(24) Do Changes in Orthognathic Surgery Reimbursement Affect the Volume of Procedures Performed at an Academic Medical Center?

Abstract: Previous literature has described declining reimbursement rates for orthognathic surgery leading to surgical volume reduction and sparking discussion about the future of these procedures. 1 Many patients are now referred to academic medical centers, away from private practices, which may cause these centers to become havens for orthognathic surgery.2 We aimed to review the orthognathic surgical volume at an academic medical center over a 13-year period, and to determine correlations between the average charges and collections with the volume of these procedures performed per year.
A retrospective cohort study of patients who underwent LeFort osteotomy (LF), bilateral sagittal split osteotomy (BSSO), intra-oral vertical ramus osteotomy (IVRO), or genioplasty (Genio) at the University of Tennessee Medical Center (UTMC) from 01/01/2010 to 12/23/2022 was performed after Institutional Review Board approval (#5041). 618 patients with 922 procedures performed were included. From these patients, five patients (~10% of the patient population) per year were randomly selected and evaluated for insurance type, total charges, insurance reimbursement, and self-pay cost to create representative averages. Patient selection used random stratification method across three different providers at UTMC. Pearson Correlations were used to test associations (N=13; number of years) with two-tailed significance reported and statistical significance assumed at p-value < 0.05.
The average procedure charge was $6,878.80 and average total collection $1,716.42. The total number of procedures performed each year was relatively stable over time (Figure 1). There was a significant negative correlation between average procedure charge and year when adjusting to 2010 buying power (r(11)= -0.59, p=0.04). However, there were no significant correlations between the year a procedure was performed and insurance reimbursement or total collections (r(11)= -0.54, p=0.06) when analyzed with unadjusted costs or adjusted to 2010 buy power. Increasing total collection was significantly correlated with increased patient cost when unadjusted (r(11)=0.82, p< 0.001) and adjusted for 2010 buying power (r(11)=0.77, p=0.002). Increase in total procedural volume per year was also significantly negatively correlated with the average amount collected (r(11)=-0.57, p=0.04) and patient cost (r(11)=-.652, p=.016)
The year the procedure was performed was significantly positively correlated with volume of BSSOs performed (r(11)=0.72, p=0.01), and significantly negatively correlated with volume of IVROs performed r(11)= -0.72, p=0.01). Over time, BSSO volume increased and IVRO volume decreased. Increasing volume of BSSOs or LFs performed each year correlated with increased total number of surgeries performed (Table 1).

While there were variations in total collections per year, this remained relatively stable and did not affect the volume of orthognathic procedures performed at our academic medical center. This may be related to surgeon motivations other than financial gain for performing these procedures- such as resident training benefit, clinical interest, and personal satisfaction from performing the surgery. These findings may indicate the viability of orthognathic surgery at academic centers.
However, the stagnation of surgeon collection is concerning in the face of increased monetary inflation during this period. Insurance reimbursement did not change significantly during the 13 years we reviewed. Variation in collection seems to stem from cost that is being passed along to the patient- increased collection was correlated to increased patient cost. As our study found, a higher volume of surgeries per year was correlated to both decrease in patient cost, and subsequently total collection. This finding was worrying as high-volume surgeons, who traditionally have better outcomes, should not suffer financial penalties.
Trends in surgical thought were also elucidated in our study. The number of BSSOs performed increased per year, while the number of IVROs decreased. This is likely related to mandibular setbacks falling out of favor in our institution over concerns of increased patient risk of snoring and obstructive sleep apnea.

Table 1

Figure 1

Figure 2