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Malik AT, Cvetanovich GL. Editorial Commentary: Increasing Patient Out-of-Pocket Expense Does Not Increase Value of Outpatient Surgery. Arthroscopy 2024; 40:1737-1738. [PMID: 38219099 DOI: 10.1016/j.arthro.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 01/15/2024]
Abstract
In a value-based care environment, a goal is to favor outpatient surgery to reduce costs. Unfortunately, while outpatient (as compared to inpatient) surgery reduces overall cost, recent research shows that by including patient out-of-pocket expense (POPE), the proportion of overall cost born by the patient can greatly increase, which is unjust. The primary contributors to high outpatient surgery POPE are out-of-network facilities, out-of-network surgeons, and high-deductible insurance. Although historical focus on outpatient surgical cost reductions has been toward surgeon fees, anesthesia fees, facility fees, and implant fees, we must also focus on POPE. In the interim, it is essential to provide patients with price transparency, so that they understand their anticipated expenses and are not blindsided by cost burden.
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Peterman N, Shivdasani K, Naik A, Dharnipragada R, Harrop J, Vaccaro AR, Arnold PM. Geospatial Evaluation of Disparities in Access to Cervical Spine Fusion in Metropolitan Areas Across the United States. Clin Spine Surg 2024; 37:E208-E215. [PMID: 38158598 DOI: 10.1097/bsd.0000000000001564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024]
Abstract
STUDY DESIGN Retrospective study with epidemiologic analysis of public Medicare data. OBJECTIVE The purpose of this study is to use geospatial analysis to identify disparities in access to cervical spine fusions in metropolitan Medicare populations. SUMMARY OF BACKGROUND DATA Cervical spine fusion is among the most common elective procedures performed by spine surgeons and is the most common surgical intervention for degenerative cervical spine disease. Although some studies have examined demographic and socioeconomic trends in cervical spine fusion, few have attempted to identify where disparities exist and quantify them at a community level. METHODS Center for Medicare and Medicaid Services physician billing and Medicare demographic data sets from 2013 to 2020 were filtered to contain only cervical spine fusion procedures and then combined with US Census socioeconomic data. The Moran Index geospatial clustering algorithm was used to identify statistically significant hotspot and coldspots of cervical spine fusions per 100,000 Medicare members at a county level. Univariate and multivariate analysis was subsequently conducted to identify demographic and socioeconomic factors that are associated with access to care. RESULTS A total of 285,405 cervical spine fusions were analyzed. Hotspots of cervical spine fusion were located in the South, while coldspots were throughout the Northern Midwest, the Northeast, South Florida, and West Coast. The percent of Medicare patients that were Black was the largest negative predictor of cervical spine fusions per 100,000 Medicare members ( β =-0.13, 95% CI: -0.16, -0.10). CONCLUSIONS Barriers to access can have significant impacts on health outcomes, and these impacts can be disproportionately felt by marginalized groups. Accounting for socioeconomic disadvantage and geography, this analysis found the Black race to be a significant negative predictor of access to cervical spine fusions. Future studies are needed to further explore potential socioeconomic barriers that exist in access to specialized surgical care. LEVEL OF EVIDENCE Level III-retrospective.
