Download PDF
J Reconstr Microsurg
DOI: 10.1055/a-2199-4226
Original Article

Billing and Utilization Trends in Reconstructive Microsurgery Indicate Worsening Access to Care

Daniel J. Koh
1   Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
2   Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
,
Jung Ho Gong 
1   Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Nikhil Sobti
1   Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Raman Mehrzad
1   Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Dardan Beqiri
1   Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Sophia Ahn
1   Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Amy Maselli
1   Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Daniel Kwan
1   Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
› Author Affiliations Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
› Further Information
    Permissions and Reprints

Abstract

Background Within the last 20-years, Medicare reimbursements for microsurgery have been declining, while physician expenses continue to increase. As a result, hospitals may increase charges to offset revenue losses, which may impose a financial barrier to care. This study aimed to characterize the billing trends in microsurgery and their implications on patient care.

Methods The 2013 to 2020 Provider Utilization and Payment Data Physician and Other Practitioners Dataset was queried for 16 CPT codes. Service counts, hospital charges, and reimbursements were collected. The utilization, weighted mean reimbursements and charges, and charge-to-reimbursement ratios (CRRs) were calculated. The total and annual percent changes were also determined.

Results In total, 13 CPT codes (81.3%) were included. The overall number of procedures decreased by 15.0%. The average reimbursement of all microsurgical procedures increased from $618 to $722 (16.7%). The mean charge increased from $3,200 to $4,340 (35.6%). As charges had a greater increase than reimbursement rates, the CRR increased by 15.4%. At the categorical level, all groups had increases in CRRs, except for bone graft (−49.4%) and other procedures (−3.5%). The CRR for free flap breast procedures had the largest percent increase (47.1%). Additionally, lymphangiotomy (28.6%) had the second largest increases.

Conclusion Our analysis of microsurgical procedures billed to Medicare Part B from 2013 to 2020 showed that hospital charges are increasing at a faster rate than reimbursements. This may be in part due to increasing physician expenses, cost of advanced technology in microsurgical procedures, and inadequate reimbursement rates. Regardless, these increased markups may limit patients who are economically disadvantaged from accessing care. Policy makers should consider legislation aimed at updating Medicare reimbursement rates to reflect the increasing complexity and cost associated with microsurgical procedures, as well as regulating charge markups at the hospital level.

Keywords

microsurgery - Medicare - reimbursement - charges - markup - plastic surgery

Author Contributions

D.K. was responsible for conceptualization, methodology, and writing—original draft. J.H.G. was responsible for conceptualization, methodology, and formal analysis. N.S. was responsible for conceptualization, methodology, and writing—original draft. R.H. was responsible for conceptualization, writing—original draft. D.B. was responsible for conceptualization, methodology, and writing—review and editing. S.A. was responsible for formal analysis and writing—review and editing. A.M. was responsible for conceptualization, methodology, and writing—review and editing. D.K. was responsible for conceptualization, methodology, and writing—review and editing.


