Trends in Medicare Costs of Hyperbaric Oxygen Therapy, 2013 through 2022

Trends in Medicare Costs of Hyperbaric Oxygen Therapy, 2013 through 2022
Helen B. Gelly, MD1; Caroline E. Fife, MD2,3; David Walker, CHT2; Kristen Allison Eckert, MPhil4

1 Regenerative and Hyperbaric Medicine, Marietta, GA 2 Intellicure, Inc., The Woodlands, TX
3 Baylor College of Medicine, Houston, TX
4 Strategic Solutions, Inc., Bozeman, MT

CORRESPONDING AUTHOR: Helen B. Gelly – helengelly@gmail.com

INTRODUCTION

A recent cost analysis of chronic wound care among Medicare beneficiaries revealed that from 2014 to 2019, there was a decrease in overall cost. Howev- er, the prevalence rate of chronic wounds increased from 14.5% to 16.4%. The number of beneficiaries in- creased from 8.2 million to 10.5 million, and annual wound-related costs decreased from $29.7 billion to

$22.5 billion, with the largest decrease in costs seen in the outpatient setting [1]. Most wound-related costs are still generated in the hospital-based outpa- tient setting. Still, there has been a noticeable shift to the doctor’s office and away from home health care, which may be partially attributed to prior au- thorization programs initiated by the Centers for Medicare and Medicaid Services (CMS) for nonemer-

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gent indications, such as hyperbaric oxygen therapy (HBO2) [1,2]. From 2015 through 2018, CMS piloted a prior authorization program in MI, IL, and NJ, where the highest rates of HBO2 utilization were previously reported. Interestingly, while CMS observed a 16% reduction in HBO2 utilization, a 25% reduction in the number of treatments, and a cost reduction of approximately 35% per beneficiary in these three states, total Medicare expenditures remained the same in MI and NJ. In contrast, an increase in total expenditures was reported for IL [2]. These paradox- ical findings would suggest that reducing the costs of HBO2 does not reduce the overall Medicare bud- get.

Literature has long been critical of the “prohibi- tively” high costs of HBO2, particularly as it is most frequently used for wound healing indications that require dozens of treatments, such as diabetic foot ulcers (DFUs) and chronic radiation-induced procti- tis [2-6]. Multiple reviews of cost analyses have stat- ed there is little or uncertain evidence supporting the cost-effectiveness of HBO2, although it may be less costly in some cases [4,5]. However, the actual treatment costs of HBO2 and the various protocols used for different indications are not reported.

We recently analyzed HBO2 utilization and physi- cian volume data from the Hyperbaric Oxygen Ther- apy Registry (HBOTR) hosted by the US Wound Reg- istry (USWR) for 2013 to 2022 to understand current trends in physician supervision. We reported that the total annual number of treatments increased from 19,400 in 2013 to a high of 31,389 in 2021 be- fore decreasing to 25,916 in 2022, while the number of treatments per patient hovered around 25 to 28 sessions each year (mean: 26.3 treatments; standard deviation: 6.8) (authors and titles of Companion pa- per redacted for peer-review, in press for publication Undersea Hyperbaric Medicine in 2024, hereafter referred to as Companion paper). In this paper, we perform a secondary analysis of HBOTR data to esti- mate the Medicare costs of HBO2 based on standard treatment protocols and the annual mean number of treatments per patient reported by the registry.

METHODS

From 2013 through 2022, the HBOTR collected elec- tronic health record (EHR) data for all payers from 53 centers in 34 states (Companion paper). Our companion paper describes the complete data col- lection process in detail. There were 262,055 HBO2 sessions recorded during this time. For our second- ary, retrospective analysis of EHR data, we used the mean number of treatments per patient per year. We estimated the mean number of HBO2 treatments per patient by dividing the total number of treatments per physician by the total number of patients. This study is exempt from human subject regulations be- cause it does not involve using human subjects but rather the secondary analysis of deidentified data.

We analyzed the annual per-patient Medicare costs of HBO2 based on the annual average, a round- ed number of treatments patients received each year, and a standard series of up to 40 treatments previously used by the prior authorization model [2].

