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Gong JH, Koh DJ, Sobti N, Mehrzad R, Beqiri D, Maselli A, Kwan D. Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020. J Reconstr Microsurg 2024; 40:489-495. [PMID: 38052419 DOI: 10.1055/a-2222-8676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND With greater acceptance of postmastectomy breast reconstruction (PMBR) as a safe and reliable treatment option, the role of plastic surgeons in breast cancer management continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals may increase charges. Excessive markups can negatively affect uninsured and underinsured patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain insights into recent trends in utilization and billing. METHODS We queried the 2013 to 2020 Medicare Provider Utilization and Payment Data with 14 Current Procedural Terminology (CPT) codes to collect service count numbers, hospital charges, and reimbursements. We calculated utilization (service counts per million female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement ratios (CRRs). We calculated total and annual percentage changes for the included CPT codes. RESULTS Among the 14 CPT codes, 12 CPT codes (85.7%) with nonzero service counts were included. Utilization of mastectomy and breast reconstruction procedures decreased from 1,889 to 1,288 (-31.8%) procedures per million female Medicare beneficiaries from 2013 to 2020. While the utilization of immediate implant placements (CPT 19340) increased by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%. Reimbursements for the included CPT codes changed minimally over time (-2.9%) but charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to 4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%). CONCLUSIONS Our analysis of mastectomy and breast reconstruction procedures billed to Medicare Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in hospital charges and CRRs may limit uninsured and underinsured patients from accessing necessary care for breast cancer management. Legislations that monitor hospital markups for PMBR procedures may be considered by policymakers.
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Affiliation(s)
- Jung Ho Gong
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daniel J Koh
- Division of Plastic and Reconstructive Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Nikhil Sobti
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Raman Mehrzad
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dardan Beqiri
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Amy Maselli
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daniel Kwan
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Koh DJ, Gong JH, Sobti N, Mehrzad R, Beqiri D, Ahn S, Maselli A, Kwan D. Billing and Utilization Trends in Reconstructive Microsurgery Indicate Worsening Access to Care. J Reconstr Microsurg 2024; 40:416-422. [PMID: 37884057 DOI: 10.1055/a-2199-4226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND Within the last 20-years, Medicare reimbursements for microsurgery have been declining, while physician expenses continue to increase. As a result, hospitals may increase charges to offset revenue losses, which may impose a financial barrier to care. This study aimed to characterize the billing trends in microsurgery and their implications on patient care. METHODS The 2013 to 2020 Provider Utilization and Payment Data Physician and Other Practitioners Dataset was queried for 16 CPT codes. Service counts, hospital charges, and reimbursements were collected. The utilization, weighted mean reimbursements and charges, and charge-to-reimbursement ratios (CRRs) were calculated. The total and annual percent changes were also determined. RESULTS In total, 13 CPT codes (81.3%) were included. The overall number of procedures decreased by 15.0%. The average reimbursement of all microsurgical procedures increased from $618 to $722 (16.7%). The mean charge increased from $3,200 to $4,340 (35.6%). As charges had a greater increase than reimbursement rates, the CRR increased by 15.4%. At the categorical level, all groups had increases in CRRs, except for bone graft (-49.4%) and other procedures (-3.5%). The CRR for free flap breast procedures had the largest percent increase (47.1%). Additionally, lymphangiotomy (28.6%) had the second largest increases. CONCLUSION Our analysis of microsurgical procedures billed to Medicare Part B from 2013 to 2020 showed that hospital charges are increasing at a faster rate than reimbursements. This may be in part due to increasing physician expenses, cost of advanced technology in microsurgical procedures, and inadequate reimbursement rates. Regardless, these increased markups may limit patients who are economically disadvantaged from accessing care. Policy makers should consider legislation aimed at updating Medicare reimbursement rates to reflect the increasing complexity and cost associated with microsurgical procedures, as well as regulating charge markups at the hospital level.
