Over 20 years of declining Medicare reimbursement for spine surgeons: a temporal and geographic analysis from 2000 to 2021

Jack M. Haglin Mayo Clinic School of Medicine, Scottsdale, Arizona;
Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona;

Search for other papers by Jack M. Haglin in
jns
Google Scholar
PubMed
Close
 MD, MS
,
Michelle A. Zabat Department of Orthopedic Surgery, Brown University, Providence, Rhode Island

Search for other papers by Michelle A. Zabat in
jns
Google Scholar
PubMed
Close
 BA
,
Kent R. Richter Mayo Clinic School of Medicine, Scottsdale, Arizona;

Search for other papers by Kent R. Richter in
jns
Google Scholar
PubMed
Close
 MD
,
Kade S. McQuivey Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona;

Search for other papers by Kade S. McQuivey in
jns
Google Scholar
PubMed
Close
 MD
,
Jakub Godzik Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and

Search for other papers by Jakub Godzik in
jns
Google Scholar
PubMed
Close
 MD, MS
,
Naresh P. Patel Mayo Clinic School of Medicine, Scottsdale, Arizona;
Department of Neurosurgery Mayo Clinic, Phoenix, Arizona;

Search for other papers by Naresh P. Patel in
jns
Google Scholar
PubMed
Close
 MD
,
Adam E. M. Eltorai Department of Orthopedic Surgery, Brown University, Providence, Rhode Island

Search for other papers by Adam E. M. Eltorai in
jns
Google Scholar
PubMed
Close
 MD, PhD
, and
Alan H. Daniels Department of Orthopedic Surgery, Brown University, Providence, Rhode Island

Search for other papers by Alan H. Daniels in
jns
Google Scholar
PubMed
Close
 MD
Free access

OBJECTIVE

Procedural reimbursement for spine surgery has changed drastically over the past 20 years. A comprehensive understanding of these trends is important as major changes in reimbursement models of spine surgery continue to evolve within various spine specialties as well as broader national healthcare policy. In this study the authors evaluated the monetary trends in Medicare reimbursement rates for the 15 most common spinal surgery procedures from 2000 to 2021.

METHODS

The National Surgery Quality Improvement Project database (2019) was queried to determine the 15 most commonly performed spine surgery procedures. The Current Procedural Terminology (CPT) codes for each of these procedures were obtained from the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services, and comprehensive reimbursement data for each code were extracted. Changes in Medicare reimbursement rates were calculated and averaged for each procedure as both raw percent changes and percent changes adjusted for inflation to 2021 US dollars (USD) based on the consumer price index (CPI). The adjusted R2 value, the compound annual growth rate (CAGR), and both the average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all included procedures.

RESULTS

After adjustment for inflation, average reimbursement for all procedures decreased by 33.8% from 2000 to 2021. The greatest mean decrease was seen in anterior cervical arthrodesis (−38.7%), while the smallest mean decrease was in vertebral body excision (−17.1%). From 2000 to 2021, the adjusted reimbursement rate for all included procedures decreased by an average of 1.9% each year, with an average R2 value of 0.69.

CONCLUSIONS

This is the first study to evaluate monetary trends in Medicare reimbursement for spine surgery procedures. After adjusting for inflation, Medicare reimbursement for the 15 most commonly performed spine procedures has steadily decreased from 2000 to 2021. Increased awareness of these trends and the forces driving them will be critical in the coming years as negotiations regarding reimbursement models continue to unfold. Greater understanding of spine surgery reimbursement among policy makers, hospitals, and surgeons will be important to ensure continued access to quality surgical spine care in the United States.

ABBREVIATIONS

APM = alternative payment model; CAGR = compound annual growth rate; CMS = Centers for Medicare and Medicaid Services; CPI = consumer price index; CPT = Current Procedural Terminology; GPCI = geographic practice cost index; MACRA = Medicare Access and Children’s Health Insurance Program Reauthorization Act; RVU = relative value unit; SGR = Sustainable Growth Rate; USD = US dollars.

OBJECTIVE

Procedural reimbursement for spine surgery has changed drastically over the past 20 years. A comprehensive understanding of these trends is important as major changes in reimbursement models of spine surgery continue to evolve within various spine specialties as well as broader national healthcare policy. In this study the authors evaluated the monetary trends in Medicare reimbursement rates for the 15 most common spinal surgery procedures from 2000 to 2021.

METHODS

The National Surgery Quality Improvement Project database (2019) was queried to determine the 15 most commonly performed spine surgery procedures. The Current Procedural Terminology (CPT) codes for each of these procedures were obtained from the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services, and comprehensive reimbursement data for each code were extracted. Changes in Medicare reimbursement rates were calculated and averaged for each procedure as both raw percent changes and percent changes adjusted for inflation to 2021 US dollars (USD) based on the consumer price index (CPI). The adjusted R2 value, the compound annual growth rate (CAGR), and both the average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all included procedures.

