Trends in Diagnostic Flexible Laryngoscopy and Videolaryngostroboscopy Utilization in the US Medicare Population
Kyohei Itamura, BS1; Kevin Hur, MD1; Niels C. Kokot, MD1; et al Michael M. Johns III, MD1,2
Author Affiliations Article Information
JAMA Otolaryngol Head Neck Surg. Published online June 20, 2019. doi:10.1001/jamaoto.2019.1190
Key Points
Question What trends exist in diagnostic flexible laryngoscopy (DFL) and videolaryngostroboscopy (VLS) utilization and payments in the Medicare population?
Findings This population-based, cross-sectional study of all Medicare beneficiaries from 2000 through 2016 found that DFL and VLS utilization respectively increased by 30% and 380% with a 2% decrease and 300% increase in payments and 25% and 17% decrease in reimbursement rate; utilization rates differed 11-fold for DFL and 279-fold for VLS between the highest and lowest utilizing states.
Meaning Diagnostic flexible laryngoscopy in the Medicare population exhibited stable utilization and payment trends compared with VLS, which demonstrated significant state-level utilization differences.
Abstract
Importance Diagnostic flexible laryngoscopy (DFL) is the second-most reimbursed procedure by Medicare in otolaryngology. However, the economic trends of this procedure on a population level are unknown.
Objective To describe national- and state-level DFL and videolaryngostroboscopy (VLS) utilization and payment trends from 2000 to 2016 in the Medicare population.
Design, Setting, and Participants This population-based, cross-sectional study of all Medicare beneficiaries from 2000 through 2016 found that at the national level the total absolute number of DFLs performed in the US Medicare population increased by 87% from 344 183 to 645 172 services, whereas total absolute payments for DFLs made by Medicare concurrently increased by 41% from $38 720 243 to $54 499 071. Rates of DLS and VLS categorized as Current Procedural Terminology (CPT) code 31575 and 31579, respectively. Analysis was carried out between November 18, 2018 and December 18, 2018.
Exposures Diagnostic flexible laryngoscopy and VLS.
Main Outcomes and Measures The DFL and VLS utilization rates, payments, and reimbursement rate trends were analyzed by year and state. Utilization was assessed for physician characteristics, including specialty and credentials.
Results Nationally from 2000 to 2016 in the Medicare population, DFL utilization per Medicare enrollee increased 30% from 0.0087 to 0.0110 and payment per enrollee decreased 2% from $0.98 to $0.96, whereas VLS utilization and payment per enrollee both increased at least 300% during the same time period, with VLS procedure per enrollee and payment per enrollee increasing by 382% from 0.00028 to 0.0013 and 301% from $0.05 to $0.22, respectively. There was a weak correlation between reimbursement and utilization per enrollee for both DFL (r = 0.23; 95% CI, 0.12-0.34) and VLS (r = 0.26; 95% CI, 0.14-0.37) performed from 2012 to 2016. In 2016, the mean (SD) payment per DFL was $85.14 ($7.95), ranging from $65.45 in Puerto Rico to $104.82 in Washington, DC, a 1.6-fold difference. For VLS, there was a 2-fold difference between the lowest-reimbursing state, Maine ($92.20) and the highest, New York ($182.96). All US dollar values were uniformly adjusted for inflation to 2018 dollar values. Most DFLs in 2016 were performed by otolaryngologists (93.6%).
Conclusions and Relevance The DFL utilization rates remained stable compared with VLS in the Medicare population from 2000 to 2016. There was a decrease in both DFL and VLS payments per procedure in the same time period and also weak correlations between reimbursement and utilization. Practice patterns and reimbursement varied geographically across the United States, though VLS exhibited significantly higher variation than DFL at the state level.
Introduction
Diagnostic flexible laryngoscopy (DFL) is a commonly performed procedure in Otolaryngology–Head and Neck Surgery (OHNS) involving a thin, flexible, fiberoptic tube that can be passed transnasally to visualize the regions of the larynx. It is classified under CPT code 31575 and is defined by the American Academy of Otolaryngology–Head and Neck Surgery as a “well-established diagnostic procedure that is medically indicated for the diagnosis and management of many disorders including those involving the voice, swallowing, and upper aerodigestive tract.”1 Diagnostic flexible laryngoscopy has been one of the most commonly reimbursed procedures performed by otolaryngologists in the United States in recent years.2
Despite its mainstay in the diagnosis and treatment of a variety of diseases in OHNS, the economic impact of this procedure on the US health care system since its introduction decades ago is yet to be studied. Changes in accessibility to equipment, overall public opinion, and integration of new technologies over time can have a profound influence on how physicians use certain procedures in their clinical practice. There is a need to analyze DFL utilization patterns in the context of related emerging modalities, such as videolaryngostroboscopy (VLS), to characterize trends and possible disparities in how these important tools are used in the field.
The main objective of this study is to identify trends in DFL and VLS payments and utilization over time in the Medicare population across the United States at the national and state level. An additional objective is to further characterize Medicare providers who use these procedures.
Methods
All data were accessed online at https://www.cms.gov under Research, Statistics, Data & Systems between November 18, 2018 and December 18, 2018. The Centers for Medicare and Medicaid Services (CMS) Part B National Summary Data File was accessed for annual procedure data from 2000 to 2016 for DFL and VLS. Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (PUF) was used to obtain detailed physician and Medicare payment data for DFL and VLS from available years, 2012 to 2016. Total number of Medicare enrollees at the national and state levels were obtained from the CMS Medicare Enrollment Reports. All dollar values were adjusted for inflation to the 2018 average consumer price index. The study was approved for exempt status by the institutional review board of the University of Southern California owing to the deidentified data used.
