Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women

Abstract

Background: Laparotomy followed by inpatient hospitalization has traditionally been the most common surgical care for hysterectomy. The financial implications of the increased use of laparoscopy and outpatient hysterectomy are unknown.

Objectives: The objective of the study was to quantify the increasing use of laparoscopy and outpatient hysterectomy and to describe the financial implications among women with commercially based insurance in the United States.

Study design: Hysterectomies between 2010 and 2013 were identified in the Health Care Cost Institute, a national data set with inpatient and outpatient private insurance claims for more than 25 million women. Surgical approach was categorized with procedure codes as abdominal, laparoscopic, laparoscopic assisted vaginal, or vaginal. Payments were adjusted to 2013 US dollars to account for change because of inflation.

Results: Between 2010 and 2013, there were 386,226 women who underwent hysterectomy. The rate of utilization decreased 12.4%, from 39.9 to 35.0 hysterectomies per 10,000 women. The largest absolute decreases were observed among women younger than 55 years and among those with uterine fibroids, abnormal uterine bleeding, and endometriosis. The proportion of laparoscopic hysterectomies increased from 26.1% to 43.4%, with concomitant decreases in abdominal (38.6% to 28.3%), laparoscopic assisted vaginal (20.2 to 16.7%), and vaginal (15.1% to 11.5%) hysterectomies. There was also a shift from inpatient to outpatient surgery. In 2010, the inpatient and outpatient rates of hysterectomy were 26.6 and 13.3 per 10,000 women, respectively. By 2013, the rates were 15.4 and 19.6 per 10,000 women. In each year of analysis, the average reimbursement for outpatient procedures was 44-46% less than for similar inpatient procedures. Offsetting the lower utilization of hysterectomy and lower reimbursement for outpatient surgery were increases in average inpatient and outpatient hysterectomy reimbursement of 19.4% and 19.8%, respectively. Total payments for hysterectomy decreased 6.3%, from $823.4 million to $771.3 million.

Conclusion: Between 2010 and 2013, laparoscopy emerged as the most common surgical approach for hysterectomy, and outpatient hysterectomy became more common than inpatient among women with commercially based insurance. While average reimbursement per case increased, overall payments for hysterectomy are decreasing because of decreased utilization and dramatic differences in how hysterectomy is performed.

Keywords: hysterectomy; laparoscopy; reimbursement; trends.

Figure 1. Payment and Utilization for hysterectomy, Health Care Cost Institute, 2010-2013

NOTE: All cost share and payments are adjusted for inflation to 2013 dollars, using the Medical Consumer Price Index.

Figure 2. Change in age-adjusted utilization rates of inpatient, outpatient, and all hysterectomies, Health Care Cost Institute, 2010-2013

Rates are per 10,000 woman-years.

Figure 3. Payments for inpatient and outpatient laparoscopic and non-laparoscopic hysterectomies, Health Care Cost Institute, 2010-2013

LS: Laparoscopic NOTE 1: Non-laparoscopic hysterectomies are the sum of payments for abdominal, laparoscopically-assisted vaginal, and vaginal hysterectomies. The contribution of each surgical approach is calculated by multiplying the number of hysterectomies by its respective average annual payment. NOTE 2: All costs are adjusted for inflation to 2013 U.S. dollars, using the Medical Consumer Price Index.

Figure 4

Patient and insurance payments for hysterectomy by surgical approach, Health Care Cost Institute, 2010-2013

Figure 5. State-level hysterectomy utilization, Health Care Cost Institute, 2010-2013

NOTE: The overall utilization rate for 50 states and the District of Columbia are shown in each year between 2010 and 2013. Boxplot denotes the median and the interquartile range (25^th and 75^th percentiles).