The Evaluation of Payment for Obstetric and Gynecology Services: From ACOG.

PURPOSE: To perform an environmental scan of the current status of reimbursement for obstetric and gynecology services and identify problematic issues and opportunities for change. The areas that were evaluated include the American Medical Association (AMA) relative value unit assignment process, payer rates (where available), and trends in employment and salary determination for obstetrician-gynecologists (ob-gyns). METHODS: This report was developed by members of the American College of Obstetricians and Gynecologists' (ACOG) Committee on Health Economics and Coding using public-facing payment data from the Medicare Physician Fee Schedule and state Medicaid programs, as well as published research and commentary on payment for physicians, maternal health, and gynecologic surgery. Data from the Centers for Disease Control and Prevention were used to describe typical patient characteristics, and practice survey reports from the AMA were analyzed. Finally, an anonymous online survey was distributed to 27,854 members of ACOG in March 2022, with a response rate of 10.8% (3,018 members) and a CI of ±1.7%. FINDINGS: The evaluation found that payment for ob-gyns is heavily influenced by the values and rates set by third-party payers, a patient case-mix that includes a higher-than-average number of patients with Medicaid insurance, and the increase of employed physicians reliant on salary contracts that include productivity requirements and bonuses. RECOMMENDATIONS: The Committee identified action items, including payment reform for obstetric services; advocating for gynecologic surgery time as a priority for hospital administration; developing resources to assist employed physicians with payment, practice, and business management; developing a business and coding curriculum for students and early-career physicians; and continued advocacy with private and public policymakers who influence physician payment.

UpToDate versus DynaMed: a cross-sectional study comparing the speed and accuracy of two point-of-care information tools.

OBJECTIVE: To compare the accuracy, time to answer, user confidence, and user satisfaction between UpToDate and DynaMed (formerly DynaMed Plus), which are two popular point-of-care information tools. METHODS: A crossover study was conducted with medical residents in obstetrics and gynecology and family medicine at the University of Toronto in order to compare the speed and accuracy with which they retrieved answers to clinical questions using UpToDate and DynaMed. Experiments took place between February 2017 and December 2019. Following a short tutorial on how to use each tool and completion of a background survey, participants attempted to find answers to two clinical questions in each tool. Time to answer each question, the chosen answer, confidence score, and satisfaction score were recorded for each clinical question. RESULTS: A total of 57 residents took part in the experiment, including 32 from family medicine and 25 from obstetrics and gynecology. Accuracy in clinical answers was equal between UpToDate (average 1.35 out of 2) and DynaMed (average 1.36 out of 2). However, time to answer was 2.5 minutes faster in UpToDate compared to DynaMed. Participants were also more confident and satisfied with their answers in UpToDate compared to DynaMed. CONCLUSIONS: Despite a preference for UpToDate and a higher confidence in responses, the accuracy of clinical answers in UpToDate was equal to those in DynaMed. Previous exposure to UpToDate likely played a major role in participants' preferences. More research in this area is recommended.

Gynecologic oncology treatment modifications or delays in response to the COVID-19 pandemic in a publicly funded versus privately funded North American tertiary cancer center.

OBJECTIVE: To compare gynecologic oncology surgical treatment modifications and delays during the first wave of the COVID-19 pandemic between a publicly funded Canadian versus a privately funded American cancer center. METHODS: This is a retrospective cohort study of all planned gynecologic oncology surgeries at University Health Network (UHN) in Toronto, Canada and Brigham and Women's Hospital (BWH) in Boston, USA, between March 22,020 and July 302,020. Surgical treatment delays and modifications at both centers were compared to standard recommendations. Multivariable logistic regression was performed to adjust for confounders. RESULTS: A total of 450 surgical gynecologic oncology patients were included; 215 at UHN and 235 at BWH. There was a significant difference in median time from decision-to-treat to treatment (23 vs 15 days, p < 0.01) between UHN and BWH and a significant difference in treatment delays (32.56% vs 18.29%; p < 0.01) and modifications (8.37% vs 0.85%; p < 0.01), respectively. On multivariable analysis adjusting for age, race, treatment site and surgical priority status, treatment at UHN was an independent predictor of treatment modification (OR = 9.43,95% CI 1.81-49.05, p < 0.01). Treatment delays were higher at UHN (OR = 1.96,95% CI 1.14-3.36 p = 0.03) and for uterine disease (OR = 2.43, 95% CI 1.11-5.33, p = 0.03). CONCLUSION: During the first wave of COVID-19 pandemic, gynecologic oncology patients treated at a publicly funded Canadian center were 9.43 times more likely to have a surgical treatment modification and 1.96 times more likely to have a surgical delay compared to an equal volume privately funded center in the United States.

