes were statistically significant.

CONCLUSIONS

From 2015 to 2020, there is a trend toward vascular providers working in larger practice groups and a corresponding increase in measures of market consolidation.

Temporal trends in neurosurgical volume and length of stay in a public healthcare system: A decade in review with a focus on the COVID-19 pandemic

Background

Over the past decade, neurosurgical interventions have experienced changes in operative frequency and postoperative length of stay (LOS), with the recent COVID-19 pandemic significantly impacting these metrics. Evaluating these trends in a tertiary National Health Service center provides insights into the impact of surgical practices and health policy on LOS and is essential for optimizing healthcare management decisions.

Methods

This was a single tertiary center retrospective case series analysis of neurosurgical procedures from 2012 to 2022. Factors including procedure type, admission urgency, and LOS were extracted from a prospectively maintained database. Six subspecialties were analyzed: Spine, Neuro-oncology, Skull base (SB), Functional, Cerebrospinal fluid (CSF), and Peripheral nerve (PN). Mann-Kendall temporal trend test and exploratory data analysis were performed.

Results

19,237 elective and day case operations were analyzed. Of the 6 sub-specialties, spine, neuro-oncology, SB, and CSF procedures all showed a significant trend toward decreasing frequency. A shift toward day case over elective procedures was evident, especially in spine (P < 0.001), SB (tau = 0.733, P = 0.0042), functional (tau = 0.156, P = 0.0016), and PN surgeries (P < 0.005). Over the last decade, decreasing LOS was observed for neuro-oncology (tau = -0.648, P = 0.0077), SB (tau = -0.382, P = 0.012), and functional operations, a trend which remained consistent during the COVID-19 pandemic (P = 0.01). Spine remained constant across the decade while PN demonstrated a trend toward increasing LOS.

Conclusion

Most subspecialties demonstrate a decreasing LOS coupled with a shift toward day case procedures, potentially attributable to improvements in surgical techniques, less invasive approaches, and increased pressure on beds. Setting up extra dedicated day case theaters could help deal with the backlog of procedures, particularly with regard to the impact of COVID-19.

Procedural, workforce, and reimbursement trends in neuroendovascular procedures

BACKGROUND

This study aims to define the proportion of Medicare neuroendovascular procedures performed by different specialists from 2013 to 2019, map the geographic distribution of these specialists, and trend reimbursement for these procedures.

METHODS

The Medicare Provider Utilization Database was queried for recognized neuroendovascular procedures. Data on specialists and their geographic distribution were tabulated. Reimbursement data were gathered using the Physician Fee Schedule Look-Up Tool and adjusted for inflation using the United States Bureau of Labor Statistics' Consumer Price Index Inflation calculator.

RESULTS

The neuroendovascular workforce in 2013 and 2019, respectively, was as follows: radiologists (46% vs 44%), neurosurgeons (45% vs 35%), and neurologists (9% vs 21%). Neurologists increased proportionally (p=0.03). Overall procedure numbers increased across each specialty: radiology (360%; p=0.02), neurosurgery (270%; p<0.01), and neurology (1070%; p=0.03). Neuroendovascular revascularization (CPT 61645) increased in all fields: radiology (170%; p<0.01), neurosurgery (280%; p<0.01), neurology (240%; p<0.01); central nervous system (CNS) permanent occlusion/embolization (CPT61624) in neurosurgery (67%; p=0.03); endovascular temporary balloon artery occlusion (CPT61623) in neurology (29%; p=0.04). In 2019, radiologists were the most common neuroendovascular specialists everywhere except in the Northeast where neurosurgeons predominated. Inflation adjusted reimbursement decreased for endovascular temporary balloon occlusion (CPT61623, -13%; p=0.01), CNS transcatheter permanent occlusion or embolization (CPT61624, -13%; p=0.02), non-CNS transcatheter permanent occlusion or embolization (CPT61626, -12%; p<0.01), and intracranial stent placement (CPT61635, -12%; p=0.05).

CONCLUSIONS

The number of neuroendovascular procedures and specialists increased, with neurologists becoming more predominant. Reimbursement decreased. Coordination among neuroendovascular specialists in terms of training and practice location may maximize access to acute care.

Gastroenterology Practice Consolidation Between 2012 and 2020

INTRODUCTION

Multiple studies have indicated physicians are practicing medicine in increasingly larger groups. However, specialty-specific data on the extent of consolidation are lacking for many specialties, including gastroenterology. We aim to determine the extent of consolidation for gastroenterology in recent years.

METHODS

The Physician Compare database was used to gather information at both an individual and group level. This information included location and number of providers for each group. Cochran-Armitage tests were used to test for differences between practice sizes in 2012 and 2020.

RESULTS

Between 2012 and 2020, the number of physicians increased from 12,766 to 13,934, while the total number of practices decreased from 4517 to 3865. The total number of physicians who practice in groups of less than 9 physicians decreased by 23.9%, while the total number of physicians in practices of 100 + increased by 16.8%.

DISCUSSION

Significant consolidation has occurred in the field of gastroenterology in every geographic region of the USA. The causes of consolidation are multi-faceted and include the legislative environment, private equity and hospital acquisition of private groups, individual physician lifestyle preferences, and economic benefits of economies of scale. However, the consequences of consolidation are still unclear.

CONCLUSION

Over the last eight years, gastroenterologists have been practicing in increasingly larger groups. This trend has been consistent in each area of the country. Future research should focus on the impact of consolidation on patient care and physician wellbeing.

