Industry payments to spine surgeons from 2014 to 2019: trends and comparison of payments to spine surgeons versus all physicians

BACKGROUND CONTEXTThe ethics of industry payments to physicians and the potential impact on healthcare costs and research outcomes have long been topics of debate. Industry payments to spine surgeons are frequently scrutinized. Transparency of industry relationships with physicians provides insight into their possible impact on clinical decision-making and utilization of care.PURPOSE: To analyze trends in medical industry payments to spine surgeons and all physicians from 2014 to 2019, and further evaluate whether specific payments to spine surgeons vary based on company size.STUDY DESIGN/SETTINGCross-sectional investigation of publicly reported Center for Medicare and Medicaid Services (CMS) Open Payments Database (OPD)POPULATION SAMPLEAll US providers listed as receiving industry payments with further evaluation of payments to neurosurgeons and orthopedic spine surgeons.OUTCOME MEASURESMain measures were the magnitude and trends of industry general and research payments and subcategories of general payments, such as royalty/license and consulting fees, to spine surgeons and comparison to all physicians over the six-year period. Variations in payment patterns among spine device manufacturers with the highest reported level of spine surgeon payments in 2019.METHODSFrom 2014 to 2019 publicly reported general and research industry payments in the CMS OPD were analyzed. Trends in payments to all physicians were compared to trends in payments to neurosurgeons and orthopedic spine surgeons. Trends in payment patterns among spine device manufacturers with the highest payments in 2019 were determined. Linear regression analysis was completed to find statistically significant outcomes.RESULTSOur investigation found an aggregate of $42,710,365,196 general and research payments reported to all physicians over the 6-year period, 2.6% ($1,112,936,203) of which went to spine surgeons. Industry general and research payments to spine surgeons decreased by 17.5% ($195,571,109, 2014; $161,283,683, 2019), while increasing by 8.7% ($6,706,208,391, 2014; $7,288,003,832, 2019) to all physicians. Industry research payments to spine surgeons were notably low each year and decreased to only 0.5% of research payments made to all physicians in 2019. Median payment received by spine surgeons as well as the overall distribution of payments to the 75th and 95th percentile significantly increased over the six-year period in comparison to the stable distribution of payments to all physicians. Top eight spine device manufactures with the highest level of spine surgeon payments accounted for 72.9% payments in 2014 but decreased payments by 17.6% to 2019 ($120,409,083.75, 2014; $99,283,264.49, 2019).CONCLUSIONSIndustry general and research payments to all physicians increased from 2014 to 2019 but decreased to spine surgeons, largely due to decreasing payments from eight device manufacturers with the highest level of surgeon payments. A small subset of spine surgeons continues to receive increasing payments. The implications of decreasing investments in research by industry and of large payments made to a small group of spine surgeons bears cautious oversight, both for the future of the specialty and any impact on patient care outcomes.     

Industry Payments to Adult Reconstruction-Trained Orthopedic Surgeons: An Analysis of the Open Payments Database From 2014 to 2019

BackgroundIn recent time, there has been an increased push toward transparency in industry funding toward physicians. The Physician Payments Sunshine Act called for the creation of the Open Payments Database managed by the Centers for Medicare & Medicaid Services. To our knowledge, there have been no studies evaluating the trends in payments among adult reconstruction fellowship-trained orthopedic surgeons. The purpose of this study is to investigate trends in all payments to adult reconstruction-trained orthopedic surgeons from 2014 to 2019. Secondary outcomes included evaluating trends in yearly subpayment categories, regional variations, as well as characterizing the top 5 industry companies.MethodsA review of the Centers for Medicare & Medicaid Services Open Payments Database was performed to identify all payments to adult reconstruction-trained orthopedic surgeons. A total of 94,265 payments were made to 4911 surgeons accounting for a total of $258,865,231.20 during the study period. Our primary outcome was to assess the trend in median payment per year to individual surgeons. Secondary outcomes included evaluating payment trends with respect to subtype, location as defined by United States Census regions, as well as specifics concerning the top 5 companies.ResultsOver the study period, there was a nonsignificant increasing trend in median payment per surgeon (r = 0.49, P = .096). However, there was also a significantly increasing trend in the number of payments per year (r = 0.83, P = .014), as well as the number of surgeons receiving payments (r = 0.88, P = .019). With respect to subcategory payments, there were significantly increasing trends in the median payment per surgeon for education (1054%, r = 0.942, P < .001) and entertainment/food and beverage expenses (20.2%, r = 0.49, P = .020), as well as a significantly decreasing trend for median honoraria payments per surgeon (20.2%, r = −0.04, P = .005). No significant regional trends were identified. Of the top 5 companies, one demonstrated a significantly decreasing trend in median payment per surgeon (21.6%, r = −0.109, P < .001), whereas the others remained unchanged.ConclusionIn this study, we found a nonsignificant increasing trend in payments to adult reconstruction-trained surgeons as well as an increasing number of surgeons receiving payments. There were increasing trends in median payment per surgeon for education and entertainment expenses, but a decreasing trend for honoraria payments. No significant regional trends were identified. The majority of the top 5 companies had nonsignificant trends in their payments. Further studies are needed to characterize the disclosure of payments and the impact of industry payments on clinical outcomes.Level of EvidenceIV.     