Current Trends in Compensation for Fellowship in Minimally Invasive Gynecologic Surgery Graduates: A 6-Year Follow-Up.

STUDY OBJECTIVE: To present updated information regarding compensation patterns for Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)-graduated physicians in the United States beginning practice during the last 10 years, focusing on the variables that have an impact on differences in salary, including gender, fellowship duration, geographic region, practice setting, and practice mix. DESIGN: An online survey was sent to FMIGS graduates between March 15, 2019 and April 12, 2019. Information on physicians' demographics, compensation (on the basis of location, practice model, productivity benchmarks, academic rank, and years in practice), and attitudes toward fairness in compensation was collected. SETTING: Online survey. PARTICIPANTS: FMIGS graduates practicing in the United States. INTERVENTION: E-mail survey. MEASUREMENTS AND MAIN RESULTS: We surveyed 298 US FMIGS surgeons who had graduated during the last 10 years (2009-2018). The response rate was 48.7%. Most of the respondents were women (69%). Most of the graduates (84.8%) completed 2- or 3-year fellowship programs. After adjustment for inflation, the median starting salary for the first postfellowship job was $252 074 ($223 986-$279 983) (Table 1). The median time spent in the first job was 2.6 years, and the median total salary at the current year rose to $278 379.4 ($241 437-$350 976). The median salary for respondents entering a second postfellowship job started at $280 945 ($261 409-$329 603). Significantly lower compensation was reported for female FMIGS graduates in their initial postfellowship jobs and was consistently lower than for that of men over time. Most FMIGS graduates (59.7%) reported feeling inadequately compensated for their level of specialization. CONCLUSION: A trend toward higher self-reported salaries is noted for FMIGS graduates in recent years, with significant differences in compensation between men and women. Among obstetrics and gynecology subspecialists, FMIGS graduates earn significantly less than other fellowship-trained physicians, with median salaries that are lower than those of generalist obstetrics and gynecology physicians.

Discrepancies between author- and industry-reported disclosures of financial relationships at an annual gynecologic oncology research meeting.

OBJECTIVE: Trillions of dollars pass to physicians from industry-related businesses annually, leading to many opportunities for financial conflicts of interest. The Open Payments Database (OPD) was created to ensure transparency. We describe the industry relationships as reported in the OPD for presenters at the 2019 Society of Gynecologic Oncology (SGO) Annual Meeting and evaluate concordance between author disclosures of their financial interests and information provided by the OPD. METHODS: This is an observational, cross-sectional study. Disclosure data were collected from authors with oral and featured abstract presentations in the 2019 SGO annual conference. These disclosures were compared to data available for each author in the 2018 OPD, which included the amount and nature of industry payments. RESULTS: We examined the disclosures of 301 authors who met inclusion criteria. Of 161 authors who had disclosure statements on their presentations,147 reported "no disclosures," and 14 disclosed industry relationships. The remaining 140 did not list any disclosure information. Sixty percent (184/301) of authors had industry relationships in the 2018 OPD, including 173 of 287 (60.3%) of authors who either reported no disclosures or did not have disclosure data available in their presentations. These transactions totaled over 43 million USD from 122 different companies, with most payments (46%) categorized as "Research or Associated Research." Accurate disclosure reporting was associated with receiving higher payments or research payments, and being a presenting author. CONCLUSIONS: Most authors at the SGO annual conference did not correctly disclose their industry relationships when compared with their entries in the OPD.

Private Equity Investments in Women's Health and Obstetrics and Gynecology Practices.

Private equity has evolved into a major force in health care, with deal values and volumes rising year-over-year as these firms purchase hospital systems and physician groups. Historically, these investors have played an outsized role in highly reimbursed specialties such as dermatology and anesthesia. Private equity is relatively new to women's health; when it has invested in this sector, it has typically done so in fertility services. In recent years, however, private equity firms have ventured into general obstetrics and gynecology, drawn by its promise of steady returns, its fragmented landscape, and the potential to integrate related laboratory, ultrasound, and fertility services into obstetric care. Obstetrics and gynecology practices may soon face the prospect of acquisition by private equity firms offering professional management, centralized back-office functions, streamlined customer service, and the capital needed to reach a broader patient base. However, physicians may have concerns about the tradeoffs that accompany private equity acquisitions. Private equity-owned practices have been known to increase the use of lucrative services, deploy advanced practice professionals in place of physicians, and circumvent conflict-of-interest laws, potentially distorting clinical care and driving up costs for consumers. Furthermore, firms generally aim to exit their investment within a 3- to 7-year timeframe, and short-term growth plans may leave physician-owners with uncertain long-term management. As private equity makes headway into women's health, physicians and policymakers must pay closer attention to how this activity can change practice patterns and transform local health care markets while also demanding transparency in the process.

Real world experience of poly (ADP-ribose) polymerase inhibitor use in a community oncology practice.

OBJECTIVE: This study aims to describe the real-world experience, including the clinical and financial burden, associated with PARP inhibitors in a large community oncology practice. METHODS: Retrospective chart review identified patients prescribed olaparib, niraparib or rucaparib for maintenance therapy or treatment of recurrent ovarian, primary peritoneal or fallopian tube cancer across twelve gynecologic oncologists between December 2016 and November 2018. Demographic, financial and clinical data were extracted. One PARP cycle was defined as a single 28-day period. For patients treated with more than one PARPi, each course was described separately. RESULTS: A total of 47 patients and 506 PARP cycles were identified (122 olaparib, 24%; 89 rucaparib, 18%; 294 niraparib, 58%). Incidence of grade ≥ 3 adverse events were similar to previously reported. Toxicity resulted in dose interruption, reduction and discontinuation in 69%, 63% and 29% respectively. Dose interruptions were most frequent for niraparib but resulted in fewer discontinuations (p-value 0.01). Mean duration of use was 7.46 cycles (olaparib 10.52, rucaparib 4.68, niraparib 7.34). Average cost of PARPi therapy was $8018 per cycle. A total of 711 phone calls were documented (call rate 1.4 calls/cycle) with the highest call volume required for care coordination, lab results and toxicity management. CONCLUSIONS: Although the toxicity profile was similar to randomized clinical trials, this real-world experience demonstrated more dose modifications and discontinuations for toxicity management than previously reported. Furthermore, the clinical and financial burden of PARP inhibitors may be significant and future studies should assess the impact on patient outcomes.

Salary Disparities in Academic Urogynecology: Despite Increased Transparency, Men Still Earn More Than Women.

OBJECTIVE: To understand the compensation differences between male and female academic urogynecologists at public institutions. METHODS: Urogynecologists at public universities with publicly available salary data as of June 2019 were eligible for the study. We collected characteristics, including sex, additional advanced degrees, years of training, board certification, leadership roles, number of authored scientific publications, and total National Institutes of Health funding projects and number of registered clinical trials for which the physician was a principal or co-investigator. We also collected total number of Medicare beneficiaries treated and total Medicare reimbursement as reported by the Centers for Medicare & Medicaid Services. We used linear regression to adjust for potential confounders. RESULTS: We identified 85 academic urogynecologists at 29 public state academic institutions with available salary data eligible for inclusion in the study. Males were more likely to be an associate or a full professor (81%) compared with females (55%) and were more likely to serve as department chair, vice chair, or division director (59%) compared with females (30%). The mean annual salary was significantly higher among males ($323,227 ± $97,338) than females ($268,990 ± $72,311, P = 0.004). After adjusting for academic rank and leadership roles and years since residency, the discrepancy persisted, with females compensated on average $37,955 less annually. CONCLUSIONS: Salaries are higher for male urogynecologists than female urogynecologists, even when accounting for variables such as academic rank and leadership roles. Physician compensation is complex; the differences observed may be due to variables that are not captured in this study. Nevertheless, the magnitude of disparity found in our study warrants further critical assessment of potential biases within the field.

Clinical implications and economic effects of the Coronavirus pandemic on gynecology, obstetrics and reproductive medicine in Germany: learning from Italy.

The infection with the novel SARS Cov-2 Coronavirus, the cause of severe acute respiratory distress syndrome, possessing its origin in the Chinese province Hubei, has reached the extent of a global pandemic within a few months. After aerosol infection, most people experience mild respiratory infection with cold symptoms such as cough and fever, and healing within two weeks. In about 5% of those infected, however, a severe course develops with the occurrence of multiple subpleural bronchopulmonary infiltrates and even death as a result of respiratory failure. The Coronavirus pandemic has multiple impacts on social life that have not been seen before. For example, the government adopted measures to curb the exponential spread of the virus, which included a significant reduction in social contacts. Furthermore, the specialist societies recommended that no elective treatments be carried out during the pandemic period. This review article considers epidemiological aspects of novel Coronavirus infection and presents both the clinical as well the possible economic effects of the pandemic on gynecology, obstetrics and reproductive medicine in Germany in the past, present and future. In addition, useful preventive measures for daily clinical work and the previously known scientific findings dealing with the impact of Coronavirus on pregnancy and birth are discussed.

