An expanding role for interventional radiology: Medicare trends in fluoroscopic, endoscopic, and surgical enteric tube placement and maintenance from 2010 to 2018.

BACKGROUND: The purpose of this study is to provide an update on trends in physician volume and payments for enteric tube placement and maintenance procedures by method, provider specialty, and practice setting amongst Medicare beneficiaries from 2010 to 2018. MATERIALS AND METHODS: Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 were extracted using current procedural terminology (CPT) codes for gastrostomy and jejunostomy placement, as well as conversion of gastrostomy to gastrojejunostomy, fluoroscopy guided and non-image guided replacement. Total volumes and provider reimbursement were analyzed by provider specialty and practice setting. RESULTS: Volume of de novo placement of all enteric tubes decreased from 157,123 to 106,549 (-32.2%). While endoscopic placement decreased from 133,658 to 81,171 (-39.3%), the volume of fluoroscopic placement increased from 17,999 to 21,277 (18.2%). Fluoroscopic placement was largely performed by interventional radiology (IR) (91.7% in 2018). Surgical placement decreased from 5466 to 4101 (-25.0%). Volume of fluoroscopic replacement increased from 24,799 to 38,470 (55.1%), while non-image guided replacements decreased from 61,377 to 55,116 (-10.2%). Share of both fluoroscopic and non-image guided replacements by advanced practice providers (APPs) more than doubled over this time period. CONCLUSION: De novo placement of enteric tubes decreased from 2010 to 2018, likely related to increased awareness of the complications and limited benefits in scenarios such as end of life care. In contrast to the diminishing volume for gastroenterologists, there was increased participation by IR in both placement and maintenance procedures under fluoroscopic guidance. SUMMARY STATEMENT: Decreasing placement of enteric tubes suggests shifting attitudes and recommendations around end-of-life care. Increase in role by IR/APPs highlights the need for comprehensive care in these patients.

Percutaneous ablation versus surgical ablation and resection of liver tumors: medicare volume and physician reimbursement trends from 2010 to 2018.

PURPOSE: The purpose of this study is to analyze trends in Medicare volume and physician reimbursement for percutaneous ablation, surgical ablation, and resection of liver tumors from 2010 to 2018. METHODS: Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the CPT codes for percutaneous and surgical ablation of liver tumors and surgical liver resection. Total procedural volume and physician payment were analyzed by procedure and physician specialty. RESULTS: From 2010 to 2018, the volume of percutaneous ablation of liver tumors increased 94.3% from 1630 to 3168 procedures, and the volume of surgical ablations increased 86.2% from 593 to 1104 procedures. In contrast, there was a 16.8% decrease in liver resections from 10,807 to 8994 procedures. Physician reimbursement for percutaneous ablation decreased from $702.41 to $610.11 (- 13.1%). Conversely, reimbursement for resection increased from $849.18 to $1015.06 (19.5%). Reimbursement for surgical ablation also increased from $722.36 to $744.25 (3.0%). In 2018, physician reimbursement for resection and surgical ablation were 66% and 22% more than that for percutaneous ablation. CONCLUSION: An increasing number of patients with liver tumors were treated with percutaneous ablation from 2010 to 2018. Despite higher morbidity, a dwindling set of theoretical advantages over percutaneous ablation, and higher overall costs, the volume of surgical ablation also increased over this time period. The findings of this study suggest that a reevaluation of practice and referral patterns for surgical ablation of liver tumors is warranted in many institutions.

Effects of the MAGIC Guidelines on PICC Placement Volume: Advanced Practice Provider and Physician Trends Among Medicare Beneficiaries From 2010 to 2018.

BACKGROUND. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was published in 2015, recommending more restricted indications for peripherally inserted central catheter (PICC) placement, particularly for those placed by physicians. Changes in PICC placement volume since the publication of MAGIC is largely unknown. OBJECTIVE. The purpose of this article was to study the trends in volume and reimbursement for PICC placement by physicians and advanced practice providers (APPs) for Medicare enrollees from 2010 to 2018 with specific attention to the changes in volume after the publication of MAGIC in 2015. METHODS. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File for the years 2010-2018 were extracted using the Current Procedural Terminology code for PICC placement. Total volume and payment amounts (for the professional component) were analyzed. Trendline slopes for volume per 100,000 Medicare beneficiaries before and after the 2015 publication of MAGIC were compared. RESULTS. Volume for PICC placement by physicians and APPs steadily declined from 243,837 in 2010 to 130,361 in 2018 (46.5%). The PICC placement volume decreased sharply after the 2015 publication of the MAGIC guidelines. The slope of the trendline for all providers from 2010 to 2015 was -3.4 compared with -7.3 from 2015 to 2018. The change in slope was more pronounced for radiologists (-3.1 to -5.6) than for APPs (0.0 to -1.1). Professional payment per procedure for radiologists decreased from $78.04 in 2010 to $70.17 in 2018, and reimbursement for APPs proportionally decreased from $65.76 to $60.66 during this time. The relative share of PICC placement by radiologists declined from 77.0% in 2010 to 70.6% in 2018, with a corresponding increase in relative share by APPs from 13.5% to 18.4%. The percentage placed in outpatient procedures increased from 15.1% to 18.2%. CONCLUSION. The volume of PICC placements has steadily decreased since 2010, with a sharper decline between 2015 and 2016 corresponding with the publication of the MAGIC evidence-based guidelines. The role of APPs in PICC placement has increased over this time period. CLINICAL IMPACT. The findings of this study suggest that evidence-based guidelines impact clinical practice on a national level.