Discrepancies in spine surgeon conflict of interest disclosures between a national meeting and physician payment listings on device manufacturer web sites

Background contextPrevious studies have identified inconsistencies in physician conflict-of-interest disclosures at academic meetings. The Physician Payment Sunshine Act (PPSA) will require industry to disclose anything of value given to physicians by 2014. In preparation, some spine device companies have begun reporting payments online.PurposeTo evaluate potential inconsistencies between physician disclosures and payments reported by industry before the PPSA implementation.Study designComparison of publically available disclosure/payment data.Patient samplePhysicians participating in the 2011 North American Spine Society (NASS) annual meeting and physicians listed on the 2010 physician payment web sites of Medtronic and Depuy Spine.MethodsDisclosures of participants at NASS were compared with the published Medtronic and Depuy Spine physician payments. The periods reflected by the disclosures compared should have coincided (except the Depuy site, which was only listed for one quarter of the NASS disclosure period). Discrepancies were noted whenever participant disclosures and company listings did not match as well as whenever payment ranges did not overlap. Fisher's exact test was used to compare disclosure discrepancy rates based on Medtronic payment size. No funding was received for this work. The authors report no conflicts of interest directly related to this study; however, one of the authors does do consulting unrelated to this study.ResultsMedtronic and Depuy Spine were disclosed by 12.1% and 8.75% of NASS participants, respectively. Based on NASS disclosures, 52.4% of NASS participants affiliated with Medtronic had their disclosures inaccurately reflected on the Medtronic web site. Based on Medtronic payment postings, 45.7% of NASS participants listed on Medtronic's webpage had discrepancies in their NASS disclosures. Those who received payments <$100,000 from Medtronic were more likely to have discrepancies in their disclosures than those who received payments >$100,000 (p=.009). Based on Depuy Spine payment postings, 30% of NASS participants listed on Depuy Spine's site had discrepancies in their NASS disclosures.ConclusionsDiscrepancy rates between what spine surgeons disclosed at NASS 2011 and what companies reported for their consultants were high. This is concerning given the passage of the PPSA as well as the increased public visibility of potential discrepancies. More uniform practices will certainly be necessary.     

Industry Payments and Their Association With Academic Influence in Total Joint Arthroplasty

BackgroundThe relationship between industry payments and academic influence, as measured by the Hirsch index (h-index) and number of publications, among adult reconstruction surgeons is not well characterized. The aims of the present study are to determine the relationship between an adult reconstruction surgeons’ academic influence and their relevant industry payments and National Institutes of Health (NIH) funding.MethodsAdult reconstruction surgeons were identified through the websites for the orthopedic surgery residency programs in the United States during the 2019-2020 academic year.Academic influence was approximated by each physician’s h-index and total number of publications. Industry payment data were obtained through the Open Payments Database, and NIH funding was determined through the NIH website. Mann-Whitney U testing and Spearman correlations were performed to examine relevant associations.ResultsSurgeons who received industry research payments had a higher mean h-index (16.1 vs 10.2, P < .001) and mean number of publications (79.1 vs 35.9, P < .001) than physicians who received no industry research payments. Surgeons receiving NIH funding had a higher mean h-index (48.1 vs 10.4, P < .001) and mean number of publications (294.5 vs 36.8, P < .001) than surgeons who did not receive NIH funding. There was no association between the average h-index (P = .668) and number of publications (P = .387) among adult reconstruction surgeons receiving industry nonresearch funding.Conclusionh-index and total publications do not seem to be associated with industry nonresearch payments in the field of total joint arthroplasty. Altogether, these data suggest that industry bias may not play a strong role in total joint arthroplasty.     

