Haglin, Jack M.

Abstract Background Although telehealth holds promise in expanding access to orthopaedic surgical care, high-speed internet connectivity remains a major limiting factor for many communities. Despite persistent federal efforts to study and address the health information technology needs of patients, there is limited information regarding the current high-speed internet landscape as it relates to access to orthopaedic surgical care. Questions/purposes (1) What is the distribution of practicing orthopaedic surgeons in the United States relative to the presence of broadband internet access? (2) What geographic, demographic, and socioeconomic factors are associated with the absence of high-speed internet and access to a local orthopaedic surgeon? Methods The Federal Communications Commission (FCC) Mapping Broadband in America interactive tool was used to determine the proportion of county residents with access to broadband-speed internet for all 3141 US counties. Data regarding the geographic distribution of orthopaedic surgeons and county-level characteristics were obtained from the 2015 Physician Compare National Downloadable File and the Area Health Resource File, respectively. The FCC mapping broadband public use files are considered the most comprehensive datasets describing high-speed internet infrastructure within the United States. The year 2015 represents the most recently available FCC data for which county-level broadband penetration estimates are available. Third-party audits of the FCC data have shown that broadband expansion has been slow over the past decade and that many large improvements have been driven by changes in the reporting methodology. Therefore, we believe the 2015 FCC data still hold relevance. The primary outcome measure was the simultaneous absence of at least 50% broadband penetration and at least one orthopaedic surgeon practicing in county limits. Statistical analyses using Kruskal-Wallis tests and multivariable logistic regression were conducted to assess for factors associated with inaccessibility to orthopaedic telehealth. All statistical tests were two-sided with a significance threshold of p < 0.05. Results In 2015, 14% (448 of 3141) of counties were considered “low access” in that they both had no orthopaedic surgeons and possessed less than 50% broadband access. A total of 4,660,559 people lived within these low-access counties, representing approximately 1.4% (4.6 million of 320.7 million) of the US population. After controlling for potential confounding variables, such as the age, sex, income level, and educational attainment, lower population density per square mile (OR 0.92 [95% confidence interval (CI) 0.90 to 0.94]; p < 0.01), a lower number of primary care physicians per 100,000 (OR 0.88 [95% CI 0.81 to 0.97]; p < 0.01), a higher unemployment level (OR 1.3 [95% CI 1.2 to 1.4]; p < 0.01), and greater number preventable hospital stays per 100,000 (OR 1.01 [95% CI 1.01 to 1.02]; p < 0.01) were associated with increased odds of being a low-access county (though the effect size of the finding was small for population density and number of primary care physicians). Stated another way, each additional person per square mile was associated with an 8% (95% CI 6% to 10%; p < 0.01) decrease in the odds of being a low-access county, and each additional percentage point of unemployment was associated with a 30% (95% CI 20% to 40%) increase in the odds of being a low-access county. Conclusion Despite the potential for telehealth programs to improve the delivery of high-quality orthopaedic surgical care, broadband internet access remains a major barrier to implementation. Until targeted investments are made to expand broadband infrastructure across the country, health systems, policymakers, and surgeon leaders must capitalize on existing federal subsidy programs, such as the lifeline or affordability connectivity initiatives, to reach unemployed patients living in economically depressed regions. The incorporation of internet access questions into clinic-based social determinants screening may facilitate the development of alternative follow-up protocols for patients unable to participate in synchronous videoconferencing. Clinical Relevance Some orthopaedic patients lack the broadband capacity necessary for telehealth visits, in which case surgeons may pursue alternative methods of follow-up such as mobile phone–based surveillance of postoperative wounds, surgical sites, and clinical symptoms.

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.

Purpose The purpose of this study was to assess the price variation of various Medicare severity diagnosis‐related group codes for orthopaedic upper extremity procedures for the top 20 orthopaedic hospitals using chargemaster price listings from each hospital. Methods The top 20 orthopaedic hospitals in the United States were determined by querying the U.S. News and World Report ’s 2020 orthopaedic hospital ranking. This report ranks orthopaedic hospitals according to 4 major domains: outcomes, structure, process/expert opinion, and patient experience. Chargemaster data for the top 20 orthopaedic hospitals was compiled from their websites. Five DRG codes that represented orthopaedic upper extremity procedures were selected, and the pricing information for each was extracted from hospital chargemasters. The median income and cost‐of‐living index were also compiled for the county that each hospital is located in so that pricing data could be compared to economic measures through regression analysis. Results Of the top 20 orthopaedic hospitals, 18 had publicly available pricing information in DRG format on their websites. The DRG code with the highest pricing variability was Hand Injury Procedures (DRG 906; range, $12,832‐$253,633). The procedure with the least pricing variability was Hand or Wrist Procedures (DRG 514; range, $24,533‐$128,403). Additionally, only the cost of living index was a statistically significant predictor of procedure pricing with a weak correlation. Conclusion Hospital chargemaster listings are lacking in 2 major areas: true price transparency and standardization/consistency between hospitals. Chargemaster data are often difficult to find, confusing to patients, and inaccurate. Additionally, the price range for a single DRG code can also vary substantially depending on the hospital. It is possible that hospitals located in areas with high costs of living and median incomes would charge higher prices, but these factors were not found to support this hypothesis.

