Trends in Medicare Utilization and Reimbursement for Traumatic Brain Injury: 2003–2021

Abstract

Traumatic brain injury (TBI) is a significant public health issue among Medicare beneficiaries, with many specialties reporting consistent annual decreases in utilization and reimbursement. This study investigates the trends in Medicare utilization and rates of reimbursement for neurosurgical procedures related to TBI from 2003 to 2021, aiming to provide insights into the economic aspects of TBI care. Utilizing the Medicare Part B National Summary Data files, we analyzed 14 neurosurgical procedures over the 18-year period, assessing the changes in procedural volume and mean reimbursement per procedure, adjusted for inflation to the 2021 USD using the Consumer Price Index. From 2003 to 2021, TBI-related neurosurgical interventions showed a total percent change of −15.39% in procedural volume and −3.11% in inflation-adjusted mean reimbursement per procedure. Linear regression analyses indicated a significant downward trend in the overall procedural volume (p < 0.001) but no significant trend in the inflation-adjusted mean reimbursement rates (p = 0.585). Subgroup analyses did not reveal significant changes in the reimbursement rates for decompressive craniotomy/craniectomy, cranioplasty, intracranial pressure management, and traumatic fracture/penetration procedures. Our study indicates a significant decrease in neurosurgical TBI procedural volumes, while reimbursement rates remained stable when adjusted for inflation, highlighting the need for policy adjustments to ensure adequate resources for TBI care.

1. Introduction

Traumatic brain injury (TBI) represents a significant public health challenge in the United States, impacting millions of individuals annually with wide-ranging consequences from mild concussions to severe brain damage. TBIs not only cause substantial morbidity and mortality but also impose a heavy economic burden on healthcare systems, particularly for Medicare, the largest healthcare payer in the country [1]. As the population ages, the overall number of TBI cases among Medicare beneficiaries is expected to increase [2,3]. Moreover, the prevalence of traumatic subdural hematoma, one of the most common forms of TBI, has been rising in the US in recent years [4,5]. This emphasizes the need for a thorough understanding of how these injuries are managed and reimbursed within this healthcare framework.

Over the past two and a half decades, several specialties that rely heavily on procedural interventions have experienced a consistent declining trend in Medicare procedural utilization and reimbursement. Neurosurgery has been particularly impacted by these prevailing annual decreases alongside other fields like orthopedic trauma surgery, craniofacial trauma surgery, and otolaryngology [2,6,7,8]. However, recent analyses pointed out that some procedural groups within neurosurgery seemed to have escaped this trend and instead saw increases in reimbursement during the same period [9,10].

The implications of these trends potentially extend into TBI care, where in-hospital and rehabilitation costs associated with these injuries are high [11,12]. This study’s exploration of Medicare utilization and the reimbursement trends for TBI-related procedures aims to illuminate the economic challenges currently influencing TBI care within the Medicare framework. By analyzing specific Current Procedural Terminology (CPT) codes associated with TBI treatments, this study endeavors to chart the changes in procedural volume and reimbursement from 2003 to 2021. We hypothesize that the utilization and rates of reimbursement for Medicare-billed neurosurgical procedures for TBI have both declined over time, consistent with broader trends in neurosurgery [2,9]. This comprehensive analysis aims to offer valuable insights into the shifting landscape of TBI care among the Medicare population, highlighting potential areas for policy improvement and resource allocation.

2. Materials and Methods

The publicly available Medicare Part B National Summary Data files containing comprehensive data on services billed to Medicare from 2003 to 2021 were utilized for this study [13]. These data capture physician services for neurosurgical procedures performed in both inpatient and outpatient settings [14]. While these procedures are typically conducted in an inpatient setting, with Medicare Part A covering facility fees, the associated physician services are billed under Medicare Part B. We do not anticipate that procedures such as craniotomies were performed on an outpatient basis, given their acute nature. Services within these files are classified using CPT codes, with each code’s data encompassing the total number of allowed services, allowed charges, and actual payments on an annual basis. The analysis focused on 14 CPT codes commonly billed in TBI treatment. Due to database limitations that prevented cross-referencing the CPT codes with specific diagnosis codes, we included all relevant neurosurgical procedures commonly associated with TBI care, even if trauma-specific cases could not be confirmed. Procedures like intracranial pressure monitoring and decompressive craniectomy address conditions such as elevated intracranial pressure, which can occur in both traumatic and non-traumatic contexts like stroke. Since reimbursement does not differ based on the underlying condition, these trends have broad implications for TBI care. We also included additional CPT codes specific to trauma in the analysis. These codes are listed with their descriptions in

Table 1. CPT codes for TBI-related neurosurgical procedures.

CPT Code	Procedure
61154	Twist drill, burr hole(s), or trephine procedures on the skull, meninges, and brain
61312	Evacuation of hematoma, supratentorial, extradural, or subdural
61316	Incision and placement of a cranial bone graft under the skin; used as an add-on with a craniectomy code
61322	Craniectomy or craniotomy, decompressive, with or without duraplasty for treatment of intracranial hypertension without evacuation of associated intraparenchymal hematoma; without lobectomy
61323	Craniectomy or craniotomy, decompressive, with or without duraplasty for treatment of intracranial hypertension without evacuation of associated intraparenchymal hematoma; with lobectomy
61570	Excision of foreign body from the brain
61571	Treatment of penetrating wound of the brain
62005	Elevation of a compound or comminuted extradural depressed skull fracture
62010	Elevation of a depressed skull fracture
62140	Cranioplasty: large (>5 cm) complex or multiple
62141	Cranioplasty: small (<5 cm) or simple
62143	Replacement of a skull bone flap or prosthetic plate
62148	Incision and retrieving a cranial bone graft that has been stored in the abdomen or in the inner lining; add-on with a cranioplasty code
62223	Creation of a ventriculoperitoneal shunt

. For each CPT code, the annual total allowed procedures, allowed charges, and actual payments were extracted from the dataset.

The total reimbursements (actual payments) were adjusted for inflation using the US Consumer Price Index (CPI) to standardize all monetary data to 2021 US dollars [15]. The annual mean reimbursement per procedure for each CPT code was calculated. Simple linear regression was employed, using the year as the predictive variable, to assess the trends in procedural volume and inflation-adjusted mean reimbursement per procedure data points over time. Linear interpolation was used to estimate the missing procedural volume and reimbursement data for CPT code 62010 in 2008. This approach ensured the continuity of our dataset and preserved the integrity of our time series analysis. The percent change in the inflation-unadjusted mean reimbursement per procedure was compared with the percent change in the CPI over the study period using a two-tailed Student’s t-test. The compound annual growth rate (CAGR) was calculated for each procedure to provide a standardized measure of annual growth rate that minimizes short-term fluctuations and considers compounding values over time [16]. The CAGR was calculated using the following formula:

$$\mathrm{C}\mathrm{A}\mathrm{G}\mathrm{R}=\left[{\left({\displaystyle \frac{2021Value}{2003Value}}\right)}^{{\displaystyle \frac{1}{(2021-2003)}}}\right]-1.$$

A subanalysis was done using simple linear regression to assess for changes in the mean inflation-adjusted reimbursement per procedure. Procedures of a similar type were categorized into one of four groups: decompressive craniotomy/craniectomy procedures, cranioplasty procedures, intracranial pressure management, and traumatic fracture and penetration procedures. All statistical analyses were performed using R statistical software (version 4.3.1; R Project for Statistical Computing, Vienna, Austria) with a p-value less than 0.05 indicating statistically significant results. This study was exempt from Institutional Review Board approval because the data used in the analyses were publicly available.

3. Results

3.1. Trends in Procedural Volume

Our analysis from 2003 to 2021, which included a total of 511,215 procedures, highlighted significant trends in the utilization and reimbursement patterns for neurosurgical procedures commonly used in TBI. Notably, the combined volume of all 14 examined procedures exhibited a total percent change of −15.39% from 2003 to 2021. However, this change was not uniform across all procedures, with the individual volume changes ranging from −68.57% to 898.70% (

Table 2. Trends in procedural volume for TBI-related neurosurgical procedures (2003–2021).

CPT Code	Procedural Volume—Year 2003	Procedural Volume—Year 2021	% Change Procedural Volume (2003–2021) (%)	Linear Regression p-Value (2003–2021)	Linear Regression R2-Value (2003–2021)
61154	8056	4123	−48.82	<0.001	0.950
61312	9768	8443	−13.56	<0.001	0.552
61316	31	85	+174.19	0.295	0.009
61322	77	769	+898.70	<0.001	0.947
61323	84	118	+40.48	0.031	0.201
61570	25	19	−24.00	0.001	0.426
61571	35	11	−68.57	<0.001	0.590
62005	32	30	−6.25	0.025	0.218
62010	106	49	−53.77	<0.001	0.680
62140	1347	690	−48.78	<0.001	0.718
62141	755	673	−10.86	0.492	−0.029
62143	318	690	+116.98	<0.001	0.642
62148	24	29	20.83	0.557	−0.037
62223	6493	7244	+11.57	0.258	0.020
Total	27,151	22,973	−15.39	<0.001	0.594

Bold indicates statistical significance.

). The procedures with the largest declines include foreign body excision from the brain (61571, −68.57%), elevation of depressed skull fracture (62010, −53.77%), burr hole craniotomy (61154, −48.82%), and large cranioplasty (62140, −48.78%). In contrast, the procedures with the greatest increases in volume include decompressive craniotomy/craniectomy without a lobectomy (61322, 898.70%), banking of the skull flap (61316, 174.19%), cranioplasty with replacement of the skull bone flap or prosthetic plate (62143, 116.98%), and decompressive craniotomy/craniectomy with a lobectomy (61323, 40.48%). Through simple linear regression, the annual combined volume of all 14 procedures showed a significant downward trend over the same period (p < 0.001, R² = 0.594) (Table 2).

3.2. Trends in Reimbursement

Examining the mean Medicare reimbursement per procedure revealed a unique trend. Specifically, when comparing the average percent change in inflation-unadjusted reimbursement per procedure from 2003 to 2021 (+46.78%) against the change in the CPI for the same period (+47.28%), we observed a non-significant difference (p = 0.214) using a Student’s t-test. This suggests that no substantial change in reimbursement per procedure occurred relative to the overall economic inflation (

Table 3. Comparison of inflation-unadjusted mean reimbursement per procedure vs. CPI.

CPT Code	Mean Reimbursement per Procedure— Year 2003 (2003 USD)	Mean Reimbursement per Procedure— Year 2021 (2021 USD)	Unadjusted Total % Change in Reimbursement per Procedure (2003–2021) (%)	% Change in CPI (2003–2021) (%)	t-Test Between Reimbursement per Procedure % Change and CPI p-Value
61154	720.09	1149.54	+59.64
61312	1045.02	1689.9	+61.71
61316	70.03	72.41	+3.40
61322	1290.72	1977.05	+53.17
61323	1275.54	1981.94	+55.38
61570	786.12	1317.54	+67.60
61571	1200.18	1667.65	+38.95
62005	545.27	836.75	+53.46
62010	717.42	973.31	+35.67
62140	336.29	530.64	+57.79
62141	449.49	731.09	+62.65
62143	423.99	742.90	+75.22
62148	97.18	103.02	+6.01
62223	536.04	665.80	+24.21
Total	678.10	1031.40	+46.78	+47.28	0.214

). Furthermore, the inflation-adjusted reimbursement per procedure, when averaged across all 14 procedures for each respective year, demonstrated a total percent change of −3.11% from 2003 to 2021 (

Table 4. Trend analysis of inflation-adjusted Medicare reimbursement per procedure (2003–2021).

