The reality of commercial payer-negotiated rates in cleft lip and palate repair Journal Article
| Authors: | Rochlin, D. H.; Rizk, N. M.; Flores, R. L.; Matros, E.; Sheckter, C. C. |
| Article Title: | The reality of commercial payer-negotiated rates in cleft lip and palate repair |
| Abstract: | Background: Commercial payer-negotiated rates for cleft lip and palate surgery have not been evaluated on a national scale. The aim of this study was to characterize commercial rates for cleft care, both in terms of nationwide variation and in relation to Medicaid rates. Methods: A cross-sectional analysis was performed of 2021 hospital pricing data from Turquoise Health, a data service platform that aggregates hospital price disclosures. The data were queried by CPT code to identify 20 cleft surgical services. Within- and across-hospital ratios were calculated per CPT code to quantify commercial rate variation. Generalized linear models were used to assess the relationship between median commercial rate and facility-level variables and between commercial and Medicaid rates. Results: There were 80,710 unique commercial rates from 792 hospitals. Within-hospital ratios for commercial rates ranged from 2.0 to 2.9 and across-hospital ratios ranged from 5.4 to 13.7. Median commercial rates per facility were higher than Medicaid rates for primary cleft lip and palate repair ($5492.20 versus $1739.00), secondary cleft lip and palate repair ($5429.10 versus $1917.00), and cleft rhinoplasty ($6001.00 versus $1917.00; P < 0.001). Lower commercial rates were associated with hospitals that were smaller (P < 0.001), safety-net (P < 0.001), and nonprofit (P < 0.001). Medicaid rate was positively associated with commercial rate (P < 0.001). Conclusions: Commercial rates for cleft surgical care demonstrated marked variation within and across hospitals, and were lower for small, safety-net, or nonprofit hospitals. Lower Medicaid rates were not associated with higher commercial rates, suggesting that hospitals did not use cost-shifting to compensate for budget shortfalls resulting from poor Medicaid reimbursement. © 2023 Lippincott Williams and Wilkins. All rights reserved. |
| Keywords: | hospital; hospitals; cross-sectional study; cross-sectional studies; cleft palate; cleft lip; humans; human |
| Journal Title: | Plastic and Reconstructive Surgery |
| Volume: | 152 |
| Issue: | 3 |
| ISSN: | 0032-1052 |
| Publisher: | Lippincott Williams & Wilkins |
| Date Published: | 2023-09-01 |
| Start Page: | 476e |
| End Page: | 487e |
| Language: | English |
| DOI: | 10.1097/prs.0000000000010329 |
| PUBMED: | 36847669 |
| PROVIDER: | scopus |
| PMCID: | PMC11240862 |
| DOI/URL: | |
| Notes: | Article -- MSK Cancer Center Support Grant (P30 CA008748) acknowledged in PubMed and PDF -- Source: Scopus |
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