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Affiliation(s)
- Nicholas Peterman
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign
| | - Krishin Shivdasani
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign
- Department of Orthopaedic Surgery & Rehabilitation, Loyola Medicine, Maywood IL
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis MN
| | - Rajiv Dharnipragada
- Department of Neurosurgery, University of Minnesota Twin-Cities, Minneapolis MN
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson Hospital
| | - Alexander R Vaccaro
- Department of Orthopedic Surgery, Rothman Orthopedic Institute, Philadelphia PA
| | - Paul M Arnold
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign
- Department of Neurosurgery, Carle Foundation Hospital, Urbana IL
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Lavu MS, Porto JR, Hecht CJ, Acuña AJ, Kaelber DC, Parvizi J, Kamath AF. Low-Dose Aspirin Is the Safest Prophylaxis for Prevention of Venous Thromboembolism After Total Knee Arthroplasty Across All Patient Risk Profiles. J Bone Joint Surg Am 2024:00004623-990000000-01100. [PMID: 38753809 DOI: 10.2106/jbjs.23.01158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND The International Consensus Meeting on Venous Thromboembolism (ICM-VTE) in 2022 proclaimed low-dose aspirin as the most effective agent in patients across all risk profiles undergoing joint arthroplasty. However, data on large patient populations assessing trends in chemoprophylactic choices and related outcomes following total knee arthroplasty (TKA) remain scant. The present study was designed to characterize the clinical use of various chemoprophylactic agents in patients undergoing TKA and to determine the efficacy of aspirin compared with other agents in patient groups stratified by VTE risk profiles. METHODS This study utilized a national database to determine the proportion of patients undergoing TKA who received low-dose aspirin versus other chemoprophylaxis between 2012 and 2022. VTE risk profiles were determined on the basis of comorbidities established in the ICM-VTE. The odds ratios (ORs) and 95% confidence intervals (CIs) between various classes of thromboprophylaxis in patients with high and low risk of VTE were calculated. The odds of deep-vein thrombosis (DVT), pulmonary embolus (PE), bleeding events, infections, mortality, and hospitalizations were also assessed in the 90-day postoperative period for propensity-matched cohorts receiving low-dose (81 mg) aspirin only versus other prophylaxis, segregating patients by VTE risk profile. RESULTS A total of 126,692 patients undergoing TKA across 60 health-care organizations were included. The proportion of patients receiving low-dose aspirin increased from 7.65% to 55.29% between 2012 and 2022, whereas the proportion of patients receiving other chemoprophylaxis decreased from 96.25% to 42.98%. Low-dose-aspirin-only use increased to approximately 50% in both high-risk and low-risk populations but was more likely in low-risk populations (OR, 1.17; 95% CI, 1.15 to 1.20) relative to high-risk populations. Both low-risk and high-risk patients in the low-dose-aspirin-only cohorts had decreased odds of DVT, PE, bleeding, infections, and hospitalizations compared with other prophylaxis regimens. CONCLUSIONS The findings of the present study on a very large population of patients undergoing TKA support the recent ICM-VTE statement by showing that low-dose aspirin is a safe and effective method of prophylaxis in patients across various risk profiles. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Monish S Lavu
- Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Joshua R Porto
- Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christian J Hecht
- Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alexander J Acuña
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois
| | - David C Kaelber
- Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
- Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Truong NM, Leversedge CV, Zhuang T, Shapiro LM, Whittaker M, Kamal RN. Site of Service Disparities Exist for Total Joint Arthroplasty. Orthopedics 2024; 47:179-184. [PMID: 38466828 DOI: 10.3928/01477447-20240304-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND The rate of outpatient total joint arthroplasty procedures, including those performed at ambulatory surgical centers (ASCs) and hospital outpatient departments, is increasing. The purpose of this study was to analyze if type of insurance is associated with site of service (in-patient vs outpatient) for total joint arthroplasty and adverse outcomes. MATERIALS AND METHODS We identified patients undergoing unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) using Current Procedural Terminology codes in a national administrative claims database. Eligible patients were stratified by type of insurance (Medicaid, Medicare, private). The primary outcome was site of service. Secondary outcomes included general complications, procedural complications, and revision procedures. We evaluated the associations using adjusted multivariable logistic regression models. RESULTS We identified 951,568 patients for analysis; 46,703 (4.9%) patients underwent UKA, 607,221 (63.8%) underwent TKA, and 297,644 (31.3%) underwent THA. Overall, 9.6% of procedures were outpatient. Patients with Medicaid were less likely than privately insured patients to receive outpatient UKA or THA (UKA: odds ratio [OR], 0.729 [95% CI, 0.640-0.829]; THA: OR, 0.625 [95% CI, 0.557-0.702]) but more likely than patients with Medicare to receive outpatient TKA or THA (TKA: OR, 1.391 [95% CI, 1.315-1.472]; THA: OR, 1.327 [95% CI, 1.166-1.506]). Patients with Medicaid were more likely to experience complications and revision procedures. CONCLUSION Differences in site of service and complication rates following hip and knee arthroplasty exist based on type of insurance, suggesting a disparity in care. Further exploration of drivers of this disparity is warranted and can inform interventions (eg, progressive value-based payments) to support equity in orthopedic services. [Orthopedics. 2024;47(3):179-184.].