The total number of procedures performed and the total amount paid by Medicare nationwide from 2000 to 2016 for DFL and VLS were extracted from the Part B National Summary Data File with Current Procedural Terminology (CPT) codes 31575 and 31579, respectively. To account for annual changes in total enrolled Medicare beneficiaries in the United States, the number of procedures performed and total payments were normalized to the total nationwide number of Medicare enrollees to produce the procedure per enrollee and payment per enrollee, respectively. Procedure per enrollee was calculated by dividing the total number of procedures performed by the total number of Medicare enrollees in the United States that year. Payment per enrollee was calculated by dividing the total Medicare payments for the procedure by the total number of Medicare enrollees. To quantify reimbursement to physicians, payment per procedure was calculated by dividing total Medicare payments for the procedure by the total number of procedures performed.
To study state-level data, the Physician and Other Supplier PUF database provided detailed utilization and financial data of physicians who billed for DFL and VLS from 2012 to 2016. To protect patient confidentiality, providers who billed for less than 10 procedures were not included in the original database. For each physician, the state, total number of DFL and VLS procedures performed, and the average Medicare payment received were extracted using pivot tables on Microsoft Excel (version 2016, Microsoft Corporation). As the database did not provide individual payment data, the total amount reimbursed by Medicare was calculated by multiplying the summation of the average Medicare payment amount by the number of procedures performed for each physician. Only procedures classified as nonfacility were analyzed for our study. Nonfacility procedures in the PUF database generally represent DFLs and VLSs performed in the office-based setting, compared with facility procedures that incorporate facility payments in addition to the physician’s professional fee. By only analyzing nonfacility procedures, the Medicare payment amount was representative of the fee of the procedure. Procedure per enrollee, payment per enrollee, and payment per procedure were calculated as above. To assess physician-level density, enrollees per physician was calculated by dividing the total number of Medicare enrollees in each state by the number of physicians who performed DFL or VLS. Utilization variation by state was geographically represented using Microsoft Excel (version 2016, Microsoft Corporation).
Correlation testing was then performed to evaluate the association between procedure per enrollee and payment per enrollee and between procedure per enrollee and enrollees per physician. Correlations were tested at a 95% confidence level using the Pearson correlation test.
Physician data from the physician and other supplier PUF who billed for DFL or VLS in 2016 were further characterized. Clinicians on the database were extracted then categorized by credentials as MD/DO or non-MD/DO. Non-MD/DO included speech language pathologists, nurse practitioners, physician assistants, and health care professionals who did not have credentials listed. The MD/DO specialties performing DFL or VLS were also analyzed to investigate the distribution of DFL and VLS utilization among different specialties.
Results
At the national level from 2000 to 2016, the total absolute number of DFLs performed in the US Medicare population increased by 87% from 344 183 to 645 172 services while total absolute payments for DFLs made by Medicare concurrently increased by 41% from $38 720 243 to $54 499 071 (eTable 1 in the Supplement). Diagnostic flexible laryngoscopy procedure per enrollee increased by 30% from 0.0087 to 0.0110 from 2000 to 2016, whereas DFL payment per enrollee decreased by 2% from $0.98 to $0.96. For comparison, during the same time period, VLS procedure per enrollee and payment per enrollee increased by 382% from 0.00028 to 0.00130 and 301% from $0.05 to $0.22, respectively (Figure 1 A and B). A 25% decrease, from $112.50 to $84.47, in DFL and 17% decrease, from $195.66 to $162.68, in VLS payment per procedure was also observed (Figure 1C). We therefore observed from 2000 to 2016 an overall increase in procedure per enrollee and an overall decrease in payment per procedure for both DFL and VLS.
Procedure per enrollee and payment per enrollee were also analyzed at the state level. In 2016, the mean (SD) national DFL procedure per enrollee and payment per enrollee was 0.0087 (0.0036) and $0.76 ($0.36), respectively (eTable 2 in the Supplement). New York (0.0180, $1.73), the state with the highest values in both metrics, had an 11-fold higher procedure per enrollee and a 15-fold higher payment per enrollee value than Puerto Rico (0.001700, $0.11), the state/territory with the lowest values in both metrics. For VLS, the mean (SD) national average in 2016 for procedure per enrollee was 0.00088 (0.00066) and $0.13 (0.11) for payment per enrollee (eTable 3 in the Supplement). We observed a 279-fold difference between the highest and lowest utilizing states, Maryland (0.0039) and Puerto Rico (0.000014). Furthermore, there was a 367-fold difference between Washington DC ($0.66), the state/territory with the highest VLS payment per enrollee value, and Puerto Rico ($0.00180), the state with the lowest value. Of note, some states were not found in the 2016 VLS database, including Idaho, Nebraska, South Dakota, and Wyoming. This was presumed to be owing to the lack of physicians who individually performed VLS for at least 10 beneficiaries in these states in 2016.
Overall mean (SD) payment per procedure nationwide in 2016 for nonfacility DFL and VLS were $85.14 ($7.95) and $144.25 ($19.50), respectively. The highest payment per procedure for DFL was observed in Washington DC ($104.82), which was 1.6 times higher than the lowest value found with Puerto Rico ($65.45) (Figure 2A). New York ($182.96), the state with the highest value for VLS payment per procedure, was double the state with the lowest value, Maine ($92.20) (Figure 2B).
From 2012 to 2016 at the state level we observed a weak positive correlation between procedure per enrollee and payment per procedure for both DFL (Pearson r = 0.23; 95% CI, 0.12-0.34) and VLS (Pearson r = 0.26; 95% CI, 0.14-0.37) (Figure 3). There was a moderate negative correlation between procedure per enrollee and enrollees per physician for both DFL (Pearson r = −0.52; 95% CI, 0.42-0.60) and VLS (Pearson r = −0.45; 95% CI, 0.34-0.54) (Figure 4).