Medicare costs were defined as the physician fees plus the facility fees for HBO2. Current Procedural Terminology® (CPT) Code 99183 was used to deter- mine the annual reimbursement per treatment for the physician fee, with each treatment billed as a single event [7]. We multiplied the physician charge per treatment by the average number of treatments per patient and by 40 treatments. Given that more than 90% of HBO2 treatments are done in hospital outpatient departments [8], we used the hospital Outpatient Prospective System (OPPS) fees to de- termine the charge for a single 30-minute segment of HBO2 [9]. Facility fees for HBO2 were historically reimbursed by Healthcare Common Procedure Cod- ing System code C1300, which was replaced by CMS with G0277 in 2015 as a descriptor of the direct prac- tice expense inputs corresponding to the CPT code 99183 code [10,11]. Therefore, in this cost analysis, C1300 was used for 2013 and 2014, and G0277 was used for 2015 through 2022. The unadjusted nation- al fee schedule was used instead of the geograph- ical index for this charge because the reimburse- ment based on the geographic index is too variable. While physician reimbursement via CPT code 99183 is based only on attendance and supervision and is only billable once per HBO2 session, outpatient fa-

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HBO2 COST ANALYSIS – UHM 2024 VOL 51 NO 2

cilities typically bill up to 4 segments of 30-minute increments (120 minutes) per session [12,13]. There- fore, we calculated the facility fee for each treatment based on four segments of the 30-minute HBO2 inter- vals (120 minutes total). So, the respective OPPS fee was quadrupled and multiplied by the average num- ber of treatments per patient and by the standard 40 treatments per patient. We next adjusted 2013- 2021 costs to 2022 inflation using the 2017-based Medicare Economic Index [14,15]. Quarterly indices were averaged to estimate the annual index for each year through 2021. The data inputted to analyze an- nual costs are summarized in Table 1. The 2022-ad- justed physician and facility charges were summed together to obtain the total charge of HBO2 per pa- tient based on the average number of treatments each year and the standard 40-treatment series.

Next, we calculated the 2022 cost to Medicare of standard treatment protocols for HBO2 indications that are treated in the outpatient setting only, based on the number of treatments reported for each indi-

cation by the Undersea and Hyperbaric Medical So- ciety and additional references from clinical studies and private payers (Table 2) [3,16-21]. We excluded HBO2 indications treated in-patient from this cost analysis, as the OPPS fee would not apply. The num- ber of treatments needed per indication was multi- plied by the cost of a single treatment session (based on the sum of the facility fee and physician fee). When the typical number of treatments varied, the maximum usual number of treatments was used for the calculation, as well as the maximum number that may be required in addition to the usual number of treatments, except for DFUs and delayed radiation injuries (Table 2). For DFUs, multiple clinical trials and a large real-world dataset from 682 wound cen- ters demonstrated that these chronic wounds usual- ly receive 30 to 40 treatments, while up to 60 may be medically necessary [16,17]. Depending on the type of radiation injury, the literature reports that the usual number of treatments ranges from 30 to 40, while up to 60 may be medically necessary [3,18-21].

2017 2018 2019 2020 2021 2022

mean no. of HBO2 treatments/patient

mean 2017-based MEI

outpatient facility fees

fee/segmenta

fee/4 segments

mean cost/patientb

cost/patient/40 treatmentsb

physician fees

fee/treatment

mean cost/patientb

cost/patient/40 treatmentsb

total costs/patient mean cost/patientb

cost/patient/40 treatmentsb

25 25 27 27 26 26 25 27 28 27

HBO2 COST ANALYSIS – UHM 2024 VOL 51 NO 2

2013 2014 2015 2016

0.928 0.945 0.962

$107.75 $110.93 $109.29 $431.00 $443.72 $437.16 $13,480.36 $13,628.54 $14,244.96

$21,568.58 $21,805.67 $21,103.65

$119.76 $123.59 $113.19 $3,745.73 $3,795.98 $3,688.32

$5,993.16 $6,073.57 $5,464.18

$17,226.09 $17,424.52 $17,933.29 $27,561.74 $27,879.23 $26,567.83

0.980 1.000 1.024 1.048

$107.71 $110.19 $114.16 $114.40 $430.84 $440.76 $456.64 $457.60 $13,781.16 $13,304.78 $13,461.07 $12,673.51