RESULTS

After adjustment for inflation, average reimbursement for all procedures decreased by 33.8% from 2000 to 2021. The greatest mean decrease was seen in anterior cervical arthrodesis (−38.7%), while the smallest mean decrease was in vertebral body excision (−17.1%). From 2000 to 2021, the adjusted reimbursement rate for all included procedures decreased by an average of 1.9% each year, with an average R2 value of 0.69.

CONCLUSIONS

This is the first study to evaluate monetary trends in Medicare reimbursement for spine surgery procedures. After adjusting for inflation, Medicare reimbursement for the 15 most commonly performed spine procedures has steadily decreased from 2000 to 2021. Increased awareness of these trends and the forces driving them will be critical in the coming years as negotiations regarding reimbursement models continue to unfold. Greater understanding of spine surgery reimbursement among policy makers, hospitals, and surgeons will be important to ensure continued access to quality surgical spine care in the United States.

In the United States, Medicare reimbursement to physicians is controlled at the federal level.1 Individual procedures are assigned a unique Current Procedural Terminology (CPT) code, which is tied to a specific and predetermined reimbursement amount based on the resources required to perform the procedure.2 The monetary value of reimbursement for each code is updated annually by the Centers for Medicare and Medicaid Services (CMS) and determines the reimbursement amount that a surgeon is allotted for each procedure. The numeric value is determined by first aggregating the assessed values of physician work, practice expense, and malpractice insurance associated with the procedure. Then, this value is scaled based on geographic cost variations, and an additive relative value unit (RVU) is calculated. Finally, the value is multiplied by a monetary conversion factor to determine the total reimbursement payment rate for a specific CPT code.3

The financial landscape of the US healthcare system is prominently characterized by uncertainty attributable to fluctuating political dynamics, shifting proposed government payment models,4 and steadily rising healthcare costs.5 Given this complex uncertainty, the standardized and annually updated CMS reimbursement system is a particularly valuable resource for objectively analyzing payment trends for healthcare procedures in the United States. Although some researchers have previously used national CMS data to evaluate trends in reimbursements in orthopedic surgery6 and oncology,7 a comprehensive evaluation of these trends in spine surgery has yet to be conducted. Ensuring continued success of spine surgery practices within the United States necessitates analyzing reimbursement practices and understanding how reimbursement has changed over time for these procedures. Given that these trends and data are as yet incompletely defined, in the present study we aimed to evaluate monetary and geographic trends of Medicare reimbursement rates in spine surgery from 2000 to 2021.

Methods

Data from the American College of Surgeons (ACS) National Surgery Quality Improvement Project (NSQIP) database was queried for the 15 most commonly billed CPT codes in spinal surgery for the year 2019, representative of the most commonly performed spine surgery procedures (Table 1). Longitudinal reimbursement data from the Physician Fee Schedule Look-Up Tool from the CMS 8 was obtained for each of these CPT codes. The reported Medicare reimbursement rate for each procedure is based on the average of all geographic iterations for an individual CPT code, based on pricing information collected for all Medicare Administrative Contractor options across the United States from each year between 2000 and 2021. This analysis included only reimbursement for base procedural codes and did not include any modifier codes. Medicare reimbursement data for all geographic regions across the United States were also collected for each procedure and each year of the study.

TABLE 1.

Included procedure CPT codes

ProcedureCPT Code
Lumbar laminotomy w/ nerve root decompression &/or excision of herniated disc63030
Laminectomy, facetectomy, &/or foraminotomy for treatment of lumbar stenosis, single vertebral segment63047
Lumbar arthrodesis, posterior or posterolateral technique, single level 22612
Arthrodesis, posterior interbody technique, including laminectomy &/or discectomy to prepare interspace, single interspace; lumbar22630
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace 22558
Laminotomy w/ decompression of nerve root(s), partial facetectomy, foraminotomy &/or excision of herniated disc, single interspace63042
Vertebral corpectomy, partial or complete, anterior approach w/ decompression of spinal cord &/or nerve root(s)63081
Laminectomy w/ exploration &/or decompression of cord &/or cauda equina, w/o facetectomy, foraminotomy or discectomy 63005
Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural63267
Transpedicular approach w/ decompression of spinal cord, equina &/or nerve root(s) (herniated intervertebral disc), single segment63056
Anterior instrumentation for anterior cervical discectomy w/ interbody fusion22845
Anterior cervical arthrodesis, anterior interbody technique, including minimal discectomy22554
Arthrodesis, posterior technique, craniocervical (occiput–C2)22590
Partial excision of vertebral body for intrinsic bony lesion, w/o decompression22114
Placement of posterior nonsegmental instrumentation22840