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Gill VS, Haglin JM, Tummala SV, Iturregui J, Economopoulos KJ, Chhabra A. Meniscectomy Reimbursement and Utilization Are Declining at Different Rates Across the United States. Arthroscopy 2024:S0749-8063(24)00095-1. [PMID: 38336106 DOI: 10.1016/j.arthro.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024]
Abstract
PURPOSE To evaluate how arthroscopic meniscectomy utilization, reimbursement, physician billing practices, and patient populations have changed within the Medicare population from 2013 to 2021 at a national level and regional level. METHODS The Medicare Physician & Other Practitioners database was queried for all episodes of 2-compartment and single-compartment arthroscopic meniscectomy between 2013 and 2021. Utilization per 10,000 beneficiaries and average inflation-adjusted reimbursement were assessed. Physician practice styles, measured through changes in the services billed, and Medicare beneficiary demographic characteristics were extracted each year. The Kruskal-Wallis test was performed to compare regions. RESULTS Between 2013 and 2021, two-compartment meniscectomy utilization per 10,000 Medicare beneficiaries declined by 54.9% and single-compartment meniscectomy utilization declined by 54.2%. Average reimbursement declined by 9.3% and 12.5% for 2-compartment meniscectomy and single-compartment meniscectomy, respectively. In 2021, the South had the highest utilization of both 2-compartment (3.8/10,000) and single-compartment (4.7/10,000) meniscectomies while having the lowest average reimbursement for 2-compartment meniscectomy ($383.02, P < .001). Nationally, the average number of beneficiaries per surgeon performing single-compartment meniscectomy declined by 3.8% whereas the average number of billable services performed per beneficiary increased by 46.6%. The comorbidity risk score of these patients decreased by 8.7%, with the West having the healthiest patients in 2021. CONCLUSIONS Meniscectomy utilization and reimbursement have been declining nationally within the Medicare population. Surgeons in the South performed the most meniscectomies while having among the lowest reimbursement. The practice patterns of surgeons performing meniscectomies have been changing, with surgeons performing nearly 50% more total billable services per beneficiary while performing fewer unique billable services. Additionally, the patient population of surgeons who perform meniscectomy was healthier in 2021 than in 2013. CLINICAL RELEVANCE This study highlights changes in meniscectomy utilization and reimbursement over time in the face of changing evidence of meniscectomy use in elderly patients and new Medicare legislature regarding reimbursement.
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Affiliation(s)
- Vikram S Gill
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A.; Mayo Clinic Alix School of Medicine, Phoenix, Arizona, U.S.A..
| | - Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
| | - Sailesh V Tummala
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
| | - Jose Iturregui
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
| | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A
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Tiao J, Wang K, Herrera M, Rosenberg A, Carbone A, Zubizarreta N, Anthony SG. Hip Arthroscopy Trends: Increasing Patient Out-of-Pocket Costs, Lower Surgeon Reimbursement, and Cost Reduction With Utilization of Ambulatory Surgery Centers. Arthroscopy 2023; 39:2313-2324.e2. [PMID: 37100212 DOI: 10.1016/j.arthro.2023.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE To (1) report on trends in immediate procedure reimbursement, patient out-of-pocket expenditures, and surgeon reimbursement in hip arthroscopy (2) compare trends in ambulatory surgery centers (ASC) versus outpatient hospitals (OH) utilization; (3) quantify the cost differences (if any) associated with ASC versus OH settings; and 4) determine the factors that predict ASC utilization for hip arthroscopy. METHODS The cohort for this descriptive epidemiology study was any patient over 18 years identified in the IBM MarketScan Commercial Claims Encounter database who underwent an outpatient hip arthroscopy, identified by Current Procedural Terminology codes, in the United States from 2013 to 2017. Immediate procedure reimbursement, patient out-of-pocket expenditure, and surgeon reimbursement were calculated, and a multivariable model was used to determine the influence of specific factors on these outcome variables. Statistically significant P values were less than .05, and significant standardized differences were more than 0.1. RESULTS The cohort included 20,335 patients. An increasing trend in ASC utilization was observed (P = .001), and ASC utilization for hip arthroscopy was 32.4% in 2017. Patient out-of-pocket expenditures for femoroacetabular impingement surgery increased 24.3% over the study period (P = .003), which was higher than the rate for immediate procedure reimbursement (4.2%; P = .007). ASCs were associated with $3,310 (28.8%; P = .001) reduction in immediate procedure reimbursement and $47 (6.2%; P = .001) reduction in patient out-of-pocket expenditure per hip arthroscopy. CONCLUSIONS ASCs provide a significant cost difference for hip arthroscopy. Although there is an increasing trend toward ASC utilization, it remains relatively low at 32.4% in 2017. Thus, there are opportunities for expanded ASC utilization, which is associated with significant immediate procedure reimbursement difference of $3,310 and patient out-of-pocket expenditure difference of $47 per hip arthroscopy case, ultimately benefiting healthcare systems, surgeons, and patients alike. LEVEL OF EVIDENCE Level III, retrospective comparative trial.
