Trends in physician reimbursements and procedural volumes for radiosurgery versus open surgery in brain tumor care: an analysis of Medicare data from 2009 to 2018

Meeki Lad MPH1, Radhika Gupta BS2, Alex Raman MS3, Neil Parikh BS3, Raghav Gupta MD1,4, Ankush Chandra MD, MS5,6, Ashok Para MD1, Manish K. Aghi MD, PhD6, and Justin Moore MD, MPH, PhD7
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  • 1 Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey
  • | 2 Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, Maryland
  • | 3 University of California at Los Angeles
  • | 4 Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
  • | 5 Vivian L. Smith Department of Neurosurgery, University of Texas at Houston Medical Center, Houston, Texas
  • | 6 Department of Neurological Surgery, University of California, San Francisco, California; and
  • | 7 Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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OBJECTIVE

Given its minimally invasive nature and effectiveness, stereotactic radiosurgery (SRS) has become a mainstay for the multimodal treatment of intracranial neoplasm. However, no studies have evaluated recent trends in the use of SRS versus those of open resection for the management of brain tumor or trends in the involvement of neurosurgeons in SRS (which is primarily delivered by radiation oncologists). Here, the authors used publicly available Medicare data from 2009 to 2018 to elucidate trends in the treatment of intracranial neoplasm and to compare reimbursements between these approaches.

METHODS

By using CPT Professional 2019, the authors identified 10 open resection and 9 SRS codes (4 for neurosurgery and 5 for radiation oncology) for the treatment of intracranial neoplasm. Medicare payments (inflation adjusted) and allowed services (number of reimbursed procedures) for each code were abstracted from the Centers for Medicare and Medicaid Services Part B National Summary Data File (2009–2018). Payments per procedure and procedures per 100,000 Medicare enrollees were analyzed with linear regression and compared with tests for equality of slopes (α = 0.05). The average payment per procedure over the study period was compared by using the 2-tailed Welsh unequal variances t-test, and more granular comparisons were conducted by using ANOVA with post hoc Tukey honestly significant difference (HSD) tests.

RESULTS

From 2009 to 2018, the number of SRS treatments per 100,000 Medicare enrollees for intracranial neoplasm increased by 3.97 cases/year (R2 = 0.99, p < 0.001), while comparable open resections decreased by 0.34 cases/year (R2 = 0.85, p < 0.001) (t16 = 7.5, p < 0.001). By 2018, 2.6 times more SRS treatments were performed per 100,000 enrollees than open resections (74.9 vs 28.7 procedures). However, neurosurgeon involvement in SRS treatment declined over the study period, from 23.4% to 11.5% of SRS treatments; simultaneously, the number of lesions treated per session increased from 1.46 to 1.84 (R2 = 0.98, p < 0.001). Overall, physician payments from 2013 to 2018 averaged $1816.08 (95% CI $1788.71–$1843.44) per SRS treatment and $1565.59 (95% CI $1535.83–$1595.34) per open resection (t10 = 15.9, p < 0.001). For neurosurgeons specifically, reimbursements averaged $1566 per open resection, but this decreased to $1031–$1198 per SRS session; comparatively, radiation oncologists were reimbursed even less (average $359–$898) per SRS session (p < 0.05 according to the Tukey HSD test for all comparisons).

CONCLUSIONS

Over a decade, the number of open resections for intracranial neoplasm in Medicare enrollees declined slightly, while the number of SRS procedures increased greatly. This latter expansion is largely attributable to radiation oncologists; meanwhile, neurosurgeons have shifted their involvement in SRS toward sessions for the management of multiple lesions.

ABBREVIATIONS

ACGME = Accreditation Council for Graduate Medical Education; AVM = arteriovenous malformation; CMS = Centers for Medicare and Medicaid Services; CPT = Current Procedural Terminology; EBRT = electron-beam radiation therapy; HSD = honestly significant difference; SRS = stereotactic radiosurgery; WBRT = whole-brain radiation therapy.

Illustration from Schneider et al. (pp 205–214). Copyright Elyssa Siegel. Published with permission.

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