Is the Future of Cleft Care Financially Sustainable? An Economic Analysis of Inflation-Adjusted Reimbursements.

Objective: As Medicaid continues to expand, it remains unclear if reimbursement rates for cleft care are keeping up with the national economy. The purpose of this study is to determine how financial trends in cleft lip and palate repair reimbursements compare to annual changes in the U.S. economy.

Design: Current Procedural Terminology (CPT) codes for cleft lip and palate repair were retrospectively reviewed between 2018 and 2023. Reimbursements were adjusted for inflation to 2023 U.S. dollars using Medicaid physician fee schedules. Annual percentage changes in inflation-adjusted reimbursements, and reimbursement Compounded Annual Growth Rate (CAGR) were compared to the annual change in the U.S. Consumer Price Index (CPI).

Setting: Multi-state, Medicaid.

Participants: Medicaid reimbursements of 6 U.S. states, 5 with highest birthrates: California, Texas, Florida, New York, and Pennsylvania. Colorado, the study institution, was evaluated.

Main Outcome(s): Primary outcomes included annual changes in overall and inflation-adjusted reimbursement rates for cleft lip and palate surgical procedures as compared to annual changes in CPI.

Results: The U.S. CPI increased by 20.9% from 2018 to 2023, while the overall total percentage change in reimbursement rates for all cleft lip and palate procedures increased by 7.23%. The inflation-adjusted overall percent change in reimbursements for all procedures decreased by -12.81%. For all procedures, the average CAGR was -2.66%.

Conclusions: Inflation-adjusted reimbursement rates for cleft lip and palate repair have significantly decreased in contrast to the annual growth in U.S. CPI. These findings show a potential lack of financial sustainