Analysis of 10-year trends in Medicare Physician Fee Schedule payments in surgery.

BACKGROUND: Medicare expenditures have steadily increased over the decades, and yet Medicare Physician Fee Schedule payments for individual services have declined. We examine trends in Medicare Physician Fee Schedule payments for office visits, inpatient visits, and surgical procedures. METHODS: The Medicare Physician Fee Schedule Look-Up Tool was queried for payment data for office visits, inpatient visits, and surgical procedures between 2013 and 2023. All data were adjusted for inflation using the Consumer Price Index. Trends in payments were calculated for 5 common procedures in each surgical specialty. Trends in aggregate national health expenditures were compared to Medicare Physician Fee Schedule payments for physician services from 2013 to 2021. RESULTS: The Consumer Price Index increased by 29.3% from 2013 to 2023. Inflation-adjusted per-visit Medicare Physician Fee Schedule payments decreased by 12.2% for outpatient office visits, 19.1% for inpatient visits, and 22.8% for surgical procedures from 2013 to 2023. This varied by surgical specialty: vascular (-25.8%), endocrine (-22.0%), general surgery (-27.0%), thoracic (-19.2%), surgical oncology (-22.1%), breast (-22.4%), urology (-2.2%), neurosurgery (-22.8%), obstetrics/gynecology (-19.9%), and orthopedics (-24.7%). Adjusted for inflation, national health expenditures increased by 33.9% for physician services from 2013 to 2021. In comparison, Medicare Physician Fee Schedule payments over the same time period 2013 to 2021 increased by 1.3% for outpatient office visits but decreased by 10.6% for inpatient visits and 9.8% for surgical procedures. CONCLUSION: Controlling rising national health expenditures is important and necessary, but 10 years of declining Medicare Physician Fee Schedule payments on a per-procedure basis in surgery would suggest that this strategy alone may not achieve those goals and could ultimately threaten access to quality surgical care. Surgeons must advocate for permanent payment reforms.

Recurrence Score Testing Does not Appear to Benefit Patients With Grade 1, Progesterone Receptor-Positive Breast Cancers: An Opportunity to Eliminate Overtreatment and Decrease Testing Costs.

BACKGROUND: We previously described a risk prediction model (Anne Arundel Medical Center [AAMC] model) based on pathology which may eliminate the need for recurrence score (RS) testing in select early-stage breast cancers. There is a concern that patients in discordant risk prediction groups (AAMC vs. RS) may be overtreated or undertreated if RS testing were omitted. METHODS: We queried the Surveillance, Epidemiology, and End Results (SEER) database for all breast cancer patients between 2004 and 2015. AAMC low-risk was defined as Grade 1 and progesterone receptor-positive (PR + ) tumors, while AAMC high-risk was defined as Grade 3 or estrogen-negative tumors. RS low-risk group was defined as RS < 16 and age ≤ 50 years, or RS ≤ 25 and age > 50 years. RS high-risk group was defined as RS > 25. RESULTS: A total of 71,212 cases were analyzed. Of these, 590 were AAMC low-risk/RS high-risk discordant, while 5,596 were AAMC high-risk/RS low-risk discordant. For AAMC low-risk/RS high-risk discordant, 10-year breast cancer-specific survival (BCSS) did not differ for patients who received adjuvant chemotherapy versus those who did not (93% chemotherapy vs. 99% unknown/no chemotherapy, p = .12). Overall survival (OS) was also comparable (92% chemotherapy vs. 91% unknown/no chemotherapy, p = .42). In the AAMC high-risk/RS low-risk discordant group, 10-year BCSS (92% chemotherapy vs. 96% unknown/no chemotherapy, p = .06) and OS (87% chemotherapy vs. 90% unknown/no chemotherapy, p = .52) did not differ between adjuvant chemotherapy and unknown/no chemotherapy groups. CONCLUSIONS: Adjuvant chemotherapy in the AAMC low-risk/RS high-risk and AAMC high-risk/RS low-risk discordant groups did not improve survival. This supports consideration of omission of RS testing in Grade 1, PR + tumors. Patients with Grade 3 tumors do benefit from RS testing.

Bundled Payments for Appendectomy: a Model of Financial Implications to Institutions.