Further characterizing provider data, of the 614 446 nonfacility DFLs performed in 2016, 588 309 (95.8%) were performed by physicians (eTable 4 in the Supplement). Out of all physicians, otolaryngologists performed 575 355 (93.6%) of all DFLs. These percentages were similar for VLS, where of 71 075 VLSs performed, 66 144 (93.1%) were performed by otolaryngologists (Table). The nonfacility setting accounted for approximately 90% of DFLs and 85% of VLSs performed from 2012 to 2016 with little change over time (eTable 5 in the Supplement).
Discussion
To our knowledge, this is the first study to report the economic impact and utilization trends of DFL, one of the most commonly billed OHNS procedures in the Medicare population, and VLS. We report nationwide and statewide utilization and payment trends that have not been described in the literature.
At the national level from 2000 to 2016 in the Medicare population, we observed increases in the absolute number of procedures performed and in total payments from Medicare for DFLs. Whereas the number of procedures per enrollee increased by 30% over these years, payment per procedure decreased by 25% such that payment per enrollee has remained relatively stable with an overall decrease of 2%. This finding suggests that despite the clear increase in utilization of DFLs over the course of nearly 2 decades, the relative impact on expenditure has remained stable. For comparison, concurrent national data for VLS showed different utilization and payment trends. From 2000 to 2016, VLS procedure and payment per enrollee both significantly increased by 382% and 301%, respectively, in the context of a 17% decrease in payment per procedure. There was substantially greater growth in utilization and payments for VLS compared with DFL.
Despite these differences, both DFL and VLS payment per enrollee correlated weakly with procedure per enrollee. This suggests that level of reimbursement is unlikely, at the state level, to be a significant driver of utilization for these procedures. We instead observed a moderate negative correlation between enrollees per physician, a proxy for physician density, and procedure per enrollee. Because most of these procedures are performed by otolaryngologists as we have shown, geographic distribution of these specialists appears to contribute to the state-level differences seen in DFL and VLS utilization. It is known that specialists such as otolaryngologists tend to practice in areas with higher overall physician density, creating pockets of specialist supply in certain locations.3 A study by Lango et al4 showed that Medicare-enrolled otolaryngologists tend to practice in areas near OHNS residency-training programs and staffed acute care centers. Because the otolaryngology workforce follows these geographic trends, we expect utilization of these procedures to distribute accordingly.
There were substantial relative differences in state-level utilization and payments for DFL and even more notably so for VLS. Identifying the cause of these observed state-level disparities is not possible in our study, though we can speculate as to why this may be the case. A prior study by Cohen et al5 showed through an analysis of a large national health claims database that factors associated with VLS usage in the outpatient otolaryngology setting include the patient’s age, geographic region of the United States, practice in an urban area, diagnosis of laryngeal disease, and comorbid diagnoses of asthma and gastroesophageal reflux disorder. Any of these factors can contribute to our findings. Videolaryngostroboscopy, being a more technically advanced modality than DFL, requires specialized equipment and training that may not be available in certain parts of the country. The increase in VLS utilization over the study time period, compared with a more established tool such as DFL, is likely the result of the growth of laryngology as a subspecialty, the expansion of laryngology fellowship training, increased training of otolaryngologists in VLS during residency, and expanded published evidence supporting the diagnostic value of VLS in laryngeal disorders.6,7
However, we must acknowledge the possibility of inappropriate use of VLS also playing a role. Clinicians with access to VLS could theoretically perform this procedure without adequate training in VLS interpretation owing to higher reimbursement potential. This possibility of overutilization has been discussed previously regarding nasal endoscopy, the most highly reimbursed Medicare procedure in OHNS, which was shown to have tremendous growth in the past 2 decades.8 Our study was limited by the lack of information on why these procedures were performed. Further studies should focus on appropriate usage of these procedures in the context of the patient’s medical indications.
Quality and value have become core issues in US health care. As such, otolaryngologists have increasingly become accountable for cost of care through alternative payment models, including bundled payments and merit-based incentive programs.9 However, there is currently a paucity of data in the otolaryngology literature on the trends in utilization, costs, and geovariation of commonly performed otolaryngology procedures. These types of studies are necessary to evaluate the economic impact of implemented reforms moving forward. For example, recent policy changes by the Centers for Medicare and Medicaid Services have proposed nearly 50% decreases in certain same-day office-based procedures.10 The finding of our study showed a large proportion of DFLs and VLSs being performed in the nonfacility setting. Introduction of such a policy change may significantly alter practice patterns. Hillel et al11 demonstrated that hospital endoscopic suites, typically used by gastroenterologists and pulmonologists, provide a facility-based setting in which to perform awake laryngology procedures faster and at less cost than in a traditional operating room and without overhead financial losses associated with unregulated otolaryngology offices. Furthermore, it may become increasingly challenging for smaller practices to implement these office-based procedures owing to high incidental cost, thereby exaggerating geographic variation in utilization and pushing otolaryngologists to the facility setting.12 We therefore may observe a shift in where and how these types of procedures are performed in the future as cost-saving models are introduced. It is important to continue to monitor for changes in practice patterns and their impact on patient care.
Diagnostic flexible laryngoscopy continues to be an integral component of the evaluation of OHNS disease. Imaging with DFL or VLS has been shown in past studies to dramatically increase diagnostic accuracy of laryngeal disease compared with medical history and physical examination alone.13 In light of these studies professional organizations such as the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF), the European Laryngological Society, and the American Broncho-Esophagological Association have endorsed these procedural tools as a recommended part of the treatment of OHNS disease.1,14,15 Recently in 2018, the AAO-HNSF revised its clinical practice guidelines for hoarseness, recommending sooner and lower thresholds for referral to otolaryngologists for visual inspection of the larynx.16 As DFL and VLS continues to grow as a part of an otolaryngologist’s set of tools, further studies will be necessary to assess appropriate usage and to elucidate what factors contribute to the decision-making process. Although factors affecting utilization patterns are expected to be complex, the decision to use these tools nonetheless should always be grounded in information gathered from a complete history and physical examination.