The Impact of Author Financial Conflicts on Robotic-Assisted Joint Arthroplasty Research

BackgroundRecent studies have suggested clinical superiority with robotic-assisted arthroplasty compared to traditional techniques. However, concerns exist regarding the author’s financial conflicts of interest (COI), which may influence research outcomes. This study aimed to determine whether COI relating to robotic-assisted arthroplasty influences the results of published outcomes following total hip (THA), total knee (TKA), and unicompartmental knee arthroplasty (UKA).MethodsWe performed a systematic review to identify all studies evaluating the use of robotics in THA, TKA, and UKA. An author’s financial COI was identified if they reported a relevant disclosure through the American Academy of Orthopedic Surgeons or within the study article. We then queried the Open Payments website to record all payments made from a robotic company in the year prior to publication. Each study was categorized as either favoring robotics (n = 42), neutral (n = 10), or favoring traditional techniques (n = 2). We then compared the number of conflicted authors, journal impact factor, level of evidence, and mean annual industry payment to each author.ResultsOf the 54 studies meeting inclusion criteria, 49 (91%) had an author financial COI. Conflicted studies were more likely to report favorable results of robotics than nonconflicted studies. When compared to studies favoring conventional techniques, those demonstrating favorable robotics outcomes had a higher number of conflicted authors and a higher mean industry payment per author. There was no difference in the level of evidence or journal impact factor.DiscussionNearly all studies comparing robotic THA, TKA, and UKA to conventional techniques involve financially conflicted authors. Further studies without COI may provide unbiased results.     

Letting the sunshine in: shining a new light on physician-industry relationships

The pending federal healthcare reform legislation includes Physician Payment Sunshine provisions that would mandate public disclosure of virtually all payments by industry to US physicians on government websites. The requirements reflect a growing trend toward public disclosure of payments following high-profile government investigations of allegedly improper payments and undisclosed conflicts of interests. The pending law world require broad disclosure and will affect most physicians. Industry and physicians groups have offered qualified support to the legislation.     

Where the Sun Shines: Industry's Payments to Transplant Surgeons

The Open Payments Program (OPP) was recently implemented to publicly disclose industry payments to physicians, with the goal of enabling patient awareness of potential conflicts of interests. Awareness of OPP, its data, and its implications for transplantation are critical. We used the first wave of OPP data to describe industry payments made to transplant surgeons. Transplant surgeons (N = 297) received a total of $759 654. The median (interquartile range [IQR]) payment to a transplant surgeon was $125 ($39–1018), and the highest payment to an individual surgeon was $83 520; 122 surgeons received <$100, and 17 received >$10 000. A higher h‐index was associated with 30% higher chance of receiving >$1000 (relative risk/10 unit h‐index increase = _1.181.30_1.44, p < 0.001). The highest payment category was consulting fees, with a total of $314 448 paid in this reported category. Recipients of consulting fees had higher h‐indices, median (IQR) of 20 (10–35) versus nine (3–17) (p < 0.001). Ten of 122 companies accounted for 62% of all payments. Kidney transplant and liver transplant (LT) centers that received >$1000 had higher center volumes (p < 0.001). LT centers that received payments of >$1000 had a higher percentage of private‐insurance/self‐pay patients (p < 0.01). Continued surveillance of industry payments may further elucidate the relationship between industry payments and physician practices.     

The Impact of Financial Conflict of Interest on Surgical Research: An Observational Study of Published Manuscripts

Background

Substantial discrepancies exist between industry-reported and self-reported conflicts of interest (COI). Although authors with relevant, self-reported financial COI are more likely to write studies favorable to industry sponsors, it is unknown whether undisclosed COI have the same effect. We hypothesized that surgeons who fail to disclose COI are more likely to publish findings that are favorable to industry than surgeons with no COI.