BACKGROUND: Bundled payments are increasingly becoming common in surgery, yet little is known regarding their potential impact on reimbursements for patients presenting with acute appendicitis. This study examines the financial impact of bundled payments for acute appendicitis. METHODS: This was a retrospective review of all open or laparoscopic appendectomies between July 2014 and June 2017. Patients that were not candidates for surgery were not included in this review. RESULTS: Of the total 741 patients, 42.1% were diagnosed with complicated acute appendicitis. The median length of stay was 1 day (range, 0 to 21 days). The median hospital cost was $4183 (range, $2075 to $71,023). The 90-day readmission rate was 3.2%, with a mean cost of $5025 per readmission (range, $1595 to $10,795). Length of stay, hospital costs, and 90-day readmissions were significantly higher for complicated versus uncomplicated acute appendicitis. In our current fee-for-service model, hospital reimbursements resulted in margins of - 4.0% to 24.6% depending on the severity of disease. If we assume that bundled payments do not reimburse for readmissions, we estimate that our hospital would incur losses of - 5.7% for patients with acute appendicitis with localized peritonitis and - 20.2% for patients with acute appendicitis with generalized peritonitis. CONCLUSIONS: As bundled payments become more common, hospitals may incur significant losses for acute appendicitis under a model that does not reflect the heterogeneous nature of patients requiring appendectomies. These losses can range up to - 20.2% for complicated cases. Improving clinical outcomes by reducing readmissions may mitigate some of these anticipated losses.

Are we ready for bundled payments for major bowel surgery?

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) recently announced a new voluntary episode payment model for major bowel surgery. The purpose of this study was to examine the financial impact of bundled payments for major bowel surgery. METHODS: An institutional database was retrospectively queried for all patients who underwent major bowel surgery between July 2016 and June 2018. Procedures were categorized using MS-DRG coding: MS-DRG 329 (with MCC, major complications and comorbidity), MS-DRG 330 (with CC, complications and comorbidity), and MS-DRG 331 (without CC/MCC). RESULTS: A total of 745 patients underwent 798 procedures, with mean age 62.1 years and BMI 29.2 kg/m2. The median LOS was 4.0 days, with 12.5% of patients being discharged to a post-acute care facility for an average of 38.5 days. The mean hospital cost was $18,525. The mean payment to a post-acute care facility was $423 per day. The 90-day readmission rate was 8.6% at an average cost of $12,859 per readmission. Patients with major complications and comorbidity (MS-DRG 329) had higher CMS Hierarchical Condition Categories scores, longer LOS, higher costs, more required home health services or post-acute care facilities, and had higher 90-day readmissions. In a fee-for-service model, hospital reimbursements resulted in a negative margin of - 8.2% for MS-DRG 329, - 2.6% for MS-DRG 330, but a positive margin of 2.8% for MS-DRG 331. In a bundled payment model, the hospital would incur a loss of - 13.1%, - 11.1%, and - 1.9% for MS-DRG 329, 330, and 331, respectively. CONCLUSIONS: Patients undergoing major bowel surgery are often a heterogeneous population with varied pre-existing comorbid conditions who require a high level of complex care and utilize greater hospital resources. Further study is needed to identify areas of cost containment without compromising the overall quality of care.

The trend toward minimally invasive complex abdominal wall reconstruction: is it worth it?

BACKGROUND: Open abdominal wall reconstruction (AWR) was previously one of the only methods available to treat complex ventral hernias. We set out to identify the impact of laparoscopy and robotics on our AWR program by performing an economic analysis before and after the institution of minimally invasive AWR. METHODS: We retrospectively reviewed inpatient hospital costs and economic factors for a consecutive series of 104 AWR cases that utilized separation of components technique (57 open, 38 laparoscopic, 9 robotic). Patients were placed into two groups by date of procedure. Group 1 (Pre MIS) was July 2012-June 2015 which included 52 open cases. Group 2 (Post MIS) was July 2015-August 2016 which included 52 cases (5 open, 38 laparoscopic, 9 robotic). RESULTS: A total of 104 patients (52 G1 vs. 52 G2) with mean age (54.2 vs. 54.1 years, p = 0.960), BMI (34.7 vs. 32.1 kg/m2, p = 0.059), and ASA score (2.5 vs. 2.3, p = 0.232) were included in this review. Total length of stay (LOS) was significantly shorter for patients in the Post MIS group (5.3 vs. 1.4 days, p < 0.001). Although operating room (OR) supply costs were $1705 higher for the Post MIS group (p = 0.149), total hospital costs were $8628 less when compared to the Pre MIS group (p < 0.001). Multiple linear regressions identified increased BMI (p = 0.021), longer OR times (p = 0.003), and LOS (p < 0.001) as predictors of higher total costs. Factors that were predictive of longer LOS included older patients (p = 0.003) and patients with larger defect areas (p = 0.004). MIS was predictive of shorter hospital stays (p < 0.001). CONCLUSIONS: Despite an increase in operating room supply costs, transition to performing MIS AWR in cases that were previously done through an open approach decreased LOS and translated into significant overall total cost savings.

The Cost of Unnecessary Hospital Days for Medicare Joint Arthroplasty Patients Discharging to Skilled Nursing Facilities.

BACKGROUND: The 72-hour Medicare mandate (3-night stay rule) requires a 3-day inpatient stay for patients discharging to skilled nursing facilities (SNFs). Studies show that 48%-64% of Medicare total joint arthroplasty (TJA) patients are safe for discharge to SNFs on postoperative day (POD) #2. The purpose of this study was to extrapolate the financial impact of the 3-night stay rule. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJAs performed in 2015. Discharge destination was recorded. Institutional cost accounting examined costs for patients discharging on POD #2 vs POD #3. RESULTS: A total of 42,423 TJAs (14,395 total hip arthroplasties [THAs] and 28,028 total knee arthroplasties [TKAs]) were performed in patients over the age of 65 years. Of these patients, 5252 THAs (36.5%) and 12,022 TKAs (42.9%) were discharged from the hospital on POD #3, with 2404 THAs (16.7%) and 5083 TKAs (18.1%) being discharged to SNFs. Institutional cost accounting revealed hospital costs for THA were $2014 more, whereas hospital costs for TKA were $1814 more for a 3-day length of stay when compared with a 2-day length of stay (P < .001). The mean charge per day for an SNF was $486. CONCLUSION: The National Surgical Quality Improvement Program database is a representative sample of all surgeries performed in the United States. Extrapolating our findings to all Medicare TJAs nationally gives an estimated $63 million in annual savings. Medicare mandated, but potentially medically unnecessary inpatient days at a higher level of care increase the total cost for TJAs. Policies regarding minimum stay requirements before discharge should be re-evaluated.

Incidence, Risk Factors, and Costs for Hospital Returns After Total Joint Arthroplasties.

BACKGROUND: Unplanned hospital returns after total joint arthroplasty (TJA) reduce any cost savings in a bundled reimbursement model. We examine the incidence, risk factors, and costs for unplanned emergency department (ED) visits and readmissions within 30 days of index TJA. METHODS: We retrospectively reviewed a consecutive series of 655 TJAs (382 total knee arthroplasty and 273 total hip arthroplasty) performed between April 2014 and March 2015. Preoperative diagnosis was osteoarthritis of the hip or knee (97%) or avascular necrosis of the hip (3%). Hospital costs were recorded for each ED visit and readmission episode. RESULTS: Of the 655 TJAs reviewed, 55 (8.4%) returned to the hospital. Of these hospital returns, 35 patients (5.3%) returned for a total of 36 unplanned ED visits whereas the remaining 20 patients (3.1%) presented 22 readmissions within 30 days of index TJA. The 2 most common reasons for unplanned ED visits were postoperative pain/swelling (36%) and medication-related side effects (22%). Avascular necrosis of the hip was a significant risk factor for an unplanned ED visit (7.27 odds ratio [OR], 95% confidence interval [CI] 1.67-31.61, P = .008). Multiple logistic regression analysis revealed the following risk factors for readmission: body mass index (1.10 OR, 95% CI 1.02-1.78, P = .013), comorbidity >2 (2.07 OR, 95% CI 1.06-6.95, P = .037), and prior total knee arthroplasty (2.61 OR, 95% CI 1.01-6.72, P = .047). Ambulating on the day of surgery trended toward a lower risk for readmission (0.13 OR, 95% CI 0.02-1.10, P = .061). The 2 most common reasons for readmission were ileus (23%) and cellulitis (18%). The total cost associated with unplanned ED visits were $15,427 whereas costs of readmissions totaled $142,654. CONCLUSION: Unplanned ED visits and readmissions in the forthcoming bundled payments reimbursement model will reduce cost savings from rapid recovery protocols for TJA. Identifying and mitigating preventable causes of unplanned visits and readmissions will be critical to improving care and controlling costs.