# Declining Medicare reimbursement and income in primary total shoulder arthroplasty: a comparison of osteopathic and allopathic orthopedic surgeons, 2013-2023

## TL;DR

This study compares Medicare reimbursement trends for shoulder surgery between osteopathic and allopathic surgeons from 2013 to 2023, finding consistent income disparities.

## Contribution

The paper quantifies the growing income gap between DO and MD orthopedic surgeons performing TSA despite similar reimbursement rates.

## Key findings

- DO physicians consistently earned 26-31% less in annual procedural income than MD physicians in both 2013 and 2023.
- Both MD and DO physicians experienced a 23-24% decline in procedural reimbursement despite rising inflation.
- DO physicians billed 25-30% fewer services than MD physicians over the study period.

## Abstract

Medicare reimbursement for arthroplasty, including total shoulder arthroplasty (TSA), has declined over the past decade. The purpose of this study is to determine whether Medicare reimbursement differed between osteopathic (DO) and allopathic (MD) orthopedic physicians performing primary TSA and how this has changed over time.

The Centers for Medicare and Medicaid Services databases were queried from 2013 to 2023 to identify physicians billing the Current Procedural Terminology code 23472 (primary TSA). Physicians were stratified by degree (12,518 MD vs. 1,167 DO). All monetary values were adjusted to 2023 United States dollars using the Consumer Price Index. Procedural reimbursement was defined as the Centers for Medicare and Medicaid Services–reported average Medicare standardized amount. Annual procedural income (API) was a physician's Medicare income from TSA (Current Procedural Terminology code 23472), calculated as average Medicare standardized amount multiplied by services billed.

In 2013, DO physicians earned 31% ($11,493) less in API than MD physicians ($25,704 vs. $37,197; P < .001), with 24% fewer mean years in practice (14 vs. 19; P < .001) and 30% fewer mean services (18 vs. 25; P < .001). In 2023, DO physicians earned 26% ($8,422) less in API than MD physicians ($24,001 vs. $32,423; P < .001), with 21% fewer mean years in practice (18 vs. 22; P < .001) and 25% fewer mean services (22 vs. 29; P < .001). From 2013 to 2023, the proportion of DO providers doubled (5% vs. 10%), as did their share of TSA services (4% vs. 8%). Over this time, procedural reimbursement did not differ significantly between degree types. However, DO physicians experienced a 23% ($335) decline in procedural reimbursement ($1,444 vs. $1,109; P < .001), with no significant change in mean services (P = .073) or API (P = .524), while MD physicians experienced a 24% ($345) decline in procedural reimbursement ($1,458 vs. $1,113; P < .001) despite billing 15% more mean services (25 vs. 29; P < .001), resulting in a 13% ($4,774) decline in API ($37,197 vs. $32,423; P < .001).

By 2023, MD physicians experienced a 13% decline in API compared with 2013 despite averaging 15% more services, highlighting a concerning trend of providers working more for less. Both MD and DO physicians had significant declines in procedural reimbursement over this period (24% and 23%, respectively) despite a 31% rise in inflation. Although procedural reimbursement did not differ between degree types in either year, DO physicians consistently billed 7 fewer services and earned $11,493 less in API in 2013 and $8,422 less in 2023.