Urethral Suspension Use Not Impacted by Medicare Payment Policy Changes

Adjunct urethral suspension use with laparoscopic radical prostatectomy did not change after CMS implemented Medicare payment policy changes that decreased reimbursement for prostatectomies, according to a study published in JAMA Network Open.

In the 2016 Medicare Physician Fee Schedule (PFS), CMS reduced the work relative value unit (wRVU) for robotic-assisted laparoscopic radical prostatectomy by 33.4 percent, resulting in a lower reimbursement rate.

Researchers hypothesized that this reduction would lead to higher use of adjunct procedures, such as urethral suspension, at the time of prostatectomies to make up for the lost compensation. Past data has suggested that urethral suspension can speed up the recovery of postoperative urinary continence.

However, surgeons are technically not allowed to bill for a preventive urethral suspension unless the patient has preexisting urinary incontinence, per CMS rules. In addition, the American Urological Association (AUA) Coding and Reimbursement Committee released a policy brief in May 2017 reaffirming this suggestion.

Researchers analyzed commercial and Medicare supplemental claims data for men diagnosed with prostate cancer between 2009 and 2019 to determine trends and geographic variation in urethral suspension use and payments.

The study sample included 87,774 men who received a robotic prostatectomy. Almost 17,000 patients (19.2 percent) had Medicare supplemental insurance, while 70,904 patients (80.8 percent) had commercial insurance. Most patients (85.1 percent) lived in a US census-defined metropolitan statistical area (MSA).

Around 3,300 men (3.8 percent) had a payment for urethral suspension associated with their prostatectomy. Men with high-deductible health plans were more likely to have a urethral suspension compared to those with preferred or extended provider organization health plans. Additionally, men who lived in the South and men with commercial insurance were more likely to have received a urethral suspension.

Between 20 to 30 percent of men with preexisting incontinence underwent urethral suspension over the study period.

There were slight changes in payments for prostatectomy after CMS announced the 2016 Medicare PFS. In 2009, payments for men with commercial insurance were higher than those for men with Medicare supplemental insurance ($2,725 versus $2,001).

Between 2015 and 2016, median payments for men with Medicare fell 17.9 percent to $1,643. During this time, payments for men with commercial insurance declined by just $9.

Payments for urethral suspension compared to no suspension increased surgical payments by 9.4 percent for commercially insured patients and 27 percent for Medicare beneficiaries.

Urethral suspension use was already increasing before the 2016 CMS payment policy change.

For example, between 2009 and 2012, the share of patients who had a prostatectomy with urethral suspension was 1.7 percent. The percentage increased to 9 percent between 2018 and 2019. However, urethral suspension use started rising in 2012 and continued growing until 2017, when it plateaued.

This plateau may be due to the AUA policy statement that recommended against routine billing for urethral suspension, researchers noted.

Men treated from 2013 to 2015 were less than half as likely to receive a urethral suspension compared to those treated between 2016 and 2017.

Men living in larger MSAs were more likely to undergo urethral suspension. Between 2015 and 2019, the share of men who received a urethral suspension was highest in Charleston, South Carolina (92 percent); Knoxville, Tennessee (66 percent); and Columbia, South Carolina (58 percent).

Interestingly, several neighboring MSAs did not have any payments for urethral suspension, including Greenville, South Carolina; Augusta, Georgia; and Nashville, Tennessee.

This may be attributed to differing local payer coverage or variation in recognizing the benefits of urethral suspension.

Reducing reimbursement for prostatectomies did not significantly boost the rate of urethral suspension use, indicating that policymakers could seek additional ways to incentivize this preventive procedure. Given the benefits that urethral suspension can provide patients, healthcare stakeholders should clarify the procedure’s value and align incentives with appropriate use, researchers said in response to the study.