Methods

PubMed was searched for articles in multiple surgical specialties. Financial COI reported by surgeons and industry were compared. COI were considered to be relevant if they were associated with the product(s) mentioned by an article. Primary outcome was favorability, which was defined as an impression favorable to the product(s) discussed by an article and was determined by 3 independent, blinded clinicians for each article. Primary analysis compared incomplete self-disclosure to no COI. Ordered logistic multivariable regression modeling was used to assess factors associated with favorability.

Results

Overall, 337 articles were reviewed. There was a high rate of discordance in the reporting of COI (70.3%). When surgeons failed to disclose COI, their conclusions were significantly more likely to favor industry than surgeons without COI (RR 1.2, 95% CI 1.1–1.4, p < 0.001). On multivariable analysis, any COI (regardless of relevance, disclosure, or monetary amount) were significantly associated with favorability.

Conclusions

Any financial COI (disclosed or undisclosed, relevant or not relevant) significantly influence whether studies report findings favorable to industry. More attention must be paid to improving research design, maximizing transparency in medical research, and insisting that surgeons disclose all COI, regardless of perceived relevance.

     

Variations in Medicare payments for episodes of spine surgery

Background contextAlthough the high cost of spine surgery is generally recognized, there is little information on the extent to which payments vary across hospitals.PurposeTo examine the variation in episode payments for spine surgery in the national Medicare population. We also sought to determine the root causes for observed variations in payment at high cost hospitals.Study designAll patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were included.Patient sampleIncluded 185,954 episodes of spine surgery performed between 2005 and 2007.Outcome measuresPayments per episode of spine surgery.MethodsAll patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were identified (n=185,954 episodes of spine surgery). Hospitals were ranked on least to most expensive and grouped into quintiles. Results were risk- and price-adjusted using the empirical Bayes method. We then assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variations in payment.ResultsEpisode payments for hospitals in the highest quintile were more than twice as high as those made to hospitals in the lowest quintile ($34,171 vs. $15,997). After risk- and price-adjustment, total episode payments to hospitals in the highest quintile remained $9,210 (47%) higher. Procedure choice, including the use of fusion, was a major determinant of the total episode payment. After adjusting for procedure choice, however, hospitals in the highest quintile continued to be 28% more expensive than those in the lowest. Differences in the use of postacute care accounted for most of this residual variation in payments across hospitals. Hospital episode payments varied to a similar degree after subgroup analyses for disc herniation, spinal stenosis, and spondylolisthesis. Hospitals expensive for one condition were also found to be expensive for services provided for other spinal diagnoses.ConclusionsMedicare payments for episodes of spine surgery vary widely across hospitals. As they respond to the new financial incentives inherent in health care reform, high cost hospitals should focus on the use of spinal fusion and postacute care.     

Financial disclosures of authors involved in spine research: an underestimated source of bias

Background

Reporting financial disclosures has become standard practice in both journal publications and during oral forum at scientific meetings. Despite this, the effect of reporting a financial disclosure of any member of an authorgroup, on the tone of the conclusion of an article has gained little attention. This study was performed to determine what effect reporting a financial disclosure has on the conclusion of an article.

Methods

A literature search for all articles on interspinous devices and cervical disc prostheses, published from January 1st, 2008 until December 1st, 2010 was performed. Financial disclosures were reported, as were funding by commercially active parties. The tone of the conclusions was graded as positive, neutral or negative.

Results

The odds ratio (OR) for a positive conclusion in cases where a financial disclosure was reported was 16.5 (95% CI: 4.7–58.1). Effect modification occurs with the presence of funding by a commercially active party. In cases where a financial disclosure was reported and funding was available for the study, the OR was 1.0 (95% CI: 0.08–12.6), whilst the OR was 33.3 (95%CI: 4.2–262.3) if funding was not provided. This discrepancy is mainly due to the large number of articles with a neutral/negative conclusion if the authors failed to report any financial disclosure and were not funded by a commercially active party.

Conclusions

Reporting a financial disclosure is a potential source of bias. Authors with disclosed financial relationships less often publish articles with a neutral/negative conclusion. This source of bias should certainly be taken into account during the critical appraisal of articles, particularly when the quality of the literature is being assessed.     

The Financial Implications of Being a Female Fellow: Does Another Year Help Close the Gap?