Limitations
There are several limitations to this study. First, the Medicare patient population is older than 65 years so the results of this study are generalizable to geriatric patients more so than the general population. Second, diagnosis codes are not available in the Medicare database. Therefore, we are only able to speculate why the procedure was performed. Third, Medicare payments can vary based on modifiers such as disease severity or geography. These possible confounding variables were not reported in the database and therefore were unable to be adjusted for.
Conclusions
Our findings suggest that DFL utilization and payments have grown to a lesser extent relative to videolaryngostroboscopy in the US Medicare population from 2000 to 2016. There was a weak correlation between reimbursement and utilization in both procedures. Practice patterns and reimbursement varied geographically across the United States for DFL and to a larger extent for VLS.
Back to top
Article Information
Corresponding Author: Michael M. Johns III, MD, Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Ste 204M, Los Angeles, CA 90033 (michael.johns@med.usc.edu).
Accepted for Publication: April 11, 2019.
Published Online: June 20, 2019. doi:10.1001/jamaoto.2019.1190
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Itamura, Hur, Johns.
Drafting of the manuscript: Itamura.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Itamura.
Administrative, technical, or material support: Hur.
Study supervision: Hur, Kokot, Johns.
Conflict of Interest Disclosures: Dr Johns reported royalties from Plural Publishing and royalties from Medbridge, Inc outside the submitted work. No other disclosures were reported.
Disclaimer: Michael Johns III, MD, is Editor at Large of JAMA Otolaryngology–Head & Neck Surgery, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
References
1.
American Academy of Otolaryngology—Head and Neck Surgery. Healthpolicy Position Statement: The Roles of Flexible Laryngoscopy Videostroboscopy. https://www.entnet.org/content/roles-flexible-laryngoscopy-videostroboscopy. Published March 20, 2014. Accessed December 20, 2018.
2.
Yang EL, Macy TM, Wang KH, Durr ML. Economic and demographic characteristics of cerumen extraction claims to Medicare. JAMA Otolaryngol Head Neck Surg. 2016;142(2):157-161. doi:10.1001/jamaoto.2015.3129
ArticlePubMedGoogle ScholarCrossref
3.
Jiang HJ, Begun JW. Dynamics of change in local physician supply: an ecological perspective. Soc Sci Med. 2002;54(10):1525-1541. doi:10.1016/S0277-9536(01)00132-0PubMedGoogle ScholarCrossref
4.
Lango MN, Handorf E, Arjmand E. The geographic distribution of the otolaryngology workforce in the United States. Laryngoscope. 2017;127(1):95-101. doi:10.1002/lary.26188PubMedGoogle ScholarCrossref
5.
Cohen SM, Thomas S, Roy N, Kim J, Courey M. Frequency and factors associated with use of videolaryngostroboscopy in voice disorder assessment. Laryngoscope. 2014;124(9):2118-2124. doi:10.1002/lary.24688PubMedGoogle ScholarCrossref
6.
Fritz MA, Persky MJ, Fang Y, et al. The accuracy of the laryngopharyngeal reflux diagnosis: utility of the stroboscopic exam. Otolaryngol Head Neck Surg. 2016;155(4):629-634. doi:10.1177/0194599816655143PubMedGoogle ScholarCrossref
7.
Paul BC, Chen S, Sridharan S, Fang Y, Amin MR, Branski RC. Diagnostic accuracy of history, laryngoscopy, and stroboscopy. Laryngoscope. 2013;123(1):215-219. doi:10.1002/lary.23630PubMedGoogle ScholarCrossref
8.
Hur K, Ference EH, Wrobel B, Liang J. Assessment of trends in utilization of nasal endoscopy in the Medicare population, 2000-2016 [published online January 31, 2019]. JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2018.4003
ArticlePubMedGoogle Scholar
9.
Institute of Medicine, Board on Health Care Services, Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Care. Variation in Health Care Spending: Target Decision Making, Not Geography. National Academies Press; Washington, DC: 2013.
10.
CMS-1693-P. August 2018. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-P.html. Accessed March 29, 2019.
11.
Hillel AT, Ochsner MC, Johns MM III, Klein AM. A cost and time analysis of laryngology procedures in the endoscopy suite versus the operating room. Laryngoscope. 2016;126(6):1385-1389. doi:10.1002/lary.25653PubMedGoogle ScholarCrossref
12.
Kuo CY, Halum SL. Office-based laser surgery of the larynx: cost-effective treatment at the office’s expense. Otolaryngol Head Neck Surg. 2012;146(5):769-773. doi:10.1177/0194599811434896PubMedGoogle ScholarCrossref
13.
Cohen SM, Pitman MJ, Noordzij JP, Courey M. Evaluation of dysphonic patients by general otolaryngologists. J Voice. 2012;26(6):772-778. doi:10.1016/j.jvoice.2011.11.009PubMedGoogle ScholarCrossref
14.
Paul BC, Branski RC, Amin MR. Diagnosis and management of new-onset hoarseness: a survey of the American Broncho-Esophagological Association. Ann Otol Rhinol Laryngol. 2012;121(10):629-634. doi:10.1177/000348941212101001PubMedGoogle ScholarCrossref
15.
Dejonckere PH, Bradley P, Clemente P, et al; Committee on Phoniatrics of the European Laryngological Society (ELS). A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. Guideline elaborated by the Committee on Phoniatrics of the European Laryngological Society (ELS). Eur Arch Otorhinolaryngol. 2001;258(2):77-82. doi:10.1007/s004050000299PubMedGoogle ScholarCrossref
16.