Medicare reimbursement trends from 2000 to 2020 in head and neck surgical oncology

Background

Considering limited data exploring reimbursement trends at the subspecialty level within head and neck surgical oncology, we sought to characterize these trends for head and neck‐specific codes from 2000 to 2020.

Methods

Using the Centers for Medicare and Medicaid Services' Physician Fee Schedule Look‐Up Tool, reimbursement data, adjusted to 2020 U.S. dollars, for 37 head and neck surgical oncologic procedure codes were collected from 2000 to 2020.

Results

From 2000 to 2020, despite gross reimbursement for all head and neck procedures increasing by 23.2%, when adjusted for inflation, physician reimbursement decreased by 19.4%. Only 4 of 37 examined codes increased in net reimbursement over the study period.

Conclusion

Medicare reimbursement for the most common head and neck oncologic procedure codes decreased from 2000 to 2020. Further research is necessary to explore the implications of these trends on the delivery of patient care.

Group practice in Urology: A cross-sectional analysis over 8 years (2014–2021)

Purpose:

Physician and medical practices have undergone significant consolidation over the last decade. This has been in response to federal and financial changes to health care delivery within the United States. As per the 2021 AUA annual census, the percentage of employed practicing urologists (not in solo or partnership practice) increased from 51.3% to 64.4% between 2015 and 2020 (AUA Census 2021). Our objective was to further examine the changing trends among provider groups within Urology between 2014 and 2021.

Methods:

Publicly available information from within Medicare Physician Compare, published by the US Centres for Medicare and Medicaid Services (CMS) was used. Practice size data were pulled from 1 month each year between 2014 and 2021 and filtered by physicians listing ‘Urology’ as their primary specialty. Practices were divided into categories based on size. Statistical calculations were conducted using R (version 4.0.2).

Results:

Solo or partnership practice declined by 15.9% compared to larger practice groups which increased by an average of 5.1%. Providers within the Northeast US illustrated the largest migration to larger practices with 101%, 162% and 232% growth among practices with 25–99, 100–499 and over 500 providers, respectively.

Conclusion:

Urologists have been moving increasingly towards larger group practice since 2014. An emphasis on value-based healthcare, integration of electronic records and an increase in administrative workload are only some of the influencing factors likely responsible for this trend. Further studies are needed to examine the effect practice consolidation has on patient outcomes and cost of care.

Practice Consolidation in Otolaryngology: The Decline of the Single-Provider Practice

Objective

To observe trends in practice consolidation within otolaryngology by analyzing changes in size and geographic distribution of practices within the United States from 2014 to 2021.

Study Design

Retrospective analysis based on the Physician Compare National Database from the US Centers for Medicare and Medicaid Services.

Setting

United States.

Methods

Annual files from the Physician Compare National Database between 2014 and 2021 were filtered for all providers that listed “otolaryngology” as their primary specialty. Organization affiliations were sorted by size of practice and categorized into quantiles (1 or 2 providers, 3-9, 10-24, 25-49, and ≥50). Both the number of practices and the number of surgeons within a practice were collected annually for each quantile. Providers were also stratified geographically within the 9 US Census Bureau divisions. Chi-square analysis was conducted to test significance for the change in surgeon and practice distributions between 2014 and 2021.

Results

Over the study period, the number of active otolaryngology providers increased from 7763 to 9150, while the number of practices fell from 3584 to 3152 in that time span. Practices with just 1 or 2 otolaryngology providers accounted for 80.2% of all practices in 2014 and fell to 73.1% in 2021. Similar trends were observed at the individual provider level. Regional analysis revealed that New England had the largest percentage decrease in otolaryngologists employed by practices of 1 or 2 active providers at 45.7% and the Mountain region had the lowest percentage decrease at 17.4%.

Conclusion

The otolaryngology practice marketplace has demonstrated a global trend toward practice consolidation.

Trends in the Neurosurgical Workforce and Implications in Providing for an Aging Population

BACKGROUND

The United States is projected to face growing physician-workforce shortages. However, the shortage in the neurosurgical workforce has yet to be characterized. This study aims to outline the current state of the neurosurgical workforce by quantifying the divide between the number of practicing neurosurgeons and the US population.

METHODS

The Medicare Physician National Medicare database was queried from 2014 to 2019 in order to obtain numbers of practicing neurosurgeons, which were compared to population counts from US Census data.

RESULTS

From 2014 to 2019, there was a total increase in neurosurgeons per capita of 9.4%. The Northeast NPCR increased by 17.1%, the South by 3.4%, the Midwest by 13.3%, and the West by 12.5%. In all regions except for the West, the surgeons per capita ratio dropped from 2017 to 2019. The greatest increase of surgeons was between 2018 to 2019 (214). In 2014, the states with the lowest NPCR were Vermont, Arkansas, and New Mexico. In 2019, these included Nevada, New Mexico, and Vermont. As of 2020, 56.6% of neurosurgeons have practiced for over 20 years.

CONCLUSIONS

While the national NPCR has slowly increased over the last five years, there is a more recent drop within the last three. Additionally, with almost 57% of surgeons being in practice for over 20 years, there is concern as to whether current practices can sustain growing patient needs. This study warrants further investigation into contributing factors to this shortage and steps that can be taken to increase production of well-trained neurosurgeons.