Supplementary Material



Publication History

Received: 11 August 2023

Accepted: 13 October 2023

Accepted Manuscript online:
26 October 2023

Article published online:
18 December 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Mavrogenis AF, Markatos K, Saranteas T. et al. The history of microsurgery. Eur J Orthop Surg Traumatol 2019; 29 (02) 247-254
    CrossrefPubMedGoogle Scholar
  • 2 Yueh JH, Slavin SA, Adesiyun T. et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg 2010; 125 (06) 1585-1595
    CrossrefPubMedGoogle Scholar
  • 3 Engel H, Lin CH, Wei FC. Role of microsurgery in lower extremity reconstruction. Plast Reconstr Surg 2011; 127 (Suppl. 01) 228S-238S
    CrossrefPubMedGoogle Scholar
  • 4 Deleyiannis FW, Porter AC. Economic factors affecting head and neck reconstructive microsurgery: the surgeons' and hospital's perspective. Plast Reconstr Surg 2007; 120 (01) 157-165
    CrossrefPubMedGoogle Scholar
  • 5 Smith BD, Chandler AR, Braswell A. et al. Prospective analysis of payment per hour in head and neck reconstruction: fiscally feasible or futile?. Plast Reconstr Surg 2016; 137 (03) 980-984
    CrossrefPubMedGoogle Scholar
  • 6 Teven CM, Gupta N, Yu JW. et al. Analysis of 20-year trends in Medicare reimbursement for reconstructive microsurgery. J Reconstr Microsurg 2021; 37 (08) 662-670
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Siotos C, Aminzada A, Whitney N. et al. Trends of Medicare reimbursement rates for lower extremity procedures. J Reconstr Microsurg 2023; (e-pub ahead of print) DOI: 10.1055/a-2161-7947.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Gupta N, Haglin JM, Marostica CW, Thornburg DA, Casey III WJ. Trends in Medicare reimbursement for reconstructive plastic surgery procedures: 2000 to 2019. Plast Reconstr Surg 2020; 146 (01) 1541-1551
    CrossrefPubMedGoogle Scholar
  • 9 Haglin JM, Richter KR, Patel NP. Trends in Medicare reimbursement for neurosurgical procedures: 2000 to 2018. J Neurosurg 2019; 132 (02) 649-655
    CrossrefPubMedGoogle Scholar
  • 10 Carter Clement R, Bhat SB, Clement ME, Krieg JC. Medicare reimbursement and orthopedic surgery: past, present, and future. Curr Rev Musculoskelet Med 2017; 10 (02) 224-232
    CrossrefPubMedGoogle Scholar
  • 11 Haglin JM, Eltorai AEM, Richter KR, Jogerst K, Daniels AH. Medicare reimbursement for general surgery procedures: 2000 to 2018. Ann Surg 2020; 271 (01) 17-22
    CrossrefPubMedGoogle Scholar
  • 12 Gong JH, Bai G, Vervoort D, Eltorai AEM, Giladi AM, Long C. Decreasing Medicare utilization, reimbursement, and reimbursement-to-charge ratio of reconstructive plastic surgery procedures: 2010 to 2019. Ann Plast Surg 2022; 88 (05) 549-554
    CrossrefPubMedGoogle Scholar
  • 13 Gupta N, Thornburg DA, Chow NA. et al. Procedural trends in Medicare reimbursement and utilization for breast reconstruction: 2000-2019. Ann Plast Surg 2022; 89 (01) 28-33
    CrossrefPubMedGoogle Scholar
  • 14 Clemens J, Gottlieb JD. In the shadow of a giant: Medicare's influence on private physician payments. J Polit Econ 2017; 125 (01) 1-39
    CrossrefPubMedGoogle Scholar
  • 15 Gong JH, Long C, Eltorai AEM, Sanghavi KK, Giladi AM. Billing and utilization trends for hand surgery indicate worsening barriers to accessing care. Hand (N Y) 2022; 18 (07) 1190-1199
    CrossrefPubMedGoogle Scholar
  • 16 Bai G, Anderson GF. Extreme markup: The fifty US hospitals with the highest charge-to-cost ratios. Health Aff (Millwood) 2015; 34 (06) 922-928
    CrossrefPubMedGoogle Scholar
  • 17 Bai G, Anderson GF. Variation in the ratio of physician charges to Medicare payments by specialty and region. JAMA 2017; 317 (03) 315-318
    CrossrefPubMedGoogle Scholar
  • 18 Bai G, Chanmugam A, Suslow VY, Anderson GF. Air ambulances with sky-high charges. Health Aff (Millwood) 2019; 38 (07) 1195-1200
    CrossrefPubMedGoogle Scholar
  • 19 CMS Program Statistics. Center for Medicare & Medicaid Services Data. Accessed March 1, 2023 at: https://data.cms.gov/collection/cms-program-statistics
    PubMedGoogle Scholar
  • 20 Consumer Price Index Historical Tables for U.S. City Average. Mid–Atlantic Information Office U.S. Bureau of Labor Statistics. Accessed March 1, 2023 at: 2023. https://www.bls.gov/regions/mid-atlantic/data/consumerpriceindexhistorical_us_table.htm
    PubMedGoogle Scholar
  • 21 Khansa I, Khansa L, Pearson GD, Jain SA. Effects of the affordable care act on payer mix and physician reimbursement in hand surgery. J Hand Surg Am 2018; 43 (06) 511-515
    CrossrefPubMedGoogle Scholar
  • 22 Anderson GF. From ‘soak the rich’ to ‘soak the poor’: recent trends in hospital pricing. Health Aff (Millwood) 2007; 26 (03) 780-789
    CrossrefPubMedGoogle Scholar
  • 23 Chinta S, Koh DJ, Sobti N. et al. Cost analysis of pre-pectoral implant-based breast reconstruction. Sci Rep 2022; 12 (01) 17512
    CrossrefPubMedGoogle Scholar
  • 24 Jimenez RB, Packowski K, Horick N. et al. The timing of acute and late complications following mastectomy and implant-based reconstruction. Ann Surg 2022; 278 (01) e203-e208
    CrossrefPubMedGoogle Scholar
  • 25 Moss HA, Havrilesky LJ, Zafar SY, Suneja G, Chino J. Trends in insurance status among patients diagnosed with cancer before and after implementation of the affordable care act. J Oncol Pract 2018; 14 (02) e92-e102
    CrossrefPubMedGoogle Scholar
  • 26 Berrian JL, Liu Y, Lian M, Schmaltz CL, Colditz GA. Relationship between insurance status and outcomes for patients with breast cancer in Missouri. Cancer 2021; 127 (06) 931-937
    CrossrefPubMedGoogle Scholar