The raw percent change in Medicare reimbursement rate from 2000 to 2021 was calculated for each procedure of interest and averaged. A two-tailed t-test comparison of means was used to compare this value to the percent change in the consumer price index (CPI) over the corresponding time period. The CPI data from January 2021 were acquired from the US Department of Labor, Bureau of Labor Statistics.9 The CPI serves as a measure of monetary inflation, and thus was utilized to calculate reimbursement data adjusted to 2021 US dollars (USD). The 2021-adjusted reimbursement data were used to perform all trend analysis, including adjusted R2 and both average annual and total percentage change. The compound annual growth rate (CAGR), an investment measure used to determine the annual rate of change over time while minimizing the effects of short-term fluctuations and variation, was calculated with the adjusted data in 2021 USD using the following formula:10 CAGR = [(2021 value/2000 value)1/(2021–2000)] – 1.

Additionally, annual estimate percent change in medical practice expense data in the United States were collected from year 2000 to year 2021 from the 2021 Federal Register Medicare Trustee’s Report, which reports annual estimates of the change in medical practice expenses in the United States via the Medical Economic Index.11 These data on practice expenses were likewise corrected for inflation by use of the same process as that used for reimbursement correction. These percentage change data were visually compared to the mean percent change in spine reimbursement for all included procedures. All data analysis was completed using SPSS version 23 software (IBM Corp.), with statistical significance set at p < 0.05 a priori. Visualization of geographic data was organized utilizing Google Sheets Geo Map (Alphabet Inc.). Given the nature of the publicly available data used for this analysis, local institutional review board approval was not required for this study.

Results

Decrease in Unadjusted Gross Reimbursement of Included Spine Procedures

From 2000 to 2021, the reimbursement rate unadjusted for inflation increased on average by 5.36% over the period. In the same period, inflation as measured by the CPI increased by 59.3%, which was significantly more than the change in rate of reimbursement (p < 0.0001).

Reimbursement Adjusted for Inflation

After correction of reimbursement data for inflation to 2021 dollars, the average reimbursement for all 15 procedures included in this analysis decreased by an average of 33.8% from 2000 to 2021 (Fig. 1). From 2000 to 2021, the adjusted reimbursement rate for all included procedures decreased by an average of 1.9% each year and had an average CAGR of −2.0%, indicating a steady annual decline in reimbursement when adjusted for inflation. In Fig. 2, this percent change in spine procedural reimbursement is visually compared to the percent change in mean medical practice expense in the United States, which demonstrates diverging trends. The average linear r2 regression value of this adjusted data when trended was 0.69, indicating a moderate linear and constant annual decline throughout each analyzed year (Table 2).

FIG. 1.
FIG. 1.

Average Medicare reimbursement amount for included spinal procedures from 2000 to 2021 (all values adjusted for inflation).

FIG. 2.
FIG. 2.

Average percent change in Medicare spine reimbursement for included procedures versus change in mean medical practice expense: 2000–2021.

TABLE 2.

Adjusted reimbursement trends

Procedure CPT CodeUnadjusted Change 2000–2021Adjusted CAGR Average Change Yr to Yr Adjusted R2Total % Change 2000–2020 Adjusted
630306.3%−1.9%−1.8%0.41−33.3%
630470.7%−2.2%−2.1%0.71−36.8%
226125.9%−1.9%−1.9%0.77−33.5%
226307.0%−1.9%−1.8%0.80−32.8%
22558−0.4%−2.2%−2.2%0.72−37.5%
63042−0.6%−2.2%−2.2%0.75−37.6%
63081−1.0%−2.2%−2.2%0.70−37.8%
630057.0%−1.9%−1.8%0.59−32.9%
632673.4%−2.0%−2.0%0.65−35.1%
630560.2%−2.2%−2.1%0.73−37.1%
228454.5%−2.0%−1.9%0.88−34.4%
22554−2.3%−2.3%−2.3%0.80−38.7%
2259012.0%−1.7%−1.6%0.47−29.7%
2211432.1%−0.9%−0.8%0.50−17.1%
228406.2%−1.9%−1.9%0.88−33.3%
Average of all procedures5.4%−2.0%−1.9%0.69−33.8%

All values adjusted for inflation.

A subanalysis comparing average adjusted reimbursement percent changes from 2000 to 2010 and 2011 to 2021, respectively, demonstrates that the average adjusted reimbursement rate for all procedures decreased by 23.4% from 2000 to 2010 and decreased by 15.6% on average from 2010 to 2021. This difference was statistically significant (p < 0.0001) (Table 3).

TABLE 3.