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Affiliation(s)
- Justin Tiao
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Kevin Wang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Michael Herrera
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Ashley Rosenberg
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Andrew Carbone
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, U.S.A
| | - Nicole Zubizarreta
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Shawn G Anthony
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A..
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Federico VP, McCormick JR, Nie JW, Mehta N, Cohn MR, Menendez ME, Denard PJ, Simcock XC, Nicholson GP, Garrigues GE. Costs of shoulder and elbow procedures are significantly reduced in ambulatory surgery centers compared to hospital outpatient departments. J Shoulder Elbow Surg 2023; 32:2123-2131. [PMID: 37422131 DOI: 10.1016/j.jse.2023.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/07/2023] [Accepted: 05/28/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Recent literature has shown the advantages of outpatient surgery for many shoulder and elbow procedures, including cost savings with equivalent safety in appropriately selected patients. Two common settings for outpatient surgeries are ambulatory surgery centers (ASCs), which function as independent financial and administrative entities, or hospital outpatient departments (HOPDs), which are owned and operated by hospital systems. The purpose of this study was to compare shoulder and elbow surgery costs between ASCs and HOPDs. METHODS Publicly available data from 2022 provided by the Centers for Medicare & Medicaid Services (CMS) was accessed via the Medicare Procedure Price Lookup Tool. Current Procedural Terminology (CPT) codes were used to identify shoulder and elbow procedures approved for the outpatient setting by CMS. Procedures were grouped into arthroscopy, fracture, or miscellaneous. Total costs, facility fees, Medicare payments, patient payment (costs not covered by Medicare), and surgeon's fees were extracted. Descriptive statistics were used to calculate means and standard deviations. Cost differences were analyzed using Mann-Whitney U tests. RESULTS Fifty-seven CPT codes were identified. Arthroscopy procedures (n = 16) at ASCs had significantly lower total costs ($2667 ± $989 vs. $4899 ± $1917; P = .009), facility fees ($1974 ± $819 vs. $4206 ± $1753; P = .008), Medicare payments ($2133 ± $791 vs. $3919 ± $1534; P = .009), and patient payments ($533 ± $198 vs. $979 ± $383; P = .009) compared with HOPDs. Fracture procedures (n = 10) at ASCs had lower total costs ($7680 ± $3123 vs. $11,335 ± $3830; P = .049), facility fees ($6851 ± $3033 vs. $10,507 ± $3733; P = .047), and Medicare payments ($6143 ± $2499 vs. $9724 ± $3676; P = .049) compared with HOPDs, although patient payments were not significantly different ($1535 ± $625 vs. $1610 ± $160; P = .449). Miscellaneous procedures (n = 31) at ASCs had lower total costs ($4202 ± $2234 vs. $6985 ± $2917; P < .001), facility fees ($3348 ± $2059 vs. $6132 ± $2736; P < .001), Medicare payments ($3361 ± $1787 vs. $5675 ± $2635; P < .001), and patient payments ($840 ± $447 vs. $1309 ± $350; P < .001) compared with HOPDs. The combined cohort (n = 57) at ASCs had lower total costs ($4381 ± $2703 vs. $7163 ± $3534; P < .001), facility fees ($3577 ± $2570 vs. $6539.1 ± $3391; P < .001), Medicare payments ($3504 ± $2162 vs. $5892 ± $3206; P < .001), and patient payments ($875 ± $540 vs. $1269 ± $393; P < .001) compared with HOPDs. CONCLUSION Shoulder and elbow procedures performed at HOPDs for Medicare recipients were found to have average total cost increase of 164% compared with those performed at ASCs (184% savings for arthroscopy, 148% for fracture, and 166% for miscellaneous). ASC use conferred lower facility fees, patient payments, and Medicare payments. Policy efforts to incentivize migration of surgeries to ASCs may translate into substantial health care cost savings.