Background: Decreases in Medicare reimbursement have been noted among many medical specialties. An in-depth analysis of the subspecialty of orthopaedic sports medicine is needed to determine changes in Medicare reimbursement in this field. Purpose/Hypothesis: The purpose was to elucidate the trends in inflation-adjusted Medicare reimbursement for orthopaedic sports medicine procedures between 2000 and 2020. It was hypothesized that Medicare reimbursement decreased substantially during the study period. Study Design: Economic decision and analysis; Level of evidence, 4. Methods: The Physician Fee Schedule Look-up Tool was used to extract Medicare reimbursement information between 2000 and 2020 for 67 procedures related to orthopaedic sports medicine. These values were adjusted for inflation using the Consumer Price Index. The compound annual growth rate (CAGR) was calculated to measure the annual rate of change, and descriptive analyses were performed using the Student t test. Results: Between 2000 and 2020, inflation-adjusted Medicare reimbursement for the 67 included procedures decreased by an average of 33% (CAGR = –2.2%; R 2 = 0.78). Reimbursement decreased for procedures related to the shoulder and elbow by 34% (CAGR = –2.3%; R 2 = 0.80), for hip-related procedures by 23% (CAGR = –1.4%; R 2 = 0.77), for knee-related procedures by 31% (CAGR = –2.0%; R 2 = 0.81), and for procedures relating to the foot and ankle by 38% (CAGR = –2.5%; R 2 = 0.79). Conclusion: Study findings indicated that inflation-adjusted Medicare reimbursement decreased substantially between 2000 and 2020 for orthopaedic sports medicine procedures, ranging from a 23% decrease for hip-related procedures to a 38% decrease for foot and ankle–related procedures. The results of this study could be used to provide further context for health care policy decisions and help ensure sustainable financial environments for orthopaedic sports medicine surgeon.

Purpose To examine and analyze Medicare reimbursement rates from 2000 to 2020 for orthopaedic foot and ankle procedures. Methods The 20 most used orthopaedic foot and ankle surgical procedures were gathered from the Centers for Medicare & Medicaid Services website using the Medicare Provider Utilization and Payment Data Public Use File 2017. The reimbursement data for each code were gathered from The Physician Fee Schedule Look‐Up Tool from Centers for Medicare & Medicaid Services. The reimbursement values were adjusted for inflation to 2020 U.S. dollars using the consumer price index. Results The average inflation‐adjusted reimbursement for included procedures decreased by 30% from 2000 to 2020. The greatest mean decreases were observed for “correction of hallux valgus” (–47%) and “partial excision of foot bone” (–41%). The procedures with the smallest mean decreases were observed in “treatment of “Amputation of toe” (–19%) and “closed treatment of metatarsal fracture” (–7%). Conclusions From 2000 to 2020, Inflation‐adjusted Medicare reimbursement for foot and ankle surgery decreased by 30%. Level of Evidence IV; economic analysis.

Purpose To analyze recent trends in orthopaedic surgery consolidation and quantify these changes temporally and geographically from 2012 to 2020. Methods We performed a retrospective cross‐sectional analysis of orthopaedic surgeon practice size in the United States using 2012 and 2020 data obtained from the Physician Compare database. Results Although we observed an increase from 21,216 unique orthopaedic surgeons in 2012 to 21,553 in 2020 (1.6% increase), the number of practices experienced a large decrease from 7,299 practices in 2012 to 5,829 in 2020 (20.1% decrease). The proportion of orthopaedic surgeons working in solo practices decreased from 13.2% (2,790) in 2012 to 7.4% (1,595) in 2020, and the proportion of orthopaedic surgeons working in groups sized 2 to 24 decreased from 35.3% (7,482) in 2012 to 22.2% (4,775) in 2020. In contrast, groups sized 25 to 99 have grown from 20.7% (4,387) of all orthopaedic surgeons to 23.4% (5,048) in 2020. Groups sized 100 to 499 have increased from 16.9% (3,593) in 2012 to 24.1% (5,190) in 2020, whereas groups sized 500 or greater have grown from 14% (2,964) in 2012 to 22.9% (4,945) in 2020. The number of unique group practices showed a significant decrease in the number of solo groups, which comprised 43.8% (3,200) of the total number of individual practices in 2012, decreasing to 32% (1,886) in 2020. All other groups increased in number and proportionally from 2012 to 2020. Conclusions This study shows that over the period from 2012 to 2020, there has been a substantial trend of orthopaedic surgeons shifting to increasing practice sizes, potentially indicating that more orthopaedic surgeons are working for large health care organizations rather than small independent practices. Clinical Relevance The impact of these changes should be examined to determine large‐scale effects on patient care, payment models, access, and outcomes, along with physician compensation, lifestyle, and satisfaction.

Introduction: There is a lack of data regarding financial trends for procedural reimbursement in stroke care. An understanding of such trends is important as progress is made to advance agreeable reimbursement models in the care of stroke patients. The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for commonly utilized procedures in stroke care from 2000 to 2019. Methods: Reimbursement data for Current Procedural Terminology (CPT) codes was extracted from the Centers for Medicare & Medicaid Services. CPT codes were determined by frequency of procedures for Stroke-related ICD codes at our institution. All monetary data was adjusted for inflation to 2019 US dollars utilizing changes to the United States consumer price index. Results: After adjusting for inflation, the average reimbursement for all four included procedures within hemorrhagic stroke (ICD I60-I62) decreased by 18.4% from 2000 to 2019. The average reimbursement for two procedures within ischemic stroke (ICD I63), craniotomy and thrombectomy, increased by 3.5% (2003 -2019) and increased 3.0% (2016-2019), respectively. Data was not available for craniotomy prior to 2003, and not available for thrombectomy prior to 2016. Further, the adjusted reimbursement rate for included telestroke codes decreased by 12.1% from 2010-2019. All other included procedures decreased by 3.5% throughout this time. The difference in reimbursement rate between telestroke and other stroke-related procedures was statistically significant (p < .0001). Conclusion: To our knowledge, this is the first study to evaluate trends in Medicare reimbursement for stroke care. When adjusted for inflation, Medicare reimbursement for included procedures has steadily decreased from 2000 to 2019. Increased awareness of these trends is important to assure continued access to quality stroke care in the United States.