In 2018, the American College of Foot and Ankle Surgeons Compensation and Benefits Survey illustrated a wage gap between male and female doctors of podiatric medicine in the United States. The purpose of the present study was to assess if an additional year of fellowship training closes that gap. To calculate the net present value, weighted mean general income data from female doctors of podiatric medicine with and without fellowship training was obtained. Demographic and clinical income data (based on 2080 hours) for 17 female graduates from 14 American College of Foot and Ankle Surgeons recognized fellowship programs was collected using an anonymous online survey. Income from general payments was collected from manual searches of Open Source Payments. Socioeconomic data from the 2018 American College of Foot and Ankle Surgeons compensation and benefits survey was used to calculate the net present value of the nonfellowship trained doctors of podiatric medicine for comparison. Overall, the net present value of female doctors of podiatric medicine with and without fellowship training was $1.91 million and $2.4 million, respectively. The comparative net present value and cumulative net income difference over 30 years for female doctors of podiatric medicine with and without fellowships was ?$492,159.00 and ?$820,000.00, respectively. The mean comparative income difference for fellowship trained female doctors of podiatric medicine annually was as follows: clinical (?$26,082.00) and general (+$1101.54). Based on the data, with consideration to the limitations of the study, the financial implications of fellowship on the gender wage gap is currently unclear. Additional research is warranted.     

Conflict of interest and professional medical associations: the North American Spine Society experience

Background contextRecently the financial relationships between industry and professional medical associations have come under increased scrutiny because of the concern that industry ties may create real or perceived conflicts of interest. Professional medical associations pursue public advocacy as well as promote medical education, develop clinical practice guidelines, fund research, and regulate professional conduct. Therefore, the conflicts of interest of a professional medical association and its leadership can have more far-reaching effects on patient care than those of an individual physician.PurposeFew if any professional medical associations have reported their experience with implementing strict divestment and disclosure policies, and among the policies that have been issued, there is little uniformity. We describe the experience of the North American Spine Society (NASS) in implementing comprehensive conflicts of interest policies.Study designA special feature article.MethodsWe discuss financial conflicts of interest as they apply to professional medical associations rather than to individual physicians. We describe the current policies of disclosure and divestment adopted by the NASS and how these policies have evolved, been refined, and have had no detrimental impact on membership, attendance at annual meetings, finances, or leadership recruitment. No funding was received for this work. The authors report no potential conflict-of-interest-associated biases in the text.ResultsThe NASS has shown that a professional medical association can manage its financial relationships with industry in a manner that minimizes influence and bias.ConclusionsThe NASS experience can provide a template for other professional medical associations to help manage their own possible conflicts of interest issues.     

Orthopaedic Surgeons Receive the Most Industry Payments to Physicians but Large Disparities are Seen in Sunshine Act Data

Background

Industry payments made to physicians by drug and device manufacturers or group purchasing organizations are now reported to the Centers for Medicare and Medicaid Services (CMS) as a part of the Physician Payments Sunshine Act. Initial reports from the program show that orthopaedic surgeons lead all physician specialties in total and average industry payments. However, before further discussion of these payments and their implications can take place, it remains to be seen whether these figures are a true reflection of the field of orthopaedic surgery in general, rather than the result of a few outlier physicians in the field. In addition, the nature and sources of these funds should be determined to better inform the national dialogue surrounding these payments.

Questions/Purposes

We asked: (1) How do industry payments to orthopaedic surgeons compare with payments to physicians and surgeons in other fields, in terms of median payments and the Gini index of disparity? (2) How much do payments to the highest-receiving orthopaedic surgeons contribute to total payments? (3) What kind of industry payments are orthopaedic surgeons receiving? (4) How much do the highest-paying manufacturers contribute to total payments to orthopaedic surgeons?

Materials and Methods

We reviewed the most recent version of the CMS Sunshine Act Open Payments database released on December 19, 2014, containing data on payments made between August 1, 2013 and December 31, 2013. Data on total payments to individual physicians, physician specialty, the types of payments made, and the manufacturers making payments were reviewed. The Gini index of statistical dispersion was calculated for payments made to orthopaedic surgeons and compared with payments made to physicians and surgeons in all other medical specialties. A Gini index of 0 indicates complete equality of payments to everyone in the population, whereas an index of 1 indicates complete inequality, or all income going to one individual.