Average adjusted percentage change in reimbursement rates from 2000 to 2010 and 2011 to 2021

Average Change From 2000 to 2010Average Change From 2011 to 2021p Value of Comparison
−23.5%−15.6%<0.0001

All values adjusted for inflation.

Geographic Variance in Reimbursement

The mean Medicare reimbursement for the spinal procedures included in this analysis in year 2021 varied by state (Fig. 3). The rate ranged from a maximum mean reimbursement of $1632.95 in Alaska to a minimum of $1133.44 in Nebraska. Additionally, the mean percent change from 2000 to 2021 in the mean inflation-adjusted Medicare reimbursement across all procedures included in this study varied across states (Fig. 4). Wisconsin (−40.8%), Michigan (−40.4%), and Hawaii (−39.6%) experienced the largest percent decrease from 2000 to 2021. Meanwhile, Alaska (−31.0%), Wyoming (−31.5%), and Montana (−31.4%) experienced the smallest percent change on average from 2000 to 2021.

FIG. 3.
FIG. 3.

Mean physician Medicare reimbursement by state for included spine procedures, 2021. Map generated in Google Sheets Geo Map (Alphabet Inc.). Figure is available in color online only.

FIG. 4.
FIG. 4.

Percent change by state in mean inflation-adjusted physician Medicare reimbursement across all spine procedures included in the study from 2000 to 2021. Map generated in Google Sheets Geo Map (Alphabet Inc.). Figure is available in color online only.

Discussion

The average Medicare reimbursement rate across the top 15 procedures in spine surgery decreased by roughly 34% from 2000 to 2021, after adjustment for inflation. While unadjusted reimbursement rates have increased by about 5%, this increase lags significantly behind that for inflation, which has increased 59% over the same period. Furthermore, physician practice expenses have increased by 60.6% over this time period, which is visually compared to the decreasing reimbursement trends in Fig. 2.12 It is vital to understand these reimbursement and expense trends in order to ensure the sustainability and solvency of spine surgical practices moving forward.

The consequences of the dynamics elucidated in this study are both timely and far-reaching. At present, federally funded health insurance programs comprise an increasingly large proportion of healthcare reimbursement, and they represent a growing segment of annual healthcare expenditures in the United States.13 Further, the federal policy decisions made by CMS regarding which procedures are covered and the rate at which they are reimbursed guide the decisions of private insurance payers, resulting in broad impacts on physician reimbursement which encompass both publicly and privately insured patients.14 Within spine surgery specifically, Rosenow and Orrico have demonstrated the increasing presence of Medicare and Medicaid, reporting that 96.8% of spine surgeons in the United States participate in Medicare in some capacity.14 The reported study by Rosenow and Orrico further demonstrated that, for responding surgeons, nearly one-third of the collective patient population was insured by Medicare. As the US population continues to age, this proportion of Medicare patients in will likely continue to grow.

The inflation-adjusted decreasing reimbursement in spine surgery demonstrated in the present study can be explained in part by underlying congressional policy during this time period. From 1997 to 2015, CMS determined Medicare and Medicaid reimbursement based on the Medicare Sustainable Growth Rate (SGR) under the Balanced Budget Act of 1997.15 This legislation was originally proposed in an effort to control Medicare spending on physician reimbursement with the hope of balancing the US federal budget by 2002. The SGR was set annually to determine changes to Medicare procedural reimbursement and was reactive to the prior year.16 Within this time period, increasing costs led to decreases in the SGR and in physician reimbursement; this was likely the driving force behind the decreasing trends observed in this study.

Additionally, the SGR legislation helps to clarify a particular discrepancy found in this study when comparing 2000–2010 reimbursement trends with those within 2011–2021. The adjusted reimbursement rate decreased more precipitously from 2000 to 2010 than from 2011 to 2021, during which reimbursement rates still declined, but to a lesser degree. The reimbursement trends from 2010 to 2021 were more in line with those found in the only analysis of spine surgery reimbursement in the literature. In this study, Meyers et al. analyzed internal billing claims for spinal surgery procedures at a single practice, reporting a 4% increase in Medicare reimbursement from 2010 to 2016.17 In comparison, the early decline in reimbursement demonstrated in our study was attributable in large part to a massive cut to Medicare reimbursement in 2002, enacted as part of a congressional effort to balance the federal budget under the SGR.15 As a result, spine reimbursement decreased 10.3% in 2002 on average in this study, the largest decrease in reimbursement of any year. Policy changes poised to enact even greater cuts to reimbursement through Medicare were scheduled for March of 2010; however, Congress voted to delay the enforcement of these policies and ultimately repealed and replaced the SGR in favor of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA) in 2015. The passage of this act effectively prevented the scheduled double-digit cuts to Medicare.18 Given that the downstream effects of MACRA remain to be seen, it is unclear if it will reliably stabilize reimbursement rates moving forward.