CPT Code	Mean Reimbursement per Procedure—Year 2003 (2021 USD)	Mean Reimbursement per Procedure—Year 2021 (2021 USD)	Adjusted Total % Change in Reimbursement per Procedure (2003–2021) (%)	Adjusted CAGR (%)	Linear Regression p-Value (2003–2021)	Linear Regression R2-Value (2003–2021)
61154	1106.04	1149.54	+3.93	+0.20	0.010	0.289
61312	1661.12	1689.90	+1.73	+0.09	0.058	0.148
61316	103.14	72.41	−29.79	−1.84	<0.001	0.742
61322	1901.01	1977.05	+4.00	+0.21	0.047	0.166
61323	1878.65	1981.94	+5.50	+0.28	0.513	−0.032
61570	1344.25	1317.54	−1.99	−0.11	0.835	−0.056
61571	1809.74	1667.65	−7.85	−0.43	0.255	0.021
62005	852.37	836.75	−1.83	−0.10	0.426	−0.019
62010	1166.27	973.31	−16.54	−0.95	0.054	0.163
62140	564.72	530.64	−6.03	−0.33	0.256	0.021
62141	756.91	731.09	−3.41	−0.18	0.068	0.134
62143	730.80	742.90	+1.65	+0.09	0.076	0.125
62148	144.35	103.02	−28.63	−1.76	<0.001	0.780
62223	882.97	665.80	−24.60	−1.47	0.008	0.308
Total	1064.45	1031.39	−3.11	−0.45	0.585	−0.040

Bold indicates statistical significance.

). When looking at individual procedures, changes in reimbursement ranged from −29.79% to 5.50%. The procedures with the sharpest decline include banking of the skull flap (61316, −29.79%), retrieval of the skull flap (62148, −28.63%), ventriculoperitoneal shunt (62223, −24.60%), and elevation of a depressed skull fracture (62010, −16.54%). The procedures with a slight increase in reimbursement include decompressive craniotomy/craniectomy with or without a lobectomy (61323, 5.50%; 61322, 4.00%), burr hole craniotomy (61154, 3.93%), craniotomy for an epidural or subdural hematoma (61312, 1.73%), and cranioplasty with replacement of the skull bone flap or prosthetic plate (62143, 1.65%). Simple linear regression analysis showed no significant trend from 2003 to 2021 (p = 0.585, R² = −0.040) (Table 4). Additionally, the average CAGR of −0.45% was in line with the negligible decline (Table 4).

3.3. Subgroup Analysis of Reimbursement Trends

To further investigate the apparent reimbursement stabilization of TBI procedures, a subgroup analysis was used to characterize any varying trends in reimbursement per procedure. After grouping the procedures into four separate categories, the annual inflation-adjusted mean reimbursement per procedure was averaged and used to evaluate the total percent change for each group from 2003 to 2021. The decompressive craniotomy/craniectomy group showed a total percent increase in the average adjusted reimbursement rates (+3.83%), whereas the cranioplasty (−4.06%), intracranial pressure management (−3.97%), and traumatic fracture and penetration (−7.30%) groups all showed a total percent decrease (Figure 1). However, no significant trend for each grouping was found over the study period through simple linear regression (

Table 5. Subgroup analysis of inflation-adjusted average reimbursement per procedure for TBI-related neurosurgical categories (2003–2021).

Subgroup	CPT Code	Mean Reimbursement per Procedure—Year 2003 (2021 USD)	Mean Reimbursement per Procedure—Year 2021 (2021 USD)	Adjusted Total % Change in Reimbursement per Procedure (2003–2021) (%)	Linear Regression p-Value (2003–2021)	Linear Regression R2-Value (2003–2021)
Decompressive Craniotomy/ Craniectomy	61316	1294.26	1343.80	+3.83	0.155	0.063
	61322
	61323
Cranioplasty	62140	549.19	526.91	−4.10	0.176	0.052
	62141
	62143
	62148
Intracranial Pressure Management	61154	1216.71	1168.41	−4.00	0.285	0.012
	61312
	62223
Traumatic Fracture and Penetration	61570	1293.16	1198.81	−7.30	0.542	−0.035
	61571
	62005
	62010

).

4. Discussion

This analysis of Medicare Part B data from 2003 to 2021 reveals a significant decline in the procedural volumes for neurosurgical TBI-related treatments. This is despite an increase in overall TBI cases resulting from our aging population [2,3]. Possible contributing factors are multifactorial and may include shifts in clinical practice guidelines or changes in patient demographics and healthcare access. The decline could also reflect broader trends in healthcare utilization, such as a move towards less invasive treatments or more conservative management strategies for TBI. For instance, the rise in chronic subdural hematomas in the aging US population, driving up the total number of TBIs, is being more commonly addressed with middle meningeal artery (MMA) embolization, reducing the need for traditional neurosurgical procedures like the craniotomy [17]. Concerning billing practices, the recent growth in Medicare Advantage or Medicare Part C enrollment may result in some procedures not being captured in the Medicare Part B dataset, as services provided to Medicare Advantage enrollees are managed by private insurers [18]. This may partially explain the observed decrease in procedural volumes within the Medicare Part B data.

