Decreasing Medicare Utilization, Reimbursement, and Reimbursement-to-Charge Ratio of Reconstructive Plastic Surgery Procedures: 2010 to 2019.
Journal
Annals of plastic surgery
ISSN: 1536-3708
Titre abrégé: Ann Plast Surg
Pays: United States
ID NLM: 7805336
Informations de publication
Date de publication:
01 05 2022
01 05 2022
Historique:
pubmed:
13
9
2021
medline:
23
4
2022
entrez:
12
9
2021
Statut:
ppublish
Résumé
This study aimed to evaluate recent trends in utilization, reimbursement, and charges for reconstructive plastic surgery procedures billed to Medicare. We queried the Physician/Supplier Procedure Summary from the Centers for Medicare and Medicaid Services for procedures billed by plastic surgeons to Medicare Part B between 2010 and 2019. We collected service counts, charges, and reimbursements. We adjusted utilization by Medicare enrollment and adjusted monetary values for inflation. We calculated the weighted mean charge and reimbursement, which were used to calculate the reimbursement-to-charge ratio (RCR). We examined trends over time by calculating differences and performing correlation analyses of utilization, charges, reimbursement, and RCR for all procedures and for different procedural categories. From 2010 to 2019, the overall enrollment-adjusted utilization for 912 reconstructive procedures decreased by 6.6% (r2 = 0.46). Utilization increased in certain procedural categories such as skin debridement (+36.9%, r2 = 0.48) and procedures of the breast (+114.9%, r2 = 0.48). Charges increased by 32.9% (r2 = 0.99), reimbursement decreased by 5.3% (r2 = 0.84), and RCR decreased by 28.7% (r2 = 0.99). Skin replacement/flaps/grafts procedures underwent the greatest relative decrease in reimbursement (-26.8%, r2 = 0.87). Reimbursement-to-charge ratio decreased for all procedural categories except for procedures of the auditory system. In the past decade, Medicare utilization and reimbursement for reconstructive plastic surgery procedures decreased, whereas charges increased. This resulted in decreasing reimbursement relative to charged amounts. These findings raise concerns regarding the economic viability of providing plastic surgery services to an aging population and may impact patients' ability to access affordable plastic surgical care.
Sections du résumé
BACKGROUND
This study aimed to evaluate recent trends in utilization, reimbursement, and charges for reconstructive plastic surgery procedures billed to Medicare.
METHODS
We queried the Physician/Supplier Procedure Summary from the Centers for Medicare and Medicaid Services for procedures billed by plastic surgeons to Medicare Part B between 2010 and 2019. We collected service counts, charges, and reimbursements. We adjusted utilization by Medicare enrollment and adjusted monetary values for inflation. We calculated the weighted mean charge and reimbursement, which were used to calculate the reimbursement-to-charge ratio (RCR). We examined trends over time by calculating differences and performing correlation analyses of utilization, charges, reimbursement, and RCR for all procedures and for different procedural categories.
RESULTS
From 2010 to 2019, the overall enrollment-adjusted utilization for 912 reconstructive procedures decreased by 6.6% (r2 = 0.46). Utilization increased in certain procedural categories such as skin debridement (+36.9%, r2 = 0.48) and procedures of the breast (+114.9%, r2 = 0.48). Charges increased by 32.9% (r2 = 0.99), reimbursement decreased by 5.3% (r2 = 0.84), and RCR decreased by 28.7% (r2 = 0.99). Skin replacement/flaps/grafts procedures underwent the greatest relative decrease in reimbursement (-26.8%, r2 = 0.87). Reimbursement-to-charge ratio decreased for all procedural categories except for procedures of the auditory system.
CONCLUSIONS
In the past decade, Medicare utilization and reimbursement for reconstructive plastic surgery procedures decreased, whereas charges increased. This resulted in decreasing reimbursement relative to charged amounts. These findings raise concerns regarding the economic viability of providing plastic surgery services to an aging population and may impact patients' ability to access affordable plastic surgical care.
Identifiants
pubmed: 34510080
doi: 10.1097/SAP.0000000000002990
pii: 00000637-202205000-00016
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
549-554Informations de copyright
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
Conflicts of interest and sources of funding: none declared.
Références
Cosmetic Surgery Coverage. Available at: https://www.medicare.gov/coverage/cosmetic-surgery . Accessed December 31, 2020.
National Coverage Determination (NCD) for Breast Reconstruction Following Mastectomy (140.2). Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=64 . Accessed January 1, 2021.