Despite the variation arising from ongoing political uncertainty, there are clear trends of decreasing Medicare reimbursement in spine surgery. Although there is a paucity of literature exploring similar trends in other specialties, a recent study did demonstrate consistent findings of decreased reimbursement in orthopedic subspecialties over a similar time period, although to a lesser degree compared with the rates of decline in our study.6 Furthermore, a shorter-term study from Vu et al. demonstrated a 14% increase in Medicare reimbursement for radiation oncology procedures from 2012 to 2015, exhibiting disparities in reimbursement trends between spine surgery and other specialties outside of orthopedics.7

The present study also demonstrates that physician reimbursement in spine surgery varies across the country. This difference is largely driven by the geographic practice cost index (GPCI), which adjusts the procedural value for differing locality in the United States. In this system, RVUs are adjusted for the relative costliness of providing the associated procedure in each locality. It is important to realize that many of the geographic boundaries of these somewhat arbitrarily assigned localities have not been updated since 1997, when they were redesignated under legislation associated with the Balanced Budget Act of 1997.15 This locality scheme was not conducted consistently across the United States, with the processes used in various localities being based on differing combinations of political boundaries, zip codes, cities, counties, or entire states.

Furthermore, the reimbursement multiplier within each locality is based on decennial census data, which are updated only every decade.15 Because of these data being slow to change, physicians and lobbyists in many states have been trying to bring about change among these policies. California was the first state to accomplish and enforce a major policy update to the GPCI legislation under the California GPCI Fix Act in 2017.18 This legislation created and assigned new localities within California, splitting the state from its previous 9 localities into 32 separate localities.19 This allowed recategorization of many areas from rural to urban, which effectively increased payment for these localities, allowing more granular and equitable adjustments for physicians working in California. It is too early to determine the effects of these changes. However, our data demonstrate that California experienced one of the largest decreases in mean reimbursement for spine procedures from 2000 to 2021, and the previously outdated legislation and designation of localities in California may have been a key driver of decreased reimbursement in the state during this time.

This issue of poorly defined geographic localities still exists in many states throughout the country. In contrast to the now 32 defined localities located in California, 33 of the 50 states in the United States only have one locality, and thus a single payment adjustment for the entire state. This results in an inability to adjust for urban and rural areas within these states, so all spine surgeons in these 33 states receive the same statewide adjustment to RVUs and the same reimbursement for services under Medicare, regardless of if they work in a city or rural area with largely variable access to resources. As such, there is room for potential improvement with this system, and GPCI will likely be an increasingly common target of policy reform in the future.

As healthcare costs continue to rise, changes may be necessary to ensure the continued financial health and success of spine surgery. There have been several strategies and alternative models of physician reimbursement that have been proposed.20 Summarily, these models are tied to implementation of high-value care and are contingent on increasing favorable patient outcomes while decreasing the overall costs of patient care. The Quality Payment Program (QPP), which was passed as part of MACRA and took effect in 2019, represents a critical driver behind the development of and shift toward these alternative payment models (APMs).18 Upon taking effect, the QPP mandated that physicians participating in fee-for-service Medicare and billing for over $30,000 per year must opt into the Merit-based Incentive Payment System (MIPS) or APMs. Under MIPS, physicians are evaluated using a composite scoring system that accounts for quality of care, allocation of resources, practice improvement, and advancement of care; reimbursement is scaled to assessed performance based on these metrics.21,22 Thus, MACRA and its components are designed to incentivize high-quality care while stabilizing reimbursement; however, it remains too early to know what impacts they will ultimately have on reimbursement in spine surgery.23

Of the APM available as an alternate route to reimbursement, Accountable Care Organizations (ACOs) in particular are being explored in the hope of achieving these aims after being promulgated by the Affordable Care Act.24 ACOs are meant to incentivize physicians to meet specific patient outcome measures, facilitating gainsharing. However, in practice ACOs have been widely criticized due to the difficulty inherent in defining standardized and attainable outcome measures, as well as the insufficiency of the gainsharing incentive to garner participation. In contrast, another increasingly utilized approach to reimbursement reform is the use of bundled payments, especially for episodes of care that lend themselves to a more formulaic mode of care, such as elective lumbar spinal fusion.25 These bundles allow for one single payment to cover an entire episode of care, incentivizing both the physician and hospital to collaborate for increased value and quality of care, with the goal of optimizing efficiency. However, challenges to operationalization include uncertainty about how to effectively perform patient risk adjustment to mitigate bias against complex patient cases, as well as difficulty fitting complex procedures into single bundles.