Stachler RJ, Francis DO, Schwartz SR, et al. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg. 2018;158(1_suppl)(suppl 1):S1-S42.PubMedGoogle ScholarCrossref
Kyohei Itamura, BS1; Kevin Hur, MD1; Niels C. Kokot, MD1; et al Michael M. Johns III, MD1,2
Author Affiliations Article Information
JAMA Otolaryngol Head Neck Surg. Published online June 20, 2019. doi:10.1001/jamaoto.2019.1190
Key Points
Question What trends exist in diagnostic flexible laryngoscopy (DFL) and videolaryngostroboscopy (VLS) utilization and payments in the Medicare population?
Findings This population-based, cross-sectional study of all Medicare beneficiaries from 2000 through 2016 found that DFL and VLS utilization respectively increased by 30% and 380% with a 2% decrease and 300% increase in payments and 25% and 17% decrease in reimbursement rate; utilization rates differed 11-fold for DFL and 279-fold for VLS between the highest and lowest utilizing states.
Meaning Diagnostic flexible laryngoscopy in the Medicare population exhibited stable utilization and payment trends compared with VLS, which demonstrated significant state-level utilization differences.
Abstract
Importance Diagnostic flexible laryngoscopy (DFL) is the second-most reimbursed procedure by Medicare in otolaryngology. However, the economic trends of this procedure on a population level are unknown.
Objective To describe national- and state-level DFL and videolaryngostroboscopy (VLS) utilization and payment trends from 2000 to 2016 in the Medicare population.
Design, Setting, and Participants This population-based, cross-sectional study of all Medicare beneficiaries from 2000 through 2016 found that at the national level the total absolute number of DFLs performed in the US Medicare population increased by 87% from 344 183 to 645 172 services, whereas total absolute payments for DFLs made by Medicare concurrently increased by 41% from $38 720 243 to $54 499 071. Rates of DLS and VLS categorized as Current Procedural Terminology (CPT) code 31575 and 31579, respectively. Analysis was carried out between November 18, 2018 and December 18, 2018.
Exposures Diagnostic flexible laryngoscopy and VLS.
Main Outcomes and Measures The DFL and VLS utilization rates, payments, and reimbursement rate trends were analyzed by year and state. Utilization was assessed for physician characteristics, including specialty and credentials.
Results Nationally from 2000 to 2016 in the Medicare population, DFL utilization per Medicare enrollee increased 30% from 0.0087 to 0.0110 and payment per enrollee decreased 2% from $0.98 to $0.96, whereas VLS utilization and payment per enrollee both increased at least 300% during the same time period, with VLS procedure per enrollee and payment per enrollee increasing by 382% from 0.00028 to 0.0013 and 301% from $0.05 to $0.22, respectively. There was a weak correlation between reimbursement and utilization per enrollee for both DFL (r = 0.23; 95% CI, 0.12-0.34) and VLS (r = 0.26; 95% CI, 0.14-0.37) performed from 2012 to 2016. In 2016, the mean (SD) payment per DFL was $85.14 ($7.95), ranging from $65.45 in Puerto Rico to $104.82 in Washington, DC, a 1.6-fold difference. For VLS, there was a 2-fold difference between the lowest-reimbursing state, Maine ($92.20) and the highest, New York ($182.96). All US dollar values were uniformly adjusted for inflation to 2018 dollar values. Most DFLs in 2016 were performed by otolaryngologists (93.6%).
Conclusions and Relevance The DFL utilization rates remained stable compared with VLS in the Medicare population from 2000 to 2016. There was a decrease in both DFL and VLS payments per procedure in the same time period and also weak correlations between reimbursement and utilization. Practice patterns and reimbursement varied geographically across the United States, though VLS exhibited significantly higher variation than DFL at the state level.
Introduction
Diagnostic flexible laryngoscopy (DFL) is a commonly performed procedure in Otolaryngology–Head and Neck Surgery (OHNS) involving a thin, flexible, fiberoptic tube that can be passed transnasally to visualize the regions of the larynx. It is classified under CPT code 31575 and is defined by the American Academy of Otolaryngology–Head and Neck Surgery as a “well-established diagnostic procedure that is medically indicated for the diagnosis and management of many disorders including those involving the voice, swallowing, and upper aerodigestive tract.”1 Diagnostic flexible laryngoscopy has been one of the most commonly reimbursed procedures performed by otolaryngologists in the United States in recent years.2
Despite its mainstay in the diagnosis and treatment of a variety of diseases in OHNS, the economic impact of this procedure on the US health care system since its introduction decades ago is yet to be studied. Changes in accessibility to equipment, overall public opinion, and integration of new technologies over time can have a profound influence on how physicians use certain procedures in their clinical practice. There is a need to analyze DFL utilization patterns in the context of related emerging modalities, such as videolaryngostroboscopy (VLS), to characterize trends and possible disparities in how these important tools are used in the field.
The main objective of this study is to identify trends in DFL and VLS payments and utilization over time in the Medicare population across the United States at the national and state level. An additional objective is to further characterize Medicare providers who use these procedures.
Methods
All data were accessed online at https://www.cms.gov under Research, Statistics, Data & Systems between November 18, 2018 and December 18, 2018. The Centers for Medicare and Medicaid Services (CMS) Part B National Summary Data File was accessed for annual procedure data from 2000 to 2016 for DFL and VLS. Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (PUF) was used to obtain detailed physician and Medicare payment data for DFL and VLS from available years, 2012 to 2016. Total number of Medicare enrollees at the national and state levels were obtained from the CMS Medicare Enrollment Reports. All dollar values were adjusted for inflation to the 2018 average consumer price index. The study was approved for exempt status by the institutional review board of the University of Southern California owing to the deidentified data used.