Our findings align with a recent investigation into Medicare utilization for inpatient neurosurgery procedures, which found a 24% decrease from 2011 to 2019 [9]. However, some individual procedures in our analysis, like skull flap banking (61316), exhibited large increases in procedural volume, suggesting specific areas where demand for certain interventions persists despite the overall declining trends. In contrast, the advent of less invasive alternatives for hematoma evacuation, such as MMA embolization, has likely contributed to the decline in the use of traditional hematoma evacuation methods captured by the 61312 CPT code [17]. This trend is particularly relevant given the increasing incidence of chronic subdural hematomas, where less invasive approaches are often preferred for management [4,5]. Additionally, while the craniotomy CPT codes (61322 and 61323) experienced a utilization increase, this may have been attenuated by the rise in MMA embolization and other less invasive treatments. Ultimately, the downward trend in the procedural volume identified by our analysis warrants attention from policymakers and healthcare providers alike, as it could have significant implications for patient outcomes, healthcare system capacity, and resource allocation.

Our findings uncovered a flat trend in the rate of reimbursement per procedure when averaged across all 14 procedures. The lack of a significant increasing or decreasing linear trend in the inflation-adjusted reimbursement rate suggests that no substantial alteration has occurred in the reimbursement landscape for neurosurgical procedures related to TBI over the study period. However, not all individual procedures followed this trend. Particularly, both the add-on procedures of skull flap banking (61316) and skull flap retrieval (62148) showed the largest declines. The subgroup analysis, which examined the inflation-adjusted average reimbursement per procedure in the four categories of decompressive craniotomy/craniectomy, cranioplasty, intracranial pressure management, and traumatic fracture and penetration, revealed no statistically significant trends over the study period. In absolute terms, reimbursement declined for all subgroups except for decompressive craniotomy. Notably, while Medicare Advantage enrollment increased during the study period, the reimbursement per procedure, as determined by Medicare Part B, continues to influence total reimbursement across the healthcare system [18]. Many commercial insurance plans use the Medicare fee schedule to determine their own rates, often as a multiple of the Medicare fee schedule [19]. Therefore, a decline in Medicare reimbursement rates typically leads to a corresponding decline in reimbursement through other payors as well. Overall, this further supports the trend of stagnation in reimbursement rates for neurosurgical interventions used in treating TBI, which is a unique observation in procedure-reliant specialties like neurosurgery.

The reimbursement findings from this study are in stark contrast with the large body of recent research, which strongly indicates that Medicare reimbursement rates per procedure are decreasing annually across multiple specialties. In neurosurgery, a previous study showed a decrease in the Medicare reimbursement rates from 2000 to 2018 for the 10 most common cranial and 10 most common spinal procedures. The average total percent change of all 20 procedures was found to be −25.8% [2]. In an adjacent specialty like otolaryngology, the average reimbursement for the 20 most common procedures decreased by 37.63% from 2000 to 2019 [8]. Furthermore, a survey of 37 procedural codes in head and neck surgical oncology from 2000–2020 showed that average physician reimbursement decreased by 19.4% [20]. Focusing specifically on trauma-related procedures, a study examining the 20 most commonly used CPT codes in orthopedic trauma found an average total decrease in reimbursement per procedure of 30.0% from 2000 to 2020 [6]. Even more recently, the 20 most utilized procedures in craniofacial trauma showed a 16.6% decrease in inflation-adjusted average reimbursement from 2000 to 2021 [7]. This prevailing decline in Medicare reimbursement rates is so ubiquitous that it was even found across all geographic localities in a study of the 15 most commonly performed spinal surgery procedures from 2000 to 2021 [21].