These considerations collectively are increasingly relevant in the face of the 2021 Medicare Physician Fee Schedule, which was originally scheduled to reduce physician reimbursement across all surgical services by approximately 5%.26 Congress, however, implemented the temporary Holding Providers Harmless From Medicare Cuts During COVID-19 Act of 2020, a bipartisan measure increasing all payments to physicians by 3.5% through 2022.27 The success of this attempt at ensuring stability and predictability for Medicare providers as they care for patients during the COVID-19 pandemic remains to be seen, although it may be ineffective at preventing cuts in reimbursements for spinal surgery, as 2021 was the second largest mean year-to-year decrease in the study at −6.4%.

Despite the desire to reform reimbursement in spine surgery, deliberations are still ongoing. Collaboration, further research, and concerted effort will be required before any meaningful positive change in the model of reimbursement can be achieved. As this is the first study to comprehensively evaluate Medicare reimbursement trends within spine surgery, future studies should look to analyze trends exhibited by other pertinent payers, including Medicaid or private insurance, to enable a more comprehensive view of the changing market. As they stand, the findings presented in this study carry relevant and important implications for policy makers, hospitals, and physicians, as future policies and procedures will need to address these declining reimbursement trends while also accounting for the rapidly evolving and ever-complex landscape of healthcare in the United States.

Some potential limitations of our study include our exclusive use of Medicare reimbursement data. Thus, this study is not completely representative of the spine surgery reimbursement market as a whole, as private insurance reimbursement data are not publicly available. However, as previously discussed, CMS reimbursement policies influence the reimbursement rates in the private payer market. Therefore, our findings are still broadly applicable and are representative of current trends. Additionally, our data were generated based on specific CPT reimbursement codes. Due to a lack of available data, this study does not include an analysis of diagnosis-related groups (DRGs), more commonly used for hospital reimbursement. As such, the study does not capture potential differences between CPT and DRG trends. However, given that CPT-coded procedures partially contribute to episodic DRG reimbursements, the trends for hospital reimbursement through DRG mechanisms may be similar to those presented in this study and should be further studied. Further, some procedures had CPT coding changes during our study period, and thus newer codes may not have been included in this study and these financial trends were not fully captured within this study. Newer codes could be analyzed in future studies. Finally, all reimbursement data were averaged across all geographical locations in the United States. This may preclude the ability to identify trends exhibited in subgeographies. However, the analysis of aggregated data allows for comprehensive analysis of large-scale trends across the country. Further, the findings are largely based on change over time, and therefore our findings would not be affected by baseline price discrepancies which may exist between regions.

Conclusions

This is the first study, to our knowledge, to evaluate comprehensive trends in Medicare reimbursement in spine surgery. After adjusting for inflation, Medicare reimbursement for all included procedures has steadily decreased from 2000 to 2021. Increased awareness and consideration of these trends will be important moving forward for policy makers, hospitals, and physicians as continued progress is made to advance agreeable reimbursement models that allow for the sustained growth of the practice of spine surgery in the United States.

Disclosures

Dr. Daniels is a consultant for Spineart, Stryker, Medtronic, Medicrea, EOS, and Orthofix and receives royalties from Medicrea, Spineart, and Southern Spine.

Author Contributions

Conception and design: all authors. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: Haglin, Zabat, Richter, McQuivey, Godzik, Patel, Daniels. Critically revising the article: all authors. Reviewed submitted version of manuscript: Haglin, Zabat, Richter, McQuivey, Patel, Daniels. Approved the final version of the manuscript on behalf of all authors: Haglin. Statistical analysis: Haglin, Zabat, Richter, McQuivey, Patel, Daniels. Administrative/technical/material support: Haglin, Zabat. Study supervision: Haglin, Zabat.

Supplemental Information

Previous Presentations

This original work (it has since been updated to 2021) was presented as a podium presentation at the AANS/CNS Spine Summit in Orlando, Florida, March 15, 2019. It was a winner of the Charlie Kuntz Scholar award.

References

  • 1

    Benzil DL, Zusman EE. Defining the value of neurosurgery in the new healthcare era. Neurosurgery. 2017;80(4S):S23S27.

  • 2

    Centers for Medicare & Medicaid Services. Percentage of Medicare Participating Physicians and Limited License Practitioners Washington. CMS; 2010.

  • 3

    Glass KP, Anderson JR. Relative value units: from A to Z (Part I of IV). J Med Pract Manage. 2002;17(5):225228.

  • 4

    Congressional Budget Office. CBO’s August 2010 Baseline: Medicare. Accessed February 14, 2022. http://www.cbo.gov/sites/default/files/cbofiles/attachments/MedicareAugust2010FactSheet.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Cutler DM, Rosen AB, Vijan S. The value of medical spending in the United States, 1960-2000. N Engl J Med. 2006;355(9):920927.