The total number of procedures performed and the total amount paid by Medicare nationwide from 2000 to 2016 for DFL and VLS were extracted from the Part B National Summary Data File with Current Procedural Terminology (CPT) codes 31575 and 31579, respectively. To account for annual changes in total enrolled Medicare beneficiaries in the United States, the number of procedures performed and total payments were normalized to the total nationwide number of Medicare enrollees to produce the procedure per enrollee and payment per enrollee, respectively. Procedure per enrollee was calculated by dividing the total number of procedures performed by the total number of Medicare enrollees in the United States that year. Payment per enrollee was calculated by dividing the total Medicare payments for the procedure by the total number of Medicare enrollees. To quantify reimbursement to physicians, payment per procedure was calculated by dividing total Medicare payments for the procedure by the total number of procedures performed.
To study state-level data, the Physician and Other Supplier PUF database provided detailed utilization and financial data of physicians who billed for DFL and VLS from 2012 to 2016. To protect patient confidentiality, providers who billed for less than 10 procedures were not included in the original database. For each physician, the state, total number of DFL and VLS procedures performed, and the average Medicare payment received were extracted using pivot tables on Microsoft Excel (version 2016, Microsoft Corporation). As the database did not provide individual payment data, the total amount reimbursed by Medicare was calculated by multiplying the summation of the average Medicare payment amount by the number of procedures performed for each physician. Only procedures classified as nonfacility were analyzed for our study. Nonfacility procedures in the PUF database generally represent DFLs and VLSs performed in the office-based setting, compared with facility procedures that incorporate facility payments in addition to the physician’s professional fee. By only analyzing nonfacility procedures, the Medicare payment amount was representative of the fee of the procedure. Procedure per enrollee, payment per enrollee, and payment per procedure were calculated as above. To assess physician-level density, enrollees per physician was calculated by dividing the total number of Medicare enrollees in each state by the number of physicians who performed DFL or VLS. Utilization variation by state was geographically represented using Microsoft Excel (version 2016, Microsoft Corporation).
Correlation testing was then performed to evaluate the association between procedure per enrollee and payment per enrollee and between procedure per enrollee and enrollees per physician. Correlations were tested at a 95% confidence level using the Pearson correlation test.
Physician data from the physician and other supplier PUF who billed for DFL or VLS in 2016 were further characterized. Clinicians on the database were extracted then categorized by credentials as MD/DO or non-MD/DO. Non-MD/DO included speech language pathologists, nurse practitioners, physician assistants, and health care professionals who did not have credentials listed. The MD/DO specialties performing DFL or VLS were also analyzed to investigate the distribution of DFL and VLS utilization among different specialties.
Results
At the national level from 2000 to 2016, the total absolute number of DFLs performed in the US Medicare population increased by 87% from 344 183 to 645 172 services while total absolute payments for DFLs made by Medicare concurrently increased by 41% from $38 720 243 to $54 499 071 (eTable 1 in the Supplement). Diagnostic flexible laryngoscopy procedure per enrollee increased by 30% from 0.0087 to 0.0110 from 2000 to 2016, whereas DFL payment per enrollee decreased by 2% from $0.98 to $0.96. For comparison, during the same time period, VLS procedure per enrollee and payment per enrollee increased by 382% from 0.00028 to 0.00130 and 301% from $0.05 to $0.22, respectively (Figure 1 A and B). A 25% decrease, from $112.50 to $84.47, in DFL and 17% decrease, from $195.66 to $162.68, in VLS payment per procedure was also observed (Figure 1C). We therefore observed from 2000 to 2016 an overall increase in procedure per enrollee and an overall decrease in payment per procedure for both DFL and VLS.
Procedure per enrollee and payment per enrollee were also analyzed at the state level. In 2016, the mean (SD) national DFL procedure per enrollee and payment per enrollee was 0.0087 (0.0036) and $0.76 ($0.36), respectively (eTable 2 in the Supplement). New York (0.0180, $1.73), the state with the highest values in both metrics, had an 11-fold higher procedure per enrollee and a 15-fold higher payment per enrollee value than Puerto Rico (0.001700, $0.11), the state/territory with the lowest values in both metrics. For VLS, the mean (SD) national average in 2016 for procedure per enrollee was 0.00088 (0.00066) and $0.13 (0.11) for payment per enrollee (eTable 3 in the Supplement). We observed a 279-fold difference between the highest and lowest utilizing states, Maryland (0.0039) and Puerto Rico (0.000014). Furthermore, there was a 367-fold difference between Washington DC ($0.66), the state/territory with the highest VLS payment per enrollee value, and Puerto Rico ($0.00180), the state with the lowest value. Of note, some states were not found in the 2016 VLS database, including Idaho, Nebraska, South Dakota, and Wyoming. This was presumed to be owing to the lack of physicians who individually performed VLS for at least 10 beneficiaries in these states in 2016.
Overall mean (SD) payment per procedure nationwide in 2016 for nonfacility DFL and VLS were $85.14 ($7.95) and $144.25 ($19.50), respectively. The highest payment per procedure for DFL was observed in Washington DC ($104.82), which was 1.6 times higher than the lowest value found with Puerto Rico ($65.45) (Figure 2A). New York ($182.96), the state with the highest value for VLS payment per procedure, was double the state with the lowest value, Maine ($92.20) (Figure 2B).
From 2012 to 2016 at the state level we observed a weak positive correlation between procedure per enrollee and payment per procedure for both DFL (Pearson r = 0.23; 95% CI, 0.12-0.34) and VLS (Pearson r = 0.26; 95% CI, 0.14-0.37) (Figure 3). There was a moderate negative correlation between procedure per enrollee and enrollees per physician for both DFL (Pearson r = −0.52; 95% CI, 0.42-0.60) and VLS (Pearson r = −0.45; 95% CI, 0.34-0.54) (Figure 4).