Gaudette É, Tysinger B, Cassil A, et al. Health and health care of Medicare beneficiaries in 2030. Forum Health Econ Policy . 2015;18:75–96. doi:10.1515/fhep-2015-0037.
doi: 10.1515/fhep-2015-0037
Mahmoudi E, Kotsis SV, Chung KC. A review of the use of Medicare claims data in plastic surgery outcomes research. Plast Reconstr Surg Glob Open . 2015;3:e530. doi:10.1097/GOX.0000000000000497.
doi: 10.1097/GOX.0000000000000497
Rosenow JM, Orrico KO. Neurosurgeons' responses to changing Medicare reimbursement. Neurosurg Focus . 2014;37:E12. doi:10.3171/2014.8.FOCUS14427.
doi: 10.3171/2014.8.FOCUS14427
Gupta N, Haglin JM, Marostica CW, et al. Trends in Medicare reimbursement for reconstructive plastic surgery procedures: 2000 to 2019. Plast Reconstr Surg . 2020;1541–1551. doi:10.1097/PRS.0000000000006914.
doi: 10.1097/PRS.0000000000006914
Physician Fee Schedule Look-Up Tool | CMS. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup . Accessed May 29, 2021.
Nurok M, Gewertz B. Relative value units and the measurement of physician performance. JAMA . 2019;322:1139–1140. doi:10.1001/jama.2019.11163.
doi: 10.1001/jama.2019.11163
Potetz Lisa, Cubanski J, Neuman T. A Primer on Medicare . Vol 11.; 2015. http://kff.org/health-reform/issue-brief/a-primer-on-medicare-financing/ . Accessed October 23, 2020.
Eltorai AEM, Durand WM, Haglin JM, et al. Trends in Medicare reimbursement for orthopedic procedures: 2000 to 2016. Orthopedics . 2018;41:95–102. doi:10.3928/01477447-20180226-04.
doi: 10.3928/01477447-20180226-04
Dominguez JL, Ederaine SA, Haglin JM, et al. Medicare reimbursement trends for facility performed otolaryngology procedures: 2000–2019. Laryngoscope . 2020;131:496–501. doi:10.1002/lary.28749.
doi: 10.1002/lary.28749
Puri P, Kaur P, Bhullar S, et al. Trends in Medicare utilization and reimbursement for wound debridement procedures 2012–2017. J Dermatolog Treat . 2020;1–4. doi:10.1080/09546634.2020.1800581.
doi: 10.1080/09546634.2020.1800581
American College of Surgeons strongly opposes proposed Medicare physician fee schedule. Available at: https://www.facs.org/media/press-releases/2020/cms-rule-080420 . Accessed November 13, 2020.
Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021. CMS. Available at: https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4 . Accessed November 2, 2020.
Dusetzina SB, Basch E, Keating NL. For uninsured cancer patients, outpatient charges can be costly, putting treatments out of reach. Health Aff . 2015;34:584–591. doi:10.1377/hlthaff.2014.0801.
doi: 10.1377/hlthaff.2014.0801
Xu T, Park A, Bai G, et al. Variation in emergency department vs internal medicine excess charges in the United States. JAMA Intern Med . 2017;177:1139–1145. doi:10.1001/jamainternmed.2017.1598.
doi: 10.1001/jamainternmed.2017.1598
Key Facts about the Uninsured Population. KFF. Available at: https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ . Accessed January 17, 2021.
Provider charges relative to Medicare rates, 2012–2017. Available at: https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/12/05/provider-charges-relative-to-medicare-rates-2012-2017/ . Accessed March 12, 2021.
Centers for Medicare and Medicaid Services. New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services ; 2020:1–2. Available at: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/MM11750.pdf . Accessed January 2, 2021.
Physician/Supplier Procedure Summary. CMS. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Physician-Supplier-Procedure-Summary/index . Accessed October 23, 2020.
CPT® overview and code approval. American Medical Association. Available at: https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval . Accessed December 31, 2020.
CMS Program Statistics. CMS. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics . Accessed November 26, 2020.
Consumer Price Index Historical Tables for U.S. City Average: Mid-Atlantic Information Office. U.S. Bureau of Labor Statistics. Available at: https://www.bls.gov/regions/mid-atlantic/data/consumerpriceindexhistorical_us_table.htm . Accessed October 23, 2020.