Our data demonstrates that trends of stabilized reimbursement rates can exist for a specific procedural grouping within a larger field. Some recent investigations into the neurosurgical Medicare reimbursement rates have also uncovered trends that diverge from the established decreases. It was found that certain neurosurgical procedural groups like cervical spine surgery, cranial functional and epilepsy procedures, cranial pain procedures, and endovascular procedures experienced increases in Medicare reimbursement rates from 2011 to 2019 [9]. In addition, the Medicare reimbursement rates for percutaneous and open placement of spinal cord stimulators saw a steady annual increase from 2000 to 2019 [10].

The stable reimbursement rates for TBI-related neurosurgical procedures, unlike the declining rates observed in other specialties, could be due to a combination of factors. This stability might stem from a greater legislative and public health focus on TBI care as it represents the most common type of neurosurgical pathology [22]. The persistent demand for TBI treatment, reflective of its life-saving nature, may contribute to the sustained reimbursement rates. This demand is underscored by the significant resource utilization associated with TBI care, including longer and more expensive inpatient stays compared to non-TBI conditions, as well as a notably higher in-hospital mortality rate [23]. Such factors suggest that TBI treatments maintain their reimbursement levels not just due to clinical necessity but also due to their substantial impact on healthcare resources and patient outcomes. Additionally, the highly emergent and non-elective nature of TBI-related procedures, which often cannot be postponed or replaced by less invasive options, may contribute to maintaining their reimbursement levels despite broader healthcare policy patterns. Unlike the trends observed in other areas of neurosurgery and orthopedic trauma, where technological advancements and changes in clinical guidelines may allow for alternative, less costly treatments, TBI care often requires immediate and complex interventions, potentially insulating it from the general downward pressures on reimbursement rates. This unique position of TBI-related neurosurgical procedures within the broader medical reimbursement landscape highlights the potential interplay between clinical necessity and economic valuation in healthcare policy.

The implications of the stable reimbursement rates for TBI-related procedures revolve around Medicare policy evaluation. The fee-for-service framework was the dominant model that influenced the TBI-related procedure reimbursement rates, particularly through the resource-based relative value scale (RBRVS), during the study period. This system is based on the relative value units (RVUs) assigned to each service, incorporating physician’s work, practice expenses, and malpractice insurance costs, and adjusted by geographic location to determine the reimbursement rate [24]. Given that TBI procedures have remained essential high-priority interventions due to their life-saving nature and immediate necessity, they might have been shielded from the reimbursement decreases that affect other procedures more likely subjected to cost-reduction pressures and efficiency metrics. This could be indicative of a system where critical emergent care is valued and preserved within the reimbursement framework.

Although TBI procedures escaped a declining reimbursement trend, stable reimbursement rates still may not align with the high costs associated with advanced neurosurgical care, potentially impacting the quality of TBI care. Additionally, there is a risk that advancements in TBI treatment, which could offer improved patient outcomes but come at a higher cost, may not be adopted due to inadequate compensation from Medicare beyond the established procedures. This could slow the integration of cutting-edge neurosurgical techniques and treatments that could significantly benefit TBI patients, highlighting a potential misalignment of the RBRVS system with optimal TBI patient outcomes.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) marked the most recent significant update of its reimbursement structure [25]. This legislation saw the repeal of the Sustainable Growth Rate (SGR) in determining Medicare fee schedules and the initiation of the Merit-Based Incentive Payments System (MIPS) [25,26]. This represented a shift towards value-based care within the Medicare framework by aiming to incentivize healthcare providers based on the quality, cost, and outcomes of care. Following this legislation, MIPS has been responsible for adjusting the Medicare payments to physicians based on their performance in four areas: quality, cost, improvement activities, and the use of electronic health records. Essentially, MIPS is an additional layer on top of the existing fee-for-service payment structure defined by RBRVS. A recent study of 20 common neurosurgical procedures from 2000 to 2018 found that the average inflation-adjusted reimbursement rate from 2008–2018 was stabilizing compared to the declining trend noted from 2000–2008. The authors speculated that this transition to a relatively flat annual change in reimbursement rate in the later period could be attributed to the effects of MACRA, though it was too early to confirm [2]. Our findings, reflecting stable reimbursement rates for TBI-related procedures predominantly under the traditional RBRVS system, underscore the need to examine how these procedures are evaluated and compensated with the addition of MIPS following 2015. Given that MIPS focuses on enhancing patient care by rewarding higher-quality, cost-efficient practices, it raises the question of how TBI care metrics are incorporated and valued within this new payment model. The integration of MIPS could potentially offer an opportunity to better align reimbursement with the actual effectiveness and outcomes of TBI treatments. Therefore, scrutinizing how neurosurgical TBI care is assessed and remunerated under MIPS is essential to ensure that vital interventions that maximize patient outcomes are not unintentionally sidelined due to cost barriers.