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Affiliation(s)
- Vincent P Federico
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - James W Nie
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nabil Mehta
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | | | | | - Xavier C Simcock
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Grant E Garrigues
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Hecht CJ, Burkhart RJ, McNassor R, Acuña AJ, Kamath AF. What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study. Clin Orthop Relat Res 2023; 481:1907-1916. [PMID: 37043552 PMCID: PMC10499078 DOI: 10.1097/corr.0000000000002649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/10/2023] [Accepted: 03/10/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized. QUESTIONS/PURPOSES (1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states? METHODS We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions. RESULTS A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08). CONCLUSION As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately. CLINICAL RELEVANCE To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.
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Affiliation(s)
- Christian J. Hecht
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert J. Burkhart
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ryan McNassor
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alexander J. Acuña
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Atul F. Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Federico VP, Zavras AG, Butler A, Nolte MT, Munim MA, Lopez GD, DeWald C, An HS, Colman MW, Phillips FM. Medicare Reimbursement Rates and Utilization Trends in Sacroiliac Joint Fusion. J Am Acad Orthop Surg 2023; 31:923-930. [PMID: 37192412 DOI: 10.5435/jaaos-d-22-00800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 04/11/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Sacroiliac joint (SIJ) fusion is a surgical treatment option for SIJ pathology in select patients who have failed conservative management. More recently, minimally invasive surgical (MIS) techniques have been developed. This study aimed to determine the trends in procedure volume and reimbursement rates for SIJ fusion. METHODS Publicly available Medicare databases were assessed using the National Summary Data Files for 2010 to 2020. Files were organized according to current procedural terminology (CPT) codes. CPT codes specific to open and MIS SI joint fusion (27279 and 27280) were identified and tracked. To track surgeon reimbursements, the CMS Medicare Physician Fee Schedule Look-Up Tool was used to extract facility prices. Descriptive statistics and linear regression were used to evaluate trends in procedure volume, utilization, and reimbursement rates. Compound annual growth rates were calculated, and discrepancies in inflation were corrected for using the Consumer Price Index. RESULTS A total of 33,963 SIJ fusions were conducted in the Medicare population between 2010 and 2020, with an overall increase in procedure volume of 2,350.9% from 318 cases in 2010 to 7,794 in 2020. Since the introduction of the 27279 CPT code in 2015, 8,806 cases (31.5%) have been open and 19,120 (68.5%) have been MIS. Surgeon reimbursement for open fusions increased nominally by 42.8% (inflation-adjusted increase of 20%) from $998 in 2010 to $1,425 in 2020. Meanwhile, reimbursement for MIS fusion experienced a nominal increase of 58.4% (inflation-adjusted increase of 44.9%) from $582 in 2015 to $922 in 2020. CONCLUSION SIJ fusion volume in the Medicare population has increased substantially in the past 10 years, with MIS SIJ fusion accounting for most of the procedures since the introduction of the 27279 CPT code in 2015. Reimbursement rates for surgeons have also increased for both open and MIS procedures, even after adjusting for inflation.
