Neurosurgeons Are Working Harder, for Less: Here's Proof

Caroline Helwick

April 18, 2019

SAN DIEGO — If neurosurgeons feel they are getting shortchanged for the work they do, they're right.

Researchers at the Mayo Clinic, Arizona, recently quantified just how much less reimbursement the nation's neurosurgeons are receiving, compared with 20 years ago — and it's considerable.

"Altogether, the Medicare compensation for the 20 most commonly performed neurosurgery procedures fell by 25.8% from 2000 to 2018," reported Kent R. Richter, BS, a second-year medical student at Mayo who conducted this analysis with Naresh P. Patel, MD, the senior author. He presented the findings here at the 2019 American Association of Neurological Surgeons Annual Scientific Meeting.

Asked to comment on the statistical design of this and other studies at the plenary session, Frederick Barker, MD, of Massachusetts General Hospital, said, "You don't need statistics to tell if beer tastes good in the summertime, and these trend lines are headed downward. We are being paid less for the same work."

Monetary Trends

The study evaluated monetary trends in Medicare reimbursement rates from 2000 to 2018 for the 10 most common spinal and 10 most common cranial neurosurgical procedures. These were identified through CPT codes in the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services (CMS).

The most common spinal procedure was lumbar laminotomy with nerve decompression and/or excision of herniated disc; craniectomy, bone flap craniotomy for excision of tumor, supratentorial and not meningioma, was the most common cranial procedure.

The investigators extracted comprehensive reimbursement data, calculated the raw percent change in reimbursement rate for each procedure, and compared this to the percent change in the consumer price index (CPI) over the same time. Data were adjusted for inflation and a trend analysis was performed.

The average annual and the total percentage changes in reimbursement were calculated based on these adjusted trends, and the compound annual growth rate was calculated for each procedure.

A 26% Decline in Reimbursement

When adjusted for inflation, reimbursement declined annually over the 18 years. Between 2000 to 2018, the average reimbursement for all procedures decreased by 25.80% after adjustments for inflation, as calculated this way:

  • Total unadjusted raw reimbursement rate increased on average by 7.63% for all procedures.

  • CPI, a measure of inflation, increased by 46.70%, which is significantly more than the change in the reimbursement rate (P < .0001).

  • After adjustments for inflation, the average reimbursement from 2000 to 2018 for spinal procedures decreased by 26.98%.

  • Reimbursements for cranial procedures decreased by 24.62%.

  • In total, reimbursement rates for neurosurgeons were reduced by 25.80%.

"Reimbursement is definitely not keeping up with the rate of inflation…. We saw a steady annual decline in reimbursement when adjusted for inflation," Richter said.

Taking a closer look at those procedures taking the biggest hit, CPT code 63081 — vertebral corpectomy, partial or complete, anterior approach with decompression of spinal cord and/or nerve root — had an unadjusted reimbursement of $1825 in the year 2000 (in 2000 dollars), rising by 1.07% to $1844 in 2018; after adjustments the total percentage change was –30.54%.

For cranial procedures, CPT code 35301 — thromboendarterectomy, including patch graft if required — was reimbursed at $1231 in 2000, falling by –3.47% to $1188 in 2018; the final rate reduction was –33.66%.

The Good News

"We saw that the rate of reimbursement began to stabilize around halfway through the study and we found this interesting so we ran a subanalysis," Richter continued. "We compared the average adjusted reimbursement percent changes from 2000 to 2008 and from 2008 to 2018."

This comparison demonstrated that the average adjusted rate for all procedures decreased by 25.55% from 2000 to 2008, but by only 0.33% from 2008 to 2018. This difference was statistically significant and similar for both cranial and spinal procedures (Table).

Table. Average Adjusted Percent Change in Reimbursement from 2000-2008 and 2008-2018a

Subspecialty

Average % Change, 2000-2008

Average % Change, 2000-2018

P Value

Spinal

–26.11

–1.11

< .001

Cranial

–25.00

 0.45

< .0001

Total

–25.55

–0.33

< .0001

a All values adjusted for inflation

Commenting on this "stark contrast" in rate changes by decade, Richter proposed that the early decline in reimbursement could be attributed to the cuts in Medicare reimbursement around that time, likely the result of the Balanced Budget Act of 1997 that was enacted by Congress in an effort to balance the federal budget.

The relatively flat rate of total observed reimbursement changes from 2008 to 2018 suggests that recent legislation may be stabilizing reimbursement trends, he said.

"The implications of these findings are widespread," he commented, but said there are efforts to correct these trends. Strategies in payment models are being discussed, proposed, and tested to potentially stabilize reimbursement in neurosurgery, including such things as bundled payments and accountable care organizations.

He acknowledged, however, that there has been difficulty in properly risk-adjusting patients under these potential models, as well as difficulty in defining standardized and attainable outcome measures.

"Despite these discussions of new payment models, the process of identifying a gold model standard of reimbursement in neurosurgery is still within its infancy," Richter said.

Gaining a comprehensive understanding of reimbursement trends will be very important when defining future policy, he said, but there are some positive signs. In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA avoids scheduled cuts to reimbursement and instead provides an annual increase in Medicare reimbursement each year through 2020. Given its recent adoption, MACRA may have a stabilizing effect on reimbursement rates moving forward, he suggested.

"It's very important that these trends of reimbursement are noted and understood by surgeons, healthcare administrators, and policymakers in order to develop and implement agreeable models of reimbursement while ensuring the quality of neurosurgical care within the United States," he commented.

"No Good News"

James R. Bean, MD, a neurosurgeon who practices in Lexington, Kentucky, was invited to comment on the study. Taking a look back on the many ways that CMS has attempted price control over the years, Bean was less optimistic that reimbursements will ever be optimal.

Medicare is government-financed healthcare, and all government-financed healthcare operates under a budget. For this government, this is done by cost control, in particular, setting an expenditure target and adjusting prices up and down depending on whether the target is met, he said.

"The Medicare method of budget control is price control," he said. "Cost is always equal to the volume of services, no matter how you bundle or unbundled them, times the price, and it's well known that attempting to control volume in healthcare doesn't work in the United States. Price control, therefore, is the default model."

Ever since the inception of Medicare in 1966, a "cost crisis has been periodically declared," he pointed out. This crisis has been addressed by a variety of measures: the charge model, relative value units, Medicare fee schedule, the conversion factor, 1997 Balanced Budget Act, and sustainable growth rate (SGR), which assumed that as the economy grows, more tax money becomes available to fund physician payments.

The SGR "worked relatively well" for 4 years until the economy faltered in 2000, he noted. While the volume of services kept growing, prices had to be cut, but the conversion factor stayed the same. If rates had been adjusted for inflation over time, reimbursements would today be approximately 50% greater now, he figured.

The CMS cost control strategy now appears to include "conversion factor stagnation" and a shift toward bundled and prospective payments. "To think this is going to help out is flawed thinking," he commented. "I have no more good news for you today."

Richter and Bean have disclosed no relevant financial relationships.

2019 American Association of Neurological Surgeons Annual Scientific Meeting: Abstract 202. Presented April 15, 2019.

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