Further characterizing provider data, of the 614 446 nonfacility DFLs performed in 2016, 588 309 (95.8%) were performed by physicians (eTable 4 in the Supplement). Out of all physicians, otolaryngologists performed 575 355 (93.6%) of all DFLs. These percentages were similar for VLS, where of 71 075 VLSs performed, 66 144 (93.1%) were performed by otolaryngologists (Table). The nonfacility setting accounted for approximately 90% of DFLs and 85% of VLSs performed from 2012 to 2016 with little change over time (eTable 5 in the Supplement).
Discussion
To our knowledge, this is the first study to report the economic impact and utilization trends of DFL, one of the most commonly billed OHNS procedures in the Medicare population, and VLS. We report nationwide and statewide utilization and payment trends that have not been described in the literature.
At the national level from 2000 to 2016 in the Medicare population, we observed increases in the absolute number of procedures performed and in total payments from Medicare for DFLs. Whereas the number of procedures per enrollee increased by 30% over these years, payment per procedure decreased by 25% such that payment per enrollee has remained relatively stable with an overall decrease of 2%. This finding suggests that despite the clear increase in utilization of DFLs over the course of nearly 2 decades, the relative impact on expenditure has remained stable. For comparison, concurrent national data for VLS showed different utilization and payment trends. From 2000 to 2016, VLS procedure and payment per enrollee both significantly increased by 382% and 301%, respectively, in the context of a 17% decrease in payment per procedure. There was substantially greater growth in utilization and payments for VLS compared with DFL.
Despite these differences, both DFL and VLS payment per enrollee correlated weakly with procedure per enrollee. This suggests that level of reimbursement is unlikely, at the state level, to be a significant driver of utilization for these procedures. We instead observed a moderate negative correlation between enrollees per physician, a proxy for physician density, and procedure per enrollee. Because most of these procedures are performed by otolaryngologists as we have shown, geographic distribution of these specialists appears to contribute to the state-level differences seen in DFL and VLS utilization. It is known that specialists such as otolaryngologists tend to practice in areas with higher overall physician density, creating pockets of specialist supply in certain locations.3 A study by Lango et al4 showed that Medicare-enrolled otolaryngologists tend to practice in areas near OHNS residency-training programs and staffed acute care centers. Because the otolaryngology workforce follows these geographic trends, we expect utilization of these procedures to distribute accordingly.
There were substantial relative differences in state-level utilization and payments for DFL and even more notably so for VLS. Identifying the cause of these observed state-level disparities is not possible in our study, though we can speculate as to why this may be the case. A prior study by Cohen et al5 showed through an analysis of a large national health claims database that factors associated with VLS usage in the outpatient otolaryngology setting include the patient’s age, geographic region of the United States, practice in an urban area, diagnosis of laryngeal disease, and comorbid diagnoses of asthma and gastroesophageal reflux disorder. Any of these factors can contribute to our findings. Videolaryngostroboscopy, being a more technically advanced modality than DFL, requires specialized equipment and training that may not be available in certain parts of the country. The increase in VLS utilization over the study time period, compared with a more established tool such as DFL, is likely the result of the growth of laryngology as a subspecialty, the expansion of laryngology fellowship training, increased training of otolaryngologists in VLS during residency, and expanded published evidence supporting the diagnostic value of VLS in laryngeal disorders.6,7
However, we must acknowledge the possibility of inappropriate use of VLS also playing a role. Clinicians with access to VLS could theoretically perform this procedure without adequate training in VLS interpretation owing to higher reimbursement potential. This possibility of overutilization has been discussed previously regarding nasal endoscopy, the most highly reimbursed Medicare procedure in OHNS, which was shown to have tremendous growth in the past 2 decades.8 Our study was limited by the lack of information on why these procedures were performed. Further studies should focus on appropriate usage of these procedures in the context of the patient’s medical indications.
Quality and value have become core issues in US health care. As such, otolaryngologists have increasingly become accountable for cost of care through alternative payment models, including bundled payments and merit-based incentive programs.9 However, there is currently a paucity of data in the otolaryngology literature on the trends in utilization, costs, and geovariation of commonly performed otolaryngology procedures. These types of studies are necessary to evaluate the economic impact of implemented reforms moving forward. For example, recent policy changes by the Centers for Medicare and Medicaid Services have proposed nearly 50% decreases in certain same-day office-based procedures.10 The finding of our study showed a large proportion of DFLs and VLSs being performed in the nonfacility setting. Introduction of such a policy change may significantly alter practice patterns. Hillel et al11 demonstrated that hospital endoscopic suites, typically used by gastroenterologists and pulmonologists, provide a facility-based setting in which to perform awake laryngology procedures faster and at less cost than in a traditional operating room and without overhead financial losses associated with unregulated otolaryngology offices. Furthermore, it may become increasingly challenging for smaller practices to implement these office-based procedures owing to high incidental cost, thereby exaggerating geographic variation in utilization and pushing otolaryngologists to the facility setting.12 We therefore may observe a shift in where and how these types of procedures are performed in the future as cost-saving models are introduced. It is important to continue to monitor for changes in practice patterns and their impact on patient care.
Diagnostic flexible laryngoscopy continues to be an integral component of the evaluation of OHNS disease. Imaging with DFL or VLS has been shown in past studies to dramatically increase diagnostic accuracy of laryngeal disease compared with medical history and physical examination alone.13 In light of these studies professional organizations such as the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF), the European Laryngological Society, and the American Broncho-Esophagological Association have endorsed these procedural tools as a recommended part of the treatment of OHNS disease.1,14,15 Recently in 2018, the AAO-HNSF revised its clinical practice guidelines for hoarseness, recommending sooner and lower thresholds for referral to otolaryngologists for visual inspection of the larynx.16 As DFL and VLS continues to grow as a part of an otolaryngologist’s set of tools, further studies will be necessary to assess appropriate usage and to elucidate what factors contribute to the decision-making process. Although factors affecting utilization patterns are expected to be complex, the decision to use these tools nonetheless should always be grounded in information gathered from a complete history and physical examination.