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Affiliation(s)
- Vincent P Federico
- From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Parameswaran P, Tarkunde Y, Broughton JS, Rizzo MG, Goldfarb J, Brophy RH. Effect of Trainee Level on Surgical Time and Postoperative Complications of Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00002. [PMID: 37142266 PMCID: PMC10155887 DOI: 10.5435/jaaosglobal-d-23-00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 05/06/2023]
Abstract
PURPOSE The objective of this study was to investigate the association between trainee level and surgical time and postoperative complications of anterior cruciate ligament reconstruction (ACLR). METHODS A retrospective chart review of patients who underwent ACLR at an academic orthopaedic ambulatory surgery center collected demographic and clinical information, including the number of trainees present and trainee level. Unadjusted and adjusted regression analyses assessed the association between trainee number and level with surgical time (time from skin incision to closure) and postoperative complications. RESULTS Of 799 patients in this study operated on by one of five academic sports surgeons, 87% had at least one trainee involved. The average surgical time overall was 93 ± 21 minutes and by trainee level was 99.7 (junior resident), 88.5 (senior residents), 96.6 (fellows), and 95.6 (no trainees). Trainee level was significantly associated with surgical time (P = 0.0008), with increased surgical time in cases involving fellows (0.0011). Fifteen complications (1.9%) were observed within 90 days of surgery. No notable risk factors of postoperative complications were identified. CONCLUSION Resident trainee level does not have a notable effect on surgical time or postoperative complications for ACLR at an ambulatory surgery center, although cases involving fellows had longer surgical times. Trainee level was not associated with risk of postoperative complications.
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Affiliation(s)
- Priyanka Parameswaran
- From the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO (Ms. Parameswaran, Mr. Tarkunde, Mr. Broughton, and Dr. Brophy); Williams College, Williamstown, MA (Mr. Goldfarb); and the Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, FL (Dr. Rizzo)
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11
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Durand WM, Musharbash FN, Ortiz-Babilonia CD, Jain A. Characteristics of Spine Surgery Performed at Ambulatory Surgical Centers. Spine (Phila Pa 1976) 2023; 48:143-145. [PMID: 36122294 DOI: 10.1097/brs.0000000000004480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/19/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Wesley M Durand
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Carlos D Ortiz-Babilonia
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
- Department of Orthopaedic Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Brush PL, Nanavati R, Toci GR, Conte E, Hornstein J. Surgeon-Performed Saphenous Nerve Block at the Medial Femoral Condyle for Arthroscopic Partial Meniscectomy and Meniscus Repair: A Randomized Control Trial. Cureus 2022; 14:e26971. [PMID: 35989798 PMCID: PMC9384692 DOI: 10.7759/cureus.26971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction With the rising number of arthroscopic partial meniscectomy and meniscus repair procedures performed in outpatient surgical centers, there has been significant interest in limiting postoperative pain and optimizing recovery. Postoperative pain is a common reason for admission at these surgical centers, and opioid-related mortality is becoming an increasing concern. A surgeon-performed saphenous nerve block (SNB) represents a promising adjunct treatment option for pain control. The purpose of this randomized controlled trial was to determine if an SNB would result in decreased postoperative pain and opioid usage compared to control following arthroscopic meniscus repair or partial meniscectomy. Methods We randomized patients between two groups: one receiving an SNB and the other without an SNB. The operating surgeon performed the SNB using a landmark-based approach at the medial femoral epicondyle/adductor hiatus with 5 mL of 1% lidocaine preoperatively and 5 mL of 0.5% ropivacaine postoperatively. Neither ultrasound nor nerve stimulator was utilized to confirm the success of the block. The visual analog scale was utilized to record pain preoperatively and in the immediate postoperative period, one day, and seven to 10 days postoperatively. The nursing staff in the post-anesthesia care unit monitored patient pain levels and provided pain medication accordingly. Results We enrolled 80 patients, with 40 patients in each group. There was no difference in age, sex, body mass index, or laterality between study groups. Overall, there were no differences between groups in preoperative or postoperative pain at any time. The average pain scores preoperatively were 2.78 in the experimental group and 3.05 in the control group (p=0.502). In the immediate postoperative period, pain scores were 1.57 for the experimental group and 2.66 for the control group (p=0.090). No statistically significant difference was detected in the number of patients requiring opioids postoperatively or in the morphine milligram equivalents (MME) provided to patients receiving opioids. Twelve patients in the experimental group received opioids in the immediate postoperative period while 18 patients in the control group received opioids (p=0.248). We observed no adverse events in patients from either group. Conclusion As a pure sensory nerve, the saphenous nerve is an excellent target for pain control without associated leg weakness. We utilized a low-resource SNB in knee arthroscopy for partial meniscectomy and meniscus repair as an adjunct therapy for postoperative pain control. This randomized controlled trial suggests that surgeon-performed blocks via a landmark-based approach are not effective in controlling pain or limiting opioid use in the immediate postoperative period. However, given our lack of confirmatory testing via ultrasound or nerve stimulation, a true nerve block may not have been achieved in all patients. We believe this adds to the external validity of this study, as these tools may not be readily available in all settings.
