Arthroscopic versus open approaches in shoulder surgery: trends in Medicare service utilization and reimbursement

Both arthroscopic and open surgical shoulder procedures are effective when nonoperative treatment of shoulder disorders fails. Understanding how utilization and reimbursement for these procedures have evolved is essential for informing health-care policy.

A retrospective analysis was performed using Medicare data to extract utilization and reimbursement data for Current Procedural Terminology from 2005 to 2024 regarding arthroscopic and open shoulder surgeries. Arthroscopic procedures included diagnostic shoulder arthroscopy, arthroscopic rotator cuff (RTC) repair, biceps tenodesis, labral repair/capsulorrhaphy, superior labrum anterior-posterior repair, arthroscopy with limited débridement, arthroscopy with extensive débridement, subacromial decompression, and distal clavicle excision. Open procedures included open RTC repair for acute tears, RTC repair for chronic tears, complete RTC avulsion reconstruction, biceps tenodesis, anterior capsulorrhaphy, acromioplasty, and distal clavicle excision. Reimbursement values were adjusted for inflation. Procedure volumes were normalized to Medicare enrollment. Temporal trends in utilization and reimbursement were assessed using the two-tailed Mann-Kendall trend test.

From 2005 to 2024, over 9 million shoulder procedures were performed for the selected Current Procedural Terminology codes. Overall normalized utilization demonstrated a significant decline (τ = -0.4, P < .05). Arthroscopic procedures demonstrated no significant utilization trend, whereas open procedures declined significantly (τ = -1.0, P < .001). Many procedures showed a decline in utilization in 2020, coincident with the COVID-19 pandemic. Arthroscopic RTC repair increased significantly by 92% (τ = 0.5, P < .05). All other open RTC repairs declined (τ = -1.0, P < .01). Both arthroscopic and open biceps tenodesis demonstrated significant increases (τ = 0.9, P < .01). Across the study period, open biceps tenodesis demonstrated significant increases in inflation-adjusted reimbursement (P < .01). Still, arthroscopic tenodesis consistently reimbursed at higher rates. From 2005 to 2024, arthroscopic RTC repair consistently had the highest reimbursement per service among all RTC repair procedures. Arthroscopic biceps tenodesis demonstrated higher reimbursement per service than open biceps tenodesis throughout the study period. Similarly, arthroscopic capsulorrhaphy maintained higher reimbursement per service compared with its open counterpart. Open acromioplasty demonstrated higher reimbursement per service than its arthroscopic equivalent, subacromial decompression.

From 2005 to 2024, normalized utilization of shoulder procedures declined overall, driven primarily by a significant reduction in open surgical procedures. Inflation-adjusted Medicare reimbursement for both open and arthroscopic shoulder procedures remained stable. For most procedures, reimbursement per service was higher for arthroscopic procedures.