Results

A total of 15,376 orthopaedic surgeons receiving payments during the 5-month period were identified, accounting for USD 109,846,482. The median payment to orthopaedic surgeons receiving payments was USD 121 (interquartile range, USD 34–619). The top 10% of orthopaedic surgeons receiving payments (1538 surgeons) received at least USD 4160 and accounted for 95% of total payments. Royalties and patent licenses accounted for 69% of all industry payments to orthopaedic surgeons.

Conclusions

Even as a relatively small specialty, orthopaedic surgeons received substantial payments from industry (more than USD 110 million) during the 5-month study period. Whether there is a true return of value from these payments remains to be seen; however, future ethical and policy discussions regarding industry payments to orthopaedic surgeons should take into account the large disparities in payments that are present and also the nature of the payments being made. It is possible that patients and policymakers may view industry payments to orthopaedic surgeons more positively in light of these new findings.

Level of Evidence

Level III, Economic and Decision Analysis.     

Case Mix, Quality and High-Cost Kidney Transplant Patients

A better understanding of high-cost kidney transplant patients would be useful for informing value-based purchasing strategies by payers. This retrospective cohort study was based on the Medicare Provider Analysis and Review (MEDPAR) files from 2003 to 2006. The focus of this analysis was high-cost kidney transplant patients (patients that qualified for Medicare outlier payments and 30-day readmission payments). Using regression techniques, we explored relationships between high-cost kidney transplant patients, center-specific case mix, and center quality. Among 43 393 kidney transplants in Medicare recipients, 35.2% were categorized as high-cost patients. These payments represented 20% of total Medicare payments for kidney transplantation and exceeded $200 million over the study period. Case mix was associated with these payments and was an important factor underlying variation in hospital payments high-cost patients. Hospital quality was also a strong determinant of future Medicare payments for high-cost patients. Compared to high-quality centers, low-quality centers cost Medicare an additional $1185 per kidney transplant. Payments for high-cost patients represent a significant proportion of the total costs of kidney transplant surgical care. Quality improvement may be an important strategy for reducing the costs of kidney transplantation.     

A perioperative cost analysis comparing single-level minimally invasive and open transforaminal lumbar interbody fusion

Background contextEmerging literature suggests superior clinical short- and long-term outcomes of MIS (minimally invasive surgery) TLIFs (transforaminal lumbar interbody fusion) versus open fusions. Few studies to date have analyzed the cost differences between the two techniques and their relationship to acute clinical outcomes.PurposeThe purpose of the study was to determine the differences in hospitalization costs and payments for patients treated with primary single-level MIS versus open TLIF. The impact of clinical outcomes and their contribution to financial differences was explored as well.Study design/settingThis study was a nonrandomized, nonblinded prospective review.Patient sampleSixty-six consecutive patients undergoing a single-level TLIF (open/MIS) were analyzed (33 open, 33 MIS). Patients in either cohort (MIS/open) were matched based on race, sex, age, smoking status, medical comorbidities (Charlson Comorbidity index), payer, and diagnosis. Every patient in the study had a diagnosis of either degenerative disc disease or spondylolisthesis and stenosis.Outcome measuresOperative time (minutes), length of stay (LOS, days), estimated blood loss (EBL, mL), anesthesia time (minutes), Visual Analog Scale (VAS) scores, and hospital cost/payment amount were assessed.MethodsThe MIS and open TLIF groups were compared based on clinical outcomes measures and hospital cost/payment data using SPSS version 20.0 for statistical analysis. The two groups were compared using bivariate chi-squared analysis. Mann-Whitney tests were used for non-normal distributed data. Effect size estimate was calculated with the Cohen d statistic and the r statistic with a 95% confidence interval.ResultsAverage surgical time was shorter for the MIS than the open TLIF group (115.8 minutes vs. 186.0 minutes respectively; p=.001). Length of stay was also reduced for the MIS versus the open group (2.3 days vs. 2.9 days, respectively; p=.018). Average anesthesia time and EBL were also lower in the MIS group (p<.001). VAS scores decreased for both groups, although these scores were significantly lower for the MIS group (p<.001). Financial analysis demonstrated lower total hospital direct costs (blood, imaging, implant, laboratory, pharmacy, physical therapy/occupational therapy/speech, room and board) in the MIS versus the open group ($19,512 vs. $23,550, p<.001). Implant costs were similar (p=.686) in both groups, although these accounted for about two-thirds of the hospital direct costs in the MIS cohort ($13,764) and half of these costs ($13,778) in the open group. Hospital payments were $6,248 higher for open TLIF patients compared with the MIS group (p=.267).ConclusionsMIS TLIF technique demonstrated significant reductions of operative time, LOS, anesthesia time, VAS scores, and EBL compared with the open technique. This reduction in perioperative parameters translated into lower total hospital costs over a 60-day perioperative period. Although hospital reimbursements appear higher in the open group over the MIS group, shorter surgical times and LOS days in the MIS technique provide opportunities for hospitals to reduce utilization of resources and to increase surgical case volume.     