Contemporary Patterns of Third-line Treatments for Privately Insured Individuals With Overactive Bladder in the United States.

OBJECTIVE: To evaluate utilization of third-line overactive bladder (OAB) treatments including percutaneous tibial nerve stimulation (PTNS), sacral nerve stimulation (SNS), and intradetrusor botulinum toxin A (BTX) among privately insured patients and examine factors associated with their use. MATERIALS AND METHODS: Using MarketScan claims (2015-2017), we identified patients who underwent third-line OAB treatments based on procedure codes. Factors of interest included location, age, health plan, among others. We fit multivariable logistic regression models to estimate associations between pertinent factors with receipt of PTNS and SNS relative to BTX and associations between provider type and practice location with each treatment modality. RESULTS: We identified 7383 patients (mean age 50.9) in our cohort. SNS was used most frequently (n = 3602, 48.8%), while PTNS was used least frequently (n = 955, 12.9%). PTNS patients were more likely to reside in metropolitan areas (vs BTX: OR 1.6, 95%CI 1.3-2.1; vs SNS: OR 2.2, 95%CI 1.7-2.8), be aged 55 years or older (vs BTX: 54% vs 47%, OR 1.6, 95%CI 1.2-2.1; vs SNS: 54% vs 45%, OR 1.6, 95%CI 1.2-2.0), and be covered under a health maintenance organization (vs BTX: 17% vs 10%; vs SNS: 17% vs 10%, P <.01). Urologists were most likely to perform SNS, and gynecologists were most likely to perform BTX. 91% of PTNS procedures were performed in office settings. CONCLUSION: Among patients receiving third-line OAB treatment, PTNS was used infrequently. PTNS utilization was concentrated within urban areas, and among older patients and those covered by cost-conscious health maintenance organizations.

Cost and reimbursement of providing routine vaccines in outpatient obstetrician/gynecologist settings.

OBJECTIVE: To determine the costs and reimbursement associated with running a vaccine program in 5 obstetrics/gynecology practices in Colorado that had participated in a 3-year randomized, controlled trial focused on increasing vaccination in this setting. MATERIALS AND METHODS: This was a secondary analysis on costs from 5 clinics participating in a cluster-randomized controlled trial that assessed the effectiveness of a multimodal intervention to improve vaccination rates in outpatient obstetrics/gynecology clinics in central Colorado. The intervention included designation of an immunization champion within the practice, purchasing recommended vaccines for the practice, guidance on storage and management, implementing practices for routine identification of eligible patients for vaccination using the medical record, implementation of standing orders for vaccination, and vaccine administration to patients. Data on costs were gathered from office invoices, claims data, surveys and in-person observations during the course of the trial. These data incorporated supply and personnel costs for administering vaccines to individual patients that were derived from a combination of time-motion studies of staff and provider clinical activity, and practice reports, as well as costs related to maintaining the vaccination program at the practice level, which were derived from practice reports and invoices. Cost data for personnel time during visits in which vaccination was assessed and/or discussed, but no vaccine was given to the patient were also included in the main analysis. Data on practice revenue were derived from practice reimbursement records. All costs were described in 2014 dollars. The primary analysis was the proportion of costs for the program that were reimbursed, aggregated over all years of the study and combining all vaccines and practices, separated by obstetrics vs gynecology patients. RESULTS: Collectively the 5 clinics served >40,000 patient during the study period and served a population that was 16% Medicaid. Over the 3-year observation period, there were 6573 vaccination claims made collectively by the practices (4657 for obstetric patients, 1916 for gynecology patients). The most expensive component of the program was the material costs of the vaccines themselves, which ranged from a low of $9.67 for influenza vaccines, to a high of $141.40 for human papillomavirus vaccine. Staff costs for assessing and delivering vaccines during patient visits were minimal ($0.09-$1.24 per patient visit depending on the practice and whether an obstetrics or gynecology visit was being assessed) compared with staff costs for maintaining the program at a practice level (ie, assessing inventory, ordering and stocking vaccines; $0.89-$105.89 per vaccine dose given). When assessing all costs compared with all reimbursement, we found that vaccines for obstetrics patients were reimbursed at 159% of the costs over the study period, and for gynecology patients at 97% of the costs. Overall, the vaccination program was financially favorable across the practices, averaging 125% reimbursement of costs across the three study years. CONCLUSION: Providing routine vaccines to patients in the ambulatory obstetrics/gynecology setting is generally not financially prohibitive for practices, and may even be financially beneficial, though there is variability between practices that can affect the overall reimbursement margin.