$20,416.54 $20,468.89 $20,709.34 $20,277.62

$112.07 $112.69 $113.04 $112.44 $3,584.75 $3,401.66 $3,332.25 $3,114.09

$5,310.75 $5,233.32 $5,126.54 $4,982.55

$17,365.92 $16,706.44 $16,793.32 $15,787.61 $25,727.29 $25,702.22 $25,835.88 $25,260.17

1.072 1.105 1.161

$115.04 $119.28 $121.80 $460.16 $477.12 $487.20 $13,455.82 $14,036.40 $13,154.40

$19,934.54 $20,051.99 $19,488.00

$114.04 $109.91 $108.66 $3,334.71 $3,233.44 $2,933.82

$4940.31 $4,619.20 $4,346.40

$16,790.53 $17,269.84 $16,088.22 $24,874.86 $24,671.20 $23,834.40

HBO2 = hyperbaric oxygen therapy; MEI = Medicare Economic Index
aHealthcare Common Procedure Coding System reimbursement code C1300 was used for 2013 and 2014 and was re- placed by G0277 in 2015; each charge is for one 30-minute segment of HBO2
badjusted for 2022 inflation using annual average of quarterly 2023-based MEIs [15]

Table 1: Medicare reimbursement cost data and total annual costs per patient for hyperbaric oxygen therapy. Costs are in US dollars.

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RESULTS

Table 1 and Supplemental Figures 1 and 2 summa- rize the Medicare reimbursement cost data and an- nual costs per patient based on the average number of HBO2 treatments per patient and a fixed number of 40 treatments per patient. Generally, all costs per patient decreased from 2013 through 2022, while the average number of treatments per patient var- ied minimally from 25 in 2013 to 27 in 2022, with a peak of 28 in 2021. The facility cost per patient per 40 HBO2 treatments decreased by 10.7% from $21,568.58 in 2013 to $19,488.00 in 2022. The physi- cian cost per patient per 40 treatments substantially decreased by -37.8%, from $5,993.16 to $4,346.40. The total cost per patient per 40 treatments de- creased by 15.6% from $27,561.74 to $23,834.40.

Table 3 and Figure 1 summarize the estimated cost ranges of standard treatment protocols per patient for different HBO2 indications for 2022. The lowest costs were for crush injury, compartment syndrome, and other acute traumatic ischemias, which ranged from $2,383.44 to $8,342.04 per patient. The highest cost range was for DFUs and delayed radiation in- juries, which typically cost $17,875.80 to $23,834.40 for 30 to 40 treatments but could cost as much as $35,751.60 for 60 treatments.

DISCUSSION

In this secondary analysis of registry data from 10 years, the average number of treatments admin- istered to this real-world population was approxi- mately 26, which is considerably less than the stan- dard 40-treatment regimen oft-cited in the literature and used by CMS but similar to the mean number of treatments (n = 27) needed in a limb salvage pro- gram previously reported [22]. When considering how much different HBO2 indications should cost Medicare (Table 3 and Figure 1), it is important to mention that the costs are not nearly as high as have been exaggerated in the literature. While authors have criticized the use of HBO2 as cost-prohibitive for indications requiring the standard 40-treatment regimen because a single treatment costs “thou- sands of dollars” [3], these criticisms are gross exag- gerations of the true costs. In 2022, a single HBO2 session cost Medicare only $595.86, which is calcu- lated assuming the facility is billing a total of four segments per session.

We estimated that the usual cost to treat a DFU with HBO2 ranged from $17,875.80 to $23,834.40, which approaches what previous authors report- ed spending on HBO2 in a limb salvage program ($17,000 per DFU) from 2005 through 2013 [22].