Alternative payment models, such as bundled payments, could also be explored for TBI-related neurosurgical procedures. These models would consolidate payments for an entire episode of care, incentivizing collaboration among healthcare providers to deliver high-quality, cost-effective treatment [6]. Bundled payments could particularly benefit TBI care, which often requires a multidisciplinary approach and long-term rehabilitation, thereby fostering more integrated and patient-centered care pathways. However, any shift towards bundled payments or other alternative models must be approached with caution. It is essential to ensure that these models are designed to handle the complexity and urgency of TBI management. This means developing bundles that are flexible enough to accommodate the varied and unpredictable nature of TBI treatment, ensuring that they do not inadvertently prioritize simpler, less resource-intensive cases over more complex, urgent ones.

In light of our findings and the evolving healthcare policy landscape, there is a pressing need for strategic initiatives that ensure the sustainability and improvement of TBI care within the Medicare framework. Future policies should not only aim to maintain but enhance the quality and accessibility of TBI care, considering the unique challenges and high stakes associated with these procedures. As healthcare continues to shift towards value-based approaches, it is imperative that TBI care metrics and outcomes are accurately captured and valued, ensuring that the advancements in neurosurgical care translate into tangible benefits for patients. This collaborative effort between healthcare professionals and policymakers is essential for fostering an environment where the best possible TBI care is financially supported. Further analyses of specific pockets within neurosurgery, such as spinal trauma surgery, should also be more closely evaluated for trends in utilization and reimbursement to better advise any future policy adjustments.

This study, while extensive in its exploration of Medicare Part B data concerning neurosurgical procedures and TBI, comes with its own set of limitations. The analysis is limited to Medicare Part B data, which does not encompass the entire spectrum of the neurosurgery reimbursement landscape. Data pertaining to private insurance reimbursements, which are not publicly available, were not included in this study. Nonetheless, decisions on reimbursements by CMS tend to influence the broader market, suggesting the findings may still hold significant relevance [6]. In addition, the utilized CPT codes were unable to be cross-referenced with trauma-related diagnosis codes and may not have been exclusively used in traumatic cases. These data also only look at procedural costs and do not take into account the other expenses associated with delivering TBI care, such as hospital stays and rehabilitation. Moreover, the lack of available data for several procedures from 2000–2002 caused these years to be excluded and limited the analysis from 2003 to 2021. Lastly, a limitation arose from the aggregate nature of the data, which encompassed the utilization and reimbursement rates from diverse geographical locations across the United States. This aggregation may have obscured potential regional variations in the utilization and reimbursement trends for TBI-related procedures. However, by consolidating the data, this analysis provides an insightful view of national trends. Future studies could explore regional variations to offer a more nuanced and specific understanding of the trends in utilization and reimbursement for neurosurgical TBI-related procedures.

5. Conclusions

The findings from our study highlight critical dynamics within the Medicare system concerning the utilization and reimbursement of neurosurgical procedures commonly used in TBI from 2003 to 2021. Despite shifts in healthcare policies and payment structures, TBI-related procedures have maintained stable reimbursement rates, contrasting with the broader declining trends in other medical fields. This consistency underscores the need for ongoing analysis and potential reform to ensure that Medicare reimbursement policies continue to reflect the evolving demands and costs associated with comprehensive TBI care. Moving forward, it is vital that these insights guide a balanced approach in policymaking, one that supports innovation while ensuring accessibility and quality care for those affected by TBI within the Medicare population.