Coding and Legal Issues in Obstetric and Gynecologic Ultrasound.

This article addresses coding and liability related to obstetric and gynecologic ultrasound examinations. The coding section includes an overview of general concepts, highlighting the differences between coding in hospital-owned facilities and provider-owned clinics. It also addresses the importance of correct International Classification of Diseases, 10th edition, coding, emphasizing the use of the most specific applicable codes. This section discusses proper coding and applicable parameters for early pregnancy and gynecologic ultrasound examination. The liability section addresses common errors leading to litigation in obstetric and gynecologic ultrasound practice. Examples are given demonstrating how such errors lead to liability actions.

Challenges in the Era of Coding and Corporatization.

The past 40 years have witnessed a major redesign of health care, largely driven by rampantly increasing costs and the perception of lack of better outcomes to justify those costs. Many demographic changes have also challenged the women's health care provider workforce, and evolving new payment systems are likewise a source of angst for these providers. Managed care is seeking to cut costs, and the challenge is to do so without sacrificing quality. Burnout is a new challenge in the present environment. There is now an opportunity to meet these challenges and provide the excellent care our patients deserve.

Gender variation in Medicare utilization and payments in gynecologic oncology.

OBJECTIVES: The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (POSPUF) and Medicare Physician and Other Supplier National Provider Identifier (POS NPI) Aggregate Report are publicly available files from the Center for Medicare and Medicaid Services that include payments to providers who care for fee-for-service Medicare recipients. The aim of this study was to analyze variability in gynecologic oncologists' Medicare reimbursements, with attention to differences in provider gender and time in practice. METHODS: The 2015 POSPUF and POS NPI were analyzed with respect to gynecologic oncologists. We searched external publicly available data sources to confirm subspecialty and to determine each provider's number of years in practice. Evaluation and management (E&M) and procedure/surgery codes were analyzed; drug delivery codes were excluded due to variability in billing by facility/hospital. RESULTS: The POS NPI file included 733 gynecologic oncologist providers receiving $55,626,739 in total payments. Female providers comprised 39% of gynecologic oncologists and received 31% of reimbursements (30% of E&M reimbursements and 24% of surgical reimbursements). During the first ten years in practice, female providers comprised 58% of providers and accounted for 52% of reimbursed services, compared to 38% of providers/26% of reimbursed services (11-20 years), and 18% of providers/19% of reimbursed services (>20 years). CONCLUSION: Male gynecologic oncologists perform more Medicare services than their female counterparts. There is a comparable number of services performed between genders among both the most senior and the most junior providers, with a gender gap in services and reimbursements among mid-career providers.

Surgical Equipment Price Awareness Amongst Obstetrician-Gynecologists.

BACKGROUND AND OBJECTIVES: Physicians typically have little information of surgical device pricing, although this trend has not been studied in the field of obstetrics and gynecology. We therefore aimed to determine how accurately obstetrician-gynecologists estimate surgical device prices, and to identify factors associated with accuracy. METHODS: An anonymous survey was emailed to all obstetrician-gynecologist attendings, fellows, and residents at 3 teaching hospitals in a single healthcare system in Arizona. We obtained demographic data, perceptions of price transparency and self-rated price knowledge, and price estimates for 31 surgical devices. RESULTS: After participants provided consent and demographics, they then estimated the purchasing price of 31 devices. We defined price accuracy as being within ±10% of the hospital's purchasing price. Fifty-six of the 170 (32.9%) invitees completed the survey and 48 (28.2%) provided price estimates. On average, participants identified 1.9 items correctly (6.1%; range, 0-7 items) out of 31 with no difference in accuracy based on seniority, surgical volume, physician reimbursement structure, nor subspecialty practice-focus. All (100%) respondents felt pricing should be transparent, and only 1.8% felt it is at least somewhat transparent. CONCLUSION: We found that price-estimate accuracy was very low and had no association with any of the demographics. Also notable was the perception that pricing is not transparent despite a unanimous desire for transparency. Although physicians reported a preference for using less-expensive surgical devices, we conclude that physicians are unequipped to make cost-conscious decisions highlighting a large potential for education.