  • 6

    Eltorai AEM, Durand WM, Haglin JM, Rubin LE, Weiss AC, Daniels AH. Trends in Medicare reimbursement for orthopedic procedures: 2000 to 2016. Orthopedics. 2018;41(2):95102.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Vu CC, Lanni TB, Nandalur SR. Trends in Medicare reimbursement and work relative value unit production in radiation oncology. J Am Coll Radiol. 2018;15(6):870875.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Centers for Medicare & Medicaid Services. Physician fee schedule look-up tool. Accessed February 14, 2022. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSLookup

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    US Department of Labor. Bureau of Labor Statistics. US inflation calculator. Accessed February 14, 2022. http://www.usinflationcalculator.com

  • 10

    Investopedia . Compound annual growth rate (CAGR). Accessed February 14, 2022. http://www.investopedia.com/terms/c/cagr.asp

  • 11

    Centers for Medicare & Medicaid Services Board of Trustees. 2021 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Accessed February 14, 2022. https://www.cms.gov/files/document/2021-medicare-trustees-report.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Medicare physician payment: why it’s still a problem, and what to do now. Health Affairs Blog, January 27, 2017. Accessed February 14, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20170127.058490/full/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kim DH, Lloyd C, Fernandez DK, Spielman A, Bradshaw D. A direct experience in a new accountable care organization: results, challenges, and the role of the neurosurgeon. Neurosurgery. 2017;80(4S):S42S49.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Rosenow JM, Orrico KO. Neurosurgeons’ responses to changing Medicare reimbursement. Neurosurg Focus. 2014;37(5):E12.

  • 15

    US Congress: Balanced Budget Act of 1997,. Pub L No. 105-33, 111 Stat 251(1997).

  • 16

    Oliver TR, Lee PR, Lipton HL. A political history of Medicare and prescription drug coverage. Milbank Q. 2004;82(2):283354.

  • 17

    Meyers JE, Wang J, Khan A, Davies JM, Pollina J. Trends in physician reimbursement for spinal procedures since 2010. Spine (Phila Pa 1976). 2018;43(15):10741079.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    US Congress: Medicare Access and CHIP Reauthorization Act of 2015,. Pub L No. 114-10, 129 Stat 87(2015).

  • 19

    Uppal S, Shahin MS, Rathbun JA, Goff BA. Since surgery isn’t getting any easier, why is reimbursement going down? An update from the SGO taskforce on coding and reimbursement. Gynecol Oncol. 2017;144(2):235237.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Wilensky GR. Developing a viable alternative to Medicare’s physician payment strategy. Health Aff (Millwood). 2014;33(1):153160.

  • 21

    Kaye DR, Ye Z, Li J, et al. The stability of physician-specific episode costs for urologic cancer surgery: implications for urologists under the merit-based incentive program. Urology. 2019;123:114119.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Squitieri L, Chung KC. Value-based payment reform and the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015: a primer for plastic surgeons. Plast Reconstr Surg. 2017;140(1):205214.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Wilensky GR. Will MACRA improve physician reimbursement?. N Engl J Med. 2018;378(14):12691271.

  • 24

    Vogus TJ, Singer SJ. Creating highly reliable accountable care organizations. Med Care Res Rev. 2016;73(6):660672.

  • 25

    Hines K, Mouchtouris N, Getz C, et al. Bundled payment models in spine surgery. Global Spine J. 2021;11(1)(suppl):7S13S.

  • 26

    Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies. Document Number: 2020-17127. Accessed February 14, 2022. https://www.federalregister.gov/documents/2020/08/17/2020-17127/medicare-program-cy-2021-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    H.R. 8702—116th Congress: Holding Providers Harmless From Medicare Cuts During COVID-19 Act of. 2020.Accessed February 14, 2022. https://www.congress.gov/bill/116th-congress/house-bill/8702

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand

Illustration from Dibble et al. (pp 384–394). © Washington University Department of Neurosurgery, published with permission.

  • FIG. 1.

    Average Medicare reimbursement amount for included spinal procedures from 2000 to 2021 (all values adjusted for inflation).

  • FIG. 2.

    Average percent change in Medicare spine reimbursement for included procedures versus change in mean medical practice expense: 2000–2021.

  • FIG. 3.

    Mean physician Medicare reimbursement by state for included spine procedures, 2021. Map generated in Google Sheets Geo Map (Alphabet Inc.). Figure is available in color online only.

  • FIG. 4.

    Percent change by state in mean inflation-adjusted physician Medicare reimbursement across all spine procedures included in the study from 2000 to 2021. Map generated in Google Sheets Geo Map (Alphabet Inc.). Figure is available in color online only.