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Emergency Department Visits After Outpatient Spine Surgery. Spine (Phila Pa 1976) 2022; 47:1011-1017. [PMID: 35797547 DOI: 10.1097/brs.0000000000004368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/24/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE This study sought to characterize the incidence and timing of postoperative emergency department (ED) visits after common outpatient spinal surgeries performed at ambulatory surgery centers (ASCs) and at hospital outpatient departments (HOPDs). SUMMARY OF BACKGROUND DATA Outpatient spine surgery has markedly grown in popularity over the past decade. The incidence of ED visits after outpatient spine surgery is not well established. METHODS This study was a retrospective analysis of a large commercial claims insurance database of patients 65 years old and below. Patients who underwent single-level anterior cervical discectomy and fusion, laminectomy, and microdiscectomy were identified. Incidence, timing, and diagnoses associated with ED visits within the postoperative global period (90 d) after surgery were assessed. RESULTS In total, 202,202 patients received outpatient spine surgery (19.1% in ASC vs. 80.9% in HOPD). Collectively, there were 22,198 ED visits during the 90-day postoperative period. Approximately 9.0% of patients had at least 1 ED visit, and the incidence varied by procedure: anterior cervical discectomy and fusion 9.9%, laminectomy 9.5%, and microdiscectomy 8.5% ( P <0.0001). After adjusting for age, sex, and comorbidity index, the odds of at least 1 ED visit were higher among patients who received surgery at HOPD versus ASC for all 3 procedures. The majority (56.1%) ED visits occurred during the first month postoperatively; 30.8% (n=6841) occurred within the first week postoperatively, and 10.7% (n=2370) occurred on the same day as the surgery. Postoperative pain was the most common reason for ED visits. CONCLUSIONS Among commercially insured patients who received outpatient spine surgery, the incidence of ED visits during the 90-day postoperative period was ~9%. Our results indicate opportunities for improved postoperative care planning after outpatient spinal surgery.
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Karhade AV, Chen AF, Makhni MC, Schwab JH, Simpson AK, Tsai TC. Home Hospital for Orthopaedic Surgery: Opportunities and Challenges of a New Delivery Model. J Bone Joint Surg Am 2022; 104:e27. [PMID: 34793370 DOI: 10.2106/jbjs.21.00786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
ABSTRACT Home Hospital (HH) is a clinical service involving the delivery of acute inpatient care in the home setting. Acute care services provided via HH include continuous telemonitoring, intravenous fluids and medications, nursing care, point-of-care imaging and laboratory tests, and in-person and virtual clinician visits. Despite offering an inpatient level of care, HH has lower fixed costs and less overhead than conventional hospital settings and offers rapid scalability. Originally implemented for acute medical conditions, HH has proven to be a safe and value-based care-delivery model for a variety of medical conditions, ranging from heart failure to chronic obstructive pulmonary disease exacerbations. For surgical conditions, HH represents an opportunity to reduce adverse hospital-acquired conditions, improve patient and caregiver satisfaction, and decrease cost. The patient profile of orthopaedic surgery inpatients matches that of patients who are most likely to benefit from HH-namely, those who are prone to functional decline, delirium, and nosocomial infections. A focus on surgeon leadership, quality and safety, and digital health with collection of patient-reported outcome measures (PROMs) will ensure that the potential of HH is realized as implementation and widespread rollout proceed.