Limitations
There are several limitations to this study. First, the Medicare patient population is older than 65 years so the results of this study are generalizable to geriatric patients more so than the general population. Second, diagnosis codes are not available in the Medicare database. Therefore, we are only able to speculate why the procedure was performed. Third, Medicare payments can vary based on modifiers such as disease severity or geography. These possible confounding variables were not reported in the database and therefore were unable to be adjusted for.
Conclusions
Our findings suggest that DFL utilization and payments have grown to a lesser extent relative to videolaryngostroboscopy in the US Medicare population from 2000 to 2016. There was a weak correlation between reimbursement and utilization in both procedures. Practice patterns and reimbursement varied geographically across the United States for DFL and to a larger extent for VLS.
Back to top
Article Information
Corresponding Author: Michael M. Johns III, MD, Caruso Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Ste 204M, Los Angeles, CA 90033 (michael.johns@med.usc.edu).
Accepted for Publication: April 11, 2019.
Published Online: June 20, 2019. doi:10.1001/jamaoto.2019.1190
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Itamura, Hur, Johns.
Drafting of the manuscript: Itamura.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Itamura.
Administrative, technical, or material support: Hur.
Study supervision: Hur, Kokot, Johns.
Conflict of Interest Disclosures: Dr Johns reported royalties from Plural Publishing and royalties from Medbridge, Inc outside the submitted work. No other disclosures were reported.
Disclaimer: Michael Johns III, MD, is Editor at Large of JAMA Otolaryngology–Head & Neck Surgery, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
References
1.
American Academy of Otolaryngology—Head and Neck Surgery. Healthpolicy Position Statement: The Roles of Flexible Laryngoscopy Videostroboscopy. https://www.entnet.org/content/roles-flexible-laryngoscopy-videostroboscopy. Published March 20, 2014. Accessed December 20, 2018.
2.
Yang EL, Macy TM, Wang KH, Durr ML. Economic and demographic characteristics of cerumen extraction claims to Medicare. JAMA Otolaryngol Head Neck Surg. 2016;142(2):157-161. doi:10.1001/jamaoto.2015.3129
ArticlePubMedGoogle ScholarCrossref
3.
Jiang HJ, Begun JW. Dynamics of change in local physician supply: an ecological perspective. Soc Sci Med. 2002;54(10):1525-1541. doi:10.1016/S0277-9536(01)00132-0PubMedGoogle ScholarCrossref
4.
Lango MN, Handorf E, Arjmand E. The geographic distribution of the otolaryngology workforce in the United States. Laryngoscope. 2017;127(1):95-101. doi:10.1002/lary.26188PubMedGoogle ScholarCrossref
5.
Cohen SM, Thomas S, Roy N, Kim J, Courey M. Frequency and factors associated with use of videolaryngostroboscopy in voice disorder assessment. Laryngoscope. 2014;124(9):2118-2124. doi:10.1002/lary.24688PubMedGoogle ScholarCrossref
6.
Fritz MA, Persky MJ, Fang Y, et al. The accuracy of the laryngopharyngeal reflux diagnosis: utility of the stroboscopic exam. Otolaryngol Head Neck Surg. 2016;155(4):629-634. doi:10.1177/0194599816655143PubMedGoogle ScholarCrossref
7.
Paul BC, Chen S, Sridharan S, Fang Y, Amin MR, Branski RC. Diagnostic accuracy of history, laryngoscopy, and stroboscopy. Laryngoscope. 2013;123(1):215-219. doi:10.1002/lary.23630PubMedGoogle ScholarCrossref
8.
Hur K, Ference EH, Wrobel B, Liang J. Assessment of trends in utilization of nasal endoscopy in the Medicare population, 2000-2016 [published online January 31, 2019]. JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2018.4003
ArticlePubMedGoogle Scholar
9.
Institute of Medicine, Board on Health Care Services, Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Care. Variation in Health Care Spending: Target Decision Making, Not Geography. National Academies Press; Washington, DC: 2013.
10.
CMS-1693-P. August 2018. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-P.html. Accessed March 29, 2019.
11.
Hillel AT, Ochsner MC, Johns MM III, Klein AM. A cost and time analysis of laryngology procedures in the endoscopy suite versus the operating room. Laryngoscope. 2016;126(6):1385-1389. doi:10.1002/lary.25653PubMedGoogle ScholarCrossref
12.
Kuo CY, Halum SL. Office-based laser surgery of the larynx: cost-effective treatment at the office’s expense. Otolaryngol Head Neck Surg. 2012;146(5):769-773. doi:10.1177/0194599811434896PubMedGoogle ScholarCrossref
13.
Cohen SM, Pitman MJ, Noordzij JP, Courey M. Evaluation of dysphonic patients by general otolaryngologists. J Voice. 2012;26(6):772-778. doi:10.1016/j.jvoice.2011.11.009PubMedGoogle ScholarCrossref
14.
Paul BC, Branski RC, Amin MR. Diagnosis and management of new-onset hoarseness: a survey of the American Broncho-Esophagological Association. Ann Otol Rhinol Laryngol. 2012;121(10):629-634. doi:10.1177/000348941212101001PubMedGoogle ScholarCrossref
15.
Dejonckere PH, Bradley P, Clemente P, et al; Committee on Phoniatrics of the European Laryngological Society (ELS). A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. Guideline elaborated by the Committee on Phoniatrics of the European Laryngological Society (ELS). Eur Arch Otorhinolaryngol. 2001;258(2):77-82. doi:10.1007/s004050000299PubMedGoogle ScholarCrossref
16.
Stachler RJ, Francis DO, Schwartz SR, et al. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg. 2018;158(1_suppl)(suppl 1):S1-S42.PubMedGoogle ScholarCrossref
Δεν υπάρχουν σχόλια:
Δημοσίευση σχολίου