Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI. Electronic address: https://twitter.com/jfahmyMD.
Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI. Electronic address: https://twitter.com/benetiz_trista.
Surgery. 2024 Nov;176(5):1412-1417. doi: 10.1016/j.surg.2024.07.010. Epub 2024 Aug 10.
Prior authorization is common for privately administered Medicare Advantage plans but is rarely used for surgical care when considering publicly administered plans. A 2020 Centers for Medicare and Medicaid services (CMS) policy, CMS-1717-FC, requires prior authorization for Medicare Fee-for-Service beneficiaries undergoing select procedures (blepharoplasty, abdominoplasty, botulinum toxin injection, rhinoplasty, and vein ablation) in hospital outpatient departments. The impact of this policy on surgical volume at hospital outpatient departments and shifts in care to ambulatory surgery centers is unknown.
This study used a segmented interrupted time series and pre-post logistic regression model. This study was a retrospective cohort study using data from the Healthcare Cost and Utilization Project state ambulatory surgery database and state inpatient database.
From 2016 through 2021, a total of 272,879 patients underwent the affected procedures. Pre-CMS-1717-FC, a trend of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (-10.82, 95% confidence interval: -18.32 to -3.33, P = .01). In the post-implementation period, no change in the rate of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (-3.45, 95% confidence interval: -36.15 to 29.25, P = .83). In the pre-policy period, Medicare Fee-for-Service beneficiaries were 46% less likely to use freestanding ambulatory surgery centers but 27% less likely to use hospital-owned ambulatory surgery centers.
CMS-1717-FC was not associated with significant changes in hospital outpatient department volume beyond baseline trends. Policy aiming to right-size prior authorization for these procedures and considering site-of-service will balance the need to ensure medical necessity while constraining costs.
私人管理的医疗保险优势计划中常见事先授权，但在考虑公共管理计划时，手术护理很少使用事先授权。2020 年医疗保险和医疗补助服务中心（CMS）的一项政策（CMS-1717-FC）要求接受特定程序（眼睑成形术、腹部成形术、肉毒杆菌毒素注射、隆鼻术和静脉消融术）的 Medicare 按服务收费受益人的事先授权在医院门诊部门进行。这项政策对医院门诊部门手术量的影响以及对门诊手术中心的护理转移尚不清楚。
本研究使用分段中断时间序列和前后逻辑回归模型。本研究是一项回顾性队列研究，使用了医疗保健成本和利用项目州门诊手术数据库和州住院数据库的数据。
在 2016 年至 2021 年期间，共有 272879 名患者接受了受影响的手术。在 CMS-1717-FC 之前， Medicare 按服务收费受益人的医院门诊部门利用率呈下降趋势（-10.82，95%置信区间：-18.32 至-3.33，P=.01）。在实施后期间， Medicare 按服务收费受益人的医院门诊部门利用率下降率没有变化（-3.45，95%置信区间：-36.15 至 29.25，P=.83）。在政策前期间， Medicare 按服务收费受益人使用独立的门诊手术中心的可能性降低了 46%，但使用医院所有的门诊手术中心的可能性降低了 27%。
除了基本趋势外，CMS-1717-FC 与医院门诊部门数量的显著变化无关。旨在为这些程序调整事先授权并考虑服务地点的政策将平衡确保医疗必要性的需求，同时限制成本。