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Affiliation(s)
- Daniel J Koh
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Jung Ho Gong
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nikhil Sobti
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Raman Mehrzad
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dardan Beqiri
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sophia Ahn
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Amy Maselli
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daniel Kwan
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Koh DJ, Eslami MH, Sung E, Seo HH, Lin B, Lin A, Cheng TW, Alonso A, King E, Farber A, Siracuse JJ. Medicare billing and utilization trends in vascular surgery. J Vasc Surg 2024:S0741-5214(24)01221-7. [PMID: 38909918 DOI: 10.1016/j.jvs.2024.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVE Within the past decade, Medicare Part B reimbursements for various surgical procedures have been declining, whereas health care expenses continue to increase. As a result, hospitals may increase service charges to offset losses in revenue, which may disproportionately affect underinsured patients. Our analysis aimed to characterize Medicare billing and utilization trends across common vascular surgical procedures. METHODS The 2017 to 2021 Medicare Physician and Other Practitioners by Provider and Service dataset was queried for Current Procedural Terminology (CPT) codes for common vascular surgery procedures. The average charges, reimbursements, charge-to-reimbursement ratios, and service counts were calculated for the most common interventions performed by vascular surgeons. Data was stratified by care setting, facility (inpatient and outpatient hospital) vs non-facility locations. All monetary values were adjusted to the 2021 United States dollars to account for inflation. RESULTS For facility settings, the mean charge billed to Medicare Part B increased from $3708 to $3952 (6.6%) from 2017 to 2021, with the average charge-to-reimbursement ratio increasing from 7.2 to 8.6. There were 17 of the 19 facility procedures that had a decline in reimbursements, decreasing from an average of $558 to $499 (-10.4%). Stab phlebectomy had the largest individual decrease in facility reimbursement (-53.5%), followed by above-knee amputation (-11.3%) and below-knee amputation (-11.0%). Both non-facility charges (-10.8%) and reimbursements (-12.2%) declined over the study period. Procedural utilization remained stable from 2017 to 2019. Tibial and femoral-popliteal atherectomy had increases of 45.9% and 33.7%, respectively, in overall procedural utilization when performed in non-facility settings from 2017 to 2019. CONCLUSIONS Our analysis of vascular surgery procedures billed to Medicare Part B from 2017 to 2021 demonstrates an increase in charges, a decline in reimbursements, and a resultant increase in charge-to-reimbursement ratios for facility care settings. In contrast, non-facility charges have decreased in the face of declining reimbursements. These markups in submitted charges in facility locations may serve as an additional barrier to accessing care for patients who are underinsured.
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Affiliation(s)
- Daniel J Koh
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Mohammad H Eslami
- Department of Vascular Surgery, CAMC Institute for Academic Medicine, Charleston, WV
| | - Eric Sung
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Hojoon H Seo
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Brenda Lin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Alex Lin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Thomas W Cheng
- Divison of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Andrea Alonso
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Elizabeth King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
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Jimenez AE, Azad TD, Mukherjee D. Decreasing Reimbursement of Pituitary Tumor Surgery: An Analysis of Medicare Data From 2010 to 2020. Neurosurgery 2024; 94:140-146. [PMID: 37638728 DOI: 10.1227/neu.0000000000002636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/12/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the extensive amount of research aimed at comparing patient outcomes between microscopic transsphenoidal surgery (MTSS) and endoscopic transsphenoidal surgery (ETSS) approaches, there has been relatively little recent investigation into the nationwide utilization and reimbursement trends of both techniques. This study aimed to identify trends in pituitary tumor surgery utilization, charges to Medicare, and reimbursement dependent on (1) MTSS/ETSS surgery type, (2) provider type (ie, neurosurgeon vs ear, nose, and throat), and (3) cosurgery status. METHODS This study used publicly available data from the Medicare Physician/Supplier Procedure Summary for the years 2010-2020. Linear regression was used to quantify temporal trends for submitted service counts, submitted charges, reimbursements, and reimbursement-to-charge across the 2010-2020 period. RESULTS Regarding service count trends from 2010 to 2020, our results demonstrate a significant increase in ETSS utilization ( = 1.55, CI = 0.99-2.12, P < .001), a significant decrease in MTSS utilization ( = -0.86, CI = -1.21 to -0.51, P < .001), a significant increase in services submitted by otolaryngologists ( = 0.59, CI = 0.24-0.93, P = .0040), and a significant increase in cosurgeries ( = 1.03, CI = 0.24-0.93, P = .0051). Importantly, our results also demonstrated a significant decrease in reimbursements for ETSS procedures ( = -12.74, CI = -22.38 to -3.09, P = .015) and for pituitary tumor surgeries submitted by neurosurgeons specifically ( = -41.56, CI = -51.67 to -31.63, P < .0001). CONCLUSION Our results demonstrated a significant increase in ETSS utilization and a significant decrease in MTSS utilization. We also noted a significant decrease in reimbursements for ETSS procedures and among procedures submitted by neurosurgeons specifically. We hope that our study highlights nationwide utilization and reimbursement patterns that may be useful for guiding future reimbursement-oriented policy development.
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Affiliation(s)
- Adrian E Jimenez
- Department of Neurosurgery, Columbia University Medical Center, New York , New York , USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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Gong JH, Bajaj A, Lin Y, Luhrs A, Giorgi M. Implications of declining medicare reimbursement of hernia repair for surgeons and patients. Am J Surg 2023; 226:291-293. [PMID: 36935284 DOI: 10.1016/j.amjsurg.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 02/28/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023]
Abstract
In conclusion, billing trends reflect declining reimbursement and utilization of hernia repair, and increasing markup ratios may create a financial barrier to accessing hernia for uninsured and underinsured patients. As a new set of hernia repair CPT codes are used in practice, close attention should be paid to the downstream effects of billing practices in hernia repair on physician and patient alike.
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Affiliation(s)
- Jung Ho Gong
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Ankush Bajaj
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Yang Lin
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew Luhrs
- Division of Bariatric Surgery, Department of General Surgery, Brown University, Providence, RI, USA
| | - Marcoandrea Giorgi
- Division of Bariatric Surgery, Department of General Surgery, Brown University, Providence, RI, USA
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