HBO2 COST ANALYSIS – UHM 2024 VOL 51 NO 2

indication

crush injury/compartment syndrome/other acute traumatic ischemias

central retinal artery occlusion diabetic foot ulcersd

intracranial abscess

necrotizing soft tissue infections

refractory osteomyelitis

delayed radiation injury (soft tissue and bony necrosis)

compromised grafts and flaps
idiopathic sudden sensorineural hearing loss

usual no. of treatmentsc

4 20 30-40 21

30 20

30-40

20 10

maximum no. of treatments

14

20

60

42 30 40

60

20 20

usual, mean cost per patient

$2,383.44

$11,917.20

$17,875.80- $23,834.40

$12,513.06

$17,875.80

$11,917.20

$17,875.80- $23,834.40

$11,917.20 $5,958.60

maximum cost per patient

$8,342.04

$11,917.20

$35,751.60

$25,026.12 $17,875.80 $23,834.40

$35,751.60

$11,917.20 $11,917.20

abased on 1 treatment session costing Medicare $595.86 in 2022 (based on facility and physician fees per session) bsevere anemia is excluded from this analysis because its treatment regimen is variable and not well-defined (Table 1),

but at least 3 sessions are required, or at least $1,787.58
cused the maximum amount of the usual number of treatments required
drepresenting the indication for problem wounds, because it is the most commonly used indication [2,6].

Table 2: Hyperbaric oxygen indications treated in the outpatient setting and the recommended number of treatments per indication.

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DFUs and delayed radiation injuries ($35,751.60) were relatively low in comparison with the annu- al costs of some prescription drugs. For example, ustekinumab (Stelara, Janssen Biotech, Inc., Horsh- am, PA), which is used to treat Crohn's disease, had a list price in March 2022 of $25.497.12 for a single 90 mg injection every eight weeks: without insurance, its annualized cost ranges between $30,000 and $70,000 [23,24]. Among 7.3 million patients with digestive diseases covered by private insurance in 2016-2018, the annualized drug cost for Crohn's dis- ease was $40,255, but the highest was for Hepatitis C at $93,432 [25].

The HBO2 per-patient costs have decreased over the past decade, with 40 sessions per patient cost- ing 15.6% less in 2022 than in 2013 (Table 1). This per-patient savings is most notably attributed to decreased physician costs, with physicians mak- ing 37.8% less per patient in 2022 than in 2013. Physicians have been shouldering the burden of decreased HBO2 costs, largely due to the reduced conversion factors used in recent years to calculate physician fees, a reduction enacted to offset the in- creased costs associated with Evaluation and Man- agement office visit codes [26].

This study is limited by its retrospective analysis and the fact that it only includes data from 53 facili- ties in 34 states registered in the HBOTR from 2013 to 2022. However, the real-world registry data report- ed herein reflect patients covered by private payers (commercial plans), Medicaid, traditional Medicare, and Medicare Advantage. Another limitation of our analysis is that being a secondary analysis of data related to physician trends, we do not know the

actual diagnoses of the patients requiring HBO2 in the HBOTR, and the number of treatments was not disaggregated per patient. As such, we cannot de- termine the actual cost of each indication, which is why we calculate the hypothetical cost ranges based on usual treatment protocols reported in the liter- ature and covered by Medicare and private payers. Facility fees are based on four segments of 30 min- utes each or 120 minutes [12,13]. It should be noted that some sessions may not last the full 120 minutes.

This real-world analysis of registry data demon- strates that the actual cost of HBO2 is not nearly as costly as the literature has insinuated, and the per-patient cost to Medicare is decreasing, largely due to decreased physician costs. Although HBO2 is most frequently used for wound healing indications, which usually require dozens of treatments, registry data show that the mean number of treatments pa- tients use is around 26, considerably lower than the standard 40-treatment regimen. Our cost analysis supports the idea that HBO2 can be affordable for Medicare.

FUNDING

This work was supported by Regenerative and Hy- perbaric Medicine Inc. and the Hyperbaric Oxygen Therapy Registry

CONFLICTS OF INTEREST

HBG is the President of Regenerative and Hyperbar- ic Medicine, Inc; CEF is the Chief Medical Officer of Intellicure; DW is the Chief Technology Officer of Intellicure; KAE was a paid consultant of Strategic Solutions to this study.

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DOI: 10.22462/702