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Affiliation(s)
- Aditya V Karhade
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Melvin C Makhni
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas C Tsai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Incidence and Risk Factors for Patient-related Short-term Cancellation of Elective Arthroscopic Surgery: A Case-matched Study. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00001. [PMID: 35389914 PMCID: PMC8989772 DOI: 10.5435/jaaosglobal-d-22-00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 11/18/2022]
Abstract
Introduction: Short-term cancellation of elective ambulatory orthopaedic surgery can result in disruption to the process flow of the operating room, with resultant negative financial implications for the health system. The risk factors for patient-related short-term cancellations within 24 hours of the surgical date have not been well defined. Methods: A retrospective review of a single orthopaedic surgery electronic internal database was done to identify all cancellations from January 1, 2016, through December 31, 2019, which were made within 24 hours of the surgical date. Inclusion criteria included elective arthroscopic procedures canceled solely for patient-related issues. Any cancellation for surgeon-related or ambulatory center–related reasons was excluded. Demographic patient and surgical data, including insurance type, employment status, previous history of cancellation for the same surgery, socioeconomic status based on the Area Deprivation Index, and surgery type, were tabulated. Each cancellation was matched 1:2 with noncanceled cases based on the anatomic site of the arthroscopy scheduled. Multivariable logistic regression was used to examine associations of patient demographic and medical characteristics with surgical cancellation. Results: There were 4,715 total arthroscopic procedures done during the study period, of which 126 (2.7%) were canceled within 24 hours of the surgery date. The mean age of the canceled cases was 44.9 ± 16.1 years (range, 14 to 77 years), with 46 females (43%) included. The presence of MRI of the involved joint within 6 months of surgery (adjusted odds ratio [aOR], 0.39, 95% confidence interval [CI], 0.17 to 0.91) and current employment (aOR, 0.56, 95% CI, 0.33-0.94) were independently predictive of noncancellation. Current smokers were more likely to cancel within 24 hours of surgery (aOR, 2.63, 95% CI, 1.4-4.9). Finally, having previously canceled the same surgery was significantly associated with a current surgical cancellation (P = 0.004). Discussion: Identification of the factors associated with short-term patient-related cancellation of elective arthroscopy may serve as the basis for preoperative interventions aimed specifically at those more likely to cancel. In turn, these interventions can minimize preventable cancellations.
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Torabi SJ, Patel RA, Birkenbeuel J, Nie J, Kasle DA, Manes RP. Ambulatory surgery centers: A 2012 to 2018 analysis on growth in number of centers, utilization, Medicare services, and Medicare reimbursements. Surgery 2021; 172:2-8. [PMID: 34973814 DOI: 10.1016/j.surg.2021.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given declining reimbursements and potential financial conflicts of interest in ownership, it is important to continually assess ambulatory surgery center role and growth. The objective of this study is to evaluate scope of practice, number of patients served, number of procedures performed, and revenue of ambulatory surgery centers within a Medicare fee-for-service population. METHODS This retrospective study includes data from Medicare Part B: Provider Utilization and Payment Datafiles (2012-2018). In addition to total number and geographic distribution, sums and medians were gathered for Medicare reimbursements, services performed, number of patients, and unique current procedural terminology codes used. RESULTS The number of Medicare fee-for-service-serving ambulatory surgery centers grew 7.0% from 4,886 to 5,227 between 2012 and 2018. A total of 8,169,288 Medicare fee-for-service services were performed on 3,910,434 patients in 2018, an increase of 10.8% and 6.5% since 2012, respectively. At the median, each ambulatory surgery center performed 1,050 services in 2018, which was slightly less than in 2012 (median: 1,094). Ambulatory surgery centers collected $5.1 billion in payments in 2018, compared to $3.6 billion in 2012 (29.1% inflation-adjusted growth). CONCLUSION Total inflation-adjusted allowed Medicare fee-for-service payments have increased 29.1% between 2012 and 2018, despite just 7% growth in number of ambulatory surgery centers and 10.8% increase in total number of services. The 16.5% increase in inflation-adjusted revenue generated per service may indicate that the increased use of complex procedures with higher reimbursement, previously only performed in an inpatient setting, are now offered more readily in ambulatory surgery centers.
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Affiliation(s)
- Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, CA; Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, CT. https://www.twitter.com/SinaJTorabi
| | - Rahul A Patel
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, CT; Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT. https://www.twitter.com/rahul_patel_11
| | - Jack Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California Irvine, Orange, CA
| | - James Nie
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, CT
| | - David A Kasle
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, CT
| | - R Peter Manes
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, CT.
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