  • 1

    Benzil DL, Zusman EE. Defining the value of neurosurgery in the new healthcare era. Neurosurgery. 2017;80(4S):S23S27.

  • 2

    Centers for Medicare & Medicaid Services. Percentage of Medicare Participating Physicians and Limited License Practitioners Washington. CMS; 2010.

  • 3

    Glass KP, Anderson JR. Relative value units: from A to Z (Part I of IV). J Med Pract Manage. 2002;17(5):225228.

  • 4

    Congressional Budget Office. CBO’s August 2010 Baseline: Medicare. Accessed February 14, 2022. http://www.cbo.gov/sites/default/files/cbofiles/attachments/MedicareAugust2010FactSheet.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Cutler DM, Rosen AB, Vijan S. The value of medical spending in the United States, 1960-2000. N Engl J Med. 2006;355(9):920927.

  • 6

    Eltorai AEM, Durand WM, Haglin JM, Rubin LE, Weiss AC, Daniels AH. Trends in Medicare reimbursement for orthopedic procedures: 2000 to 2016. Orthopedics. 2018;41(2):95102.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Vu CC, Lanni TB, Nandalur SR. Trends in Medicare reimbursement and work relative value unit production in radiation oncology. J Am Coll Radiol. 2018;15(6):870875.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Centers for Medicare & Medicaid Services. Physician fee schedule look-up tool. Accessed February 14, 2022. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSLookup

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    US Department of Labor. Bureau of Labor Statistics. US inflation calculator. Accessed February 14, 2022. http://www.usinflationcalculator.com

  • 10

    Investopedia . Compound annual growth rate (CAGR). Accessed February 14, 2022. http://www.investopedia.com/terms/c/cagr.asp

  • 11

    Centers for Medicare & Medicaid Services Board of Trustees. 2021 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Accessed February 14, 2022. https://www.cms.gov/files/document/2021-medicare-trustees-report.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Medicare physician payment: why it’s still a problem, and what to do now. Health Affairs Blog, January 27, 2017. Accessed February 14, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20170127.058490/full/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kim DH, Lloyd C, Fernandez DK, Spielman A, Bradshaw D. A direct experience in a new accountable care organization: results, challenges, and the role of the neurosurgeon. Neurosurgery. 2017;80(4S):S42S49.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Rosenow JM, Orrico KO. Neurosurgeons’ responses to changing Medicare reimbursement. Neurosurg Focus. 2014;37(5):E12.

  • 15

    US Congress: Balanced Budget Act of 1997,. Pub L No. 105-33, 111 Stat 251(1997).

  • 16

    Oliver TR, Lee PR, Lipton HL. A political history of Medicare and prescription drug coverage. Milbank Q. 2004;82(2):283354.

  • 17

    Meyers JE, Wang J, Khan A, Davies JM, Pollina J. Trends in physician reimbursement for spinal procedures since 2010. Spine (Phila Pa 1976). 2018;43(15):10741079.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    US Congress: Medicare Access and CHIP Reauthorization Act of 2015,. Pub L No. 114-10, 129 Stat 87(2015).

  • 19

    Uppal S, Shahin MS, Rathbun JA, Goff BA. Since surgery isn’t getting any easier, why is reimbursement going down? An update from the SGO taskforce on coding and reimbursement. Gynecol Oncol. 2017;144(2):235237.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Wilensky GR. Developing a viable alternative to Medicare’s physician payment strategy. Health Aff (Millwood). 2014;33(1):153160.

  • 21

    Kaye DR, Ye Z, Li J, et al. The stability of physician-specific episode costs for urologic cancer surgery: implications for urologists under the merit-based incentive program. Urology. 2019;123:114119.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Squitieri L, Chung KC. Value-based payment reform and the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015: a primer for plastic surgeons. Plast Reconstr Surg. 2017;140(1):205214.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Wilensky GR. Will MACRA improve physician reimbursement?. N Engl J Med. 2018;378(14):12691271.

  • 24

    Vogus TJ, Singer SJ. Creating highly reliable accountable care organizations. Med Care Res Rev. 2016;73(6):660672.

  • 25

    Hines K, Mouchtouris N, Getz C, et al. Bundled payment models in spine surgery. Global Spine J. 2021;11(1)(suppl):7S13S.

  • 26

    Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies. Document Number: 2020-17127. Accessed February 14, 2022. https://www.federalregister.gov/documents/2020/08/17/2020-17127/medicare-program-cy-2021-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    H.R. 8702—116th Congress: Holding Providers Harmless From Medicare Cuts During COVID-19 Act of. 2020.Accessed February 14, 2022. https://www.congress.gov/bill/116th-congress/house-bill/8702

    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1782 0 0
Full Text Views 1410 1027 129
PDF Downloads 1289 899 78
EPUB Downloads 0 0 0