Manikandan S. Measures of central tendency: the mean. J Pharmacol Pharmacother . 2011;2:140–142. doi:10.4103/0976-500X.81920.
doi: 10.4103/0976-500X.81920
Bai G, Anderson GF. Extreme markup: the fifty US hospitals with the highest charge-to-cost ratios. Health Aff . 2015;34:922–928. doi:10.1377/hlthaff.2014.1414.
doi: 10.1377/hlthaff.2014.1414
Anderson GF. From ‘soak the rich’ to ‘soak the poor’: recent trends in hospital pricing. Health Aff . 2007;26:780–789. doi:10.1377/hlthaff.26.3.780.
doi: 10.1377/hlthaff.26.3.780
Bai G, Chanmugam A, Suslow VY, et al. Air ambulances with sky-high charges. Health Aff (Millwood) . 2019;38:1195–1200. doi:10.1377/hlthaff.2018.05375.
doi: 10.1377/hlthaff.2018.05375
Fitzpatrick AM, Gao LL, Smith BL, et al. Cost and outcome analysis of breast reconstruction paradigm shift. Ann Plast Surg . 2014;73:141–149. Available at: https://journals.lww.com/annalsplasticsurgery/Fulltext/2014/08000/Cost_and_Outcome_Analysis_of_Breast_Reconstruction.7.aspx . Accessed January 1, 2021.
Sen CK. Human wounds and its burden: an updated compendium of estimates. Adv Wound Care . 2019;8:39–48. doi:10.1089/wound.2019.0946.
doi: 10.1089/wound.2019.0946
Bai G, Anderson GF. Variation in the ratio of physician charges to Medicare payments by specialty and region. JAMA . 2017;317:315–318. doi:10.1001/jama.2016.16230.
doi: 10.1001/jama.2016.16230
Cai Y, Boas SR, Summerville L, et al. National trends in hospitalization charges for autologous free flap breast reconstruction. Ann Plast Surg . 2020;85(S1 Suppl 1):S135–S140. doi:10.1097/SAP.0000000000002324.
doi: 10.1097/SAP.0000000000002324
Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Heal . 2017;21:27–32. doi:10.1016/j.jval.2017.07.007.
doi: 10.1016/j.jval.2017.07.007
Cooper Z, Morton FS, Shekita N. Surprise! Out-of-network billing for emergency care in the united states. Cambridge, MA: The University of Chicago Press Journals; 2017. doi:10.3386/w23623. Available at: https://www.journals.uchicago.edu/doi/abs/10.1086/708819 . Accessed August 23, 2021.
United States Government Accountability Office (GAO). Report to Congressional Committees. MEDICARE. Payment for Ambulatory Surgical Centers Should Be Based on the Hospital Outpatient Payment System; 2006. Available at: www.gao.gov/cgi-bin/getrpt?GAO-07-86 . Accessed January 11, 2021.
Yabroff KR, Zhao J, Han X, et al. Prevalence and correlates of medical financial hardship in the USA. J Gen Intern Med . 2019;34:1494–1502. doi:10.1007/s11606-019-05002-w.
doi: 10.1007/s11606-019-05002-w
CMS. Hospital Price Transparency Frequently Asked Questions (FAQs). Available at: www.cms.gov/files/document/hospital-price-transparency-frequently-asked-questions.pdf . Accessed March 13, 2021.
Key Facts: Cost-Sharing Charges. Beyond the Basics. Available at: https://www.healthreformbeyondthebasics.org/cost-sharing-charges-in-marketplace-health-insurance-plans-answers-to-frequently-asked-questions/ . Accessed March 13, 2021.
Billig JI, Chen JS, Lu YT, et al. The economic burden of out-of-pocket expenses for plastic surgery procedures. Plast Reconstr Surg . 2020;145:1541–1551. doi:10.1097/PRS.0000000000006847.
doi: 10.1097/PRS.0000000000006847
Billig JI, Lan W-C, Chung KC, et al. The increasing financial burden of outpatient elective surgery for the privately insured. Ann Surg . 2020;272:530–536. doi:10.1097/SLA.0000000000004201.
doi: 10.1097/SLA.0000000000004201
Harris JA, Ji YD, Patel NA. Rural oral and maxillofacial surgeon case mix leads to lower medicare reimbursement. J Oral Maxillofac Surg . 2020;78:2009.e1–2009.e7. doi:10.1016/j.joms.2020.07.019.
doi: 10.1016/j.joms.2020.07.019