The impact of accreditation on safety and cost of bariatric surgery

BackgroundThe objective of this study was to examine how much of the impact of the Centers for Medicare and Medicaid Services’ national coverage decision (NCD) on bariatric surgery was driven by the restriction of reimbursements to Centers of Excellence (COE). We used inpatient care data of those with employer-sponsored insurance plans across United States using the MarketScan Commercial Claims and Encounter Database (2003–2009).MethodsWe performed a retrospective cohort study evaluating the impact of the accreditation on subjects with a difference-in-difference approach (removing the temporal changes occurring in non-COEs) on rates of inpatient mortality, 90-day reoperations, complications, readmissions, and total payments.ResultsA total of 30,755 patients (43.9±11.0 years; 79.9% women) had bariatric surgery. A total of 17,896 patients underwent procedures at sites that became COEs (8455 pre-NCD and 9441 post-NCD, [+10.4%]) compared with 12,859 at non-COEs (6534 pre-NCD and 6325 post-NCD, [?3.3%]). Of the total number of bariatric procedures, laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable band procedures increased from 42.9% and 3.1% pre-NCD to 64.5% and 19.7% post-NCD, respectively. In the COEs, there were reductions in inpatient mortality (.3% to .1%; P = .02), 90-day reoperations (.8% to .5%; P = .006), complications (36.4% to 27.6%; P<.001), and readmissions (10.8% to 8.8%; P<.001) while payments remained similar ($24,543±$40,145 to $24,510±$37,769; P = .9). After distinguishing from temporal trends and differences occurring at non-COEs, 90-day reoperation (?.8%; P = .02) and complication rates (?2.7%; P = .01) were lower at the COEs after the NCD.ConclusionsThe accreditation-based NCD in bariatric surgery was associated with lower rates of reoperations and complications. Such policies may become a powerful tool to improve surgical safety and quality.     

The Clinical and Financial Consequences of the Centers for Medicare and Medicaid Services’ Two-Midnight Rule in Total Joint Arthroplasty

BackgroundTo lessen the financial burden of total joint arthroplasty (TJA) and encourage shorter hospital stays, the Centers for Medicare and Medicaid Services (CMS) recently removed TKA from the inpatient-only list. This policy change now requires providers and institutions to apply the two-midnight rule (TMR) to short-stay (1-midnight) inpatient hospitalizations (SSIH).MethodsThe National Inpatient Sample from 2012 through 2016 was used to analyze trends in length of stay following elective TJA. Using publically-available policy documentation, published median Medicare payments, and National Inpatient Sample hospital costs, we analyzed the application of the TMR to SSIHs and compared the results to the previous policy environment. Specifically, we modeled 3 scenarios for all 2016 Medicare SSIHs: (1) all patients kept an extra midnight to satisfy the TMR, (2) all patients discharged as an outpatient, and (3) all patients discharged as an inpatient.ResultsThe overall percentage of Medicare SSIHs increased significantly from 2.7% in 2012 to 17.8% in 2016 (P < .0001). Scenario 1 resulted in no change in out-of-pocket (OOP) costs to patients, no change in CMS payments, and hospital losses of $117.0 million. Scenario 2 resulted in no change in patient OOP costs, reduction in payments from CMS of $181.8 million, and hospital losses of $357.3 million. Scenario 3 resulted in no change in patient OOP costs, no change in CMS payments, and an estimated $1.71 billion of SSIH charges at risk to hospitals for audit.ConclusionThe results of this analysis reveal the conflict between length of stay trends following TJA and the imposition of the TMR.