Bundled Medicare Payments: Trends in Utilization and Physician Payments for Dialysis Arteriovenous Fistula and Graft Maintenance Procedures From 2010 to 2018.

OBJECTIVE. The purposes of this study were to evaluate the volume of and payments for dialysis arteriovenous fistula and arteriovenous graft maintenance procedures among Medicare beneficiaries from 2010 to 2018 and analyze trends by physician specialty and practice setting after the introduction of bundled Current Procedural Terminology (CPT) codes in 2017. MATERIALS AND METHODS. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File for the years 2010 through 2018 were extracted by use of the CPT codes for arteriovenous fistula and arteriovenous graft maintenance procedures. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty and practice setting. RESULTS. From 2010 to 2018, the volume of dialysis circuit maintenance procedures increased 25%, from 308,140 to 385,440 procedures. This increase was driven by increased volumes among nephrologists (30.0%) and surgeons (30.5%) with only a modest increase for interventional radiologists (1.5%). Total physician payments increased 20%, from $333.8 million to $399.5 million. After the introduction of bundled CPT codes in 2017, per-procedure physician payment decreased from $1073 in 2016 to $1025 in 2017 (4.5%). The true decrease in per-procedure payment was underestimated owing to inclusion of higher-cost stenting and embolization procedures in the dialysis-specific codes beginning in 2017. CONCLUSION. The volume of dialysis access maintenance procedures and total physician payments increased from 2010 to 2018 in keeping with the Centers for Medicare & Medicaid Services Fistula First Breakthrough Initiative. Introduction of bundled CPT codes in 2017, designed to reduce redundant payments, correlated with a decrease in average per-procedure physician payment.

Trends of utilization and physician payments for vertebroplasty and kyphoplasty procedures by physician specialty and practice setting: 2010 to 2018.

BACKGROUND CONTEXT: In 2010, the American Academy of Orthopedic Surgeons published guidelines strongly recommending against the use of vertebroplasty following the publication of randomized control trials that failed to show significant improvement in pain. Vertebroplasty has remained controversial since those findings. PURPOSE: To study and provide an update on utilization of vertebroplasty and kyphoplasty procedures among Medicare beneficiaries by physician specialty and practice setting following publication of recommendations against vertebroplasty in 2010. STUDY DESIGN/SETTING: This study uses Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 to determine trends in volume and reimbursement by physician specialty and practice setting. PATIENT SAMPLE: All vertebral augmentation procedures with a physician reimbursement claims approved by Medicare Part B from 2010 to 2018. OUTCOME MEASURES: This study analyzes trends in volume and physician payment of vertebroplasty and kyphoplasty procedures by physician specialty for the time period 2010 to 2018. METHODS: Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the Current Procedural Terminology codes for vertebroplasty and kyphoplasty. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty. RESULTS: Between 2010 and 2018, the total volume of vertebroplasties decreased by 61.2% (29,995 to 11,654), whereas the volume of kyphoplasties increased modestly by 14.4% (59,691 to 68,294). Radiologists performed an increasing share of both procedures over this time period, from 68.5% to 75.1% for vertebroplasties and 28.9% to 37.1% for kyphoplasties. Total payment for vertebroplasties decreased by 74.3% from $14.8 million in 2010 to $3.8 million in 2018; whereas it increased by 235.3% for kyphoplasty procedures from $26.7 million to $89.7 million. This is driven in large part by a 6,833% increase in office based kyphoplasties which bill at the higher nonfacility rate that incorporates overhead, staff, and equipment. CONCLUSIONS: Previous studies have demonstrated mixed evidence for benefits of vertebroplasty procedures and decreasing volumes over time. Data show continued downtrend in vertebroplasty and increased utilization of kyphoplasty among Medicare beneficiaries. In addition, the growing number of kyphoplasties correlated with a sharp rise in volume and increased reimbursement for office-based procedures. Radiologists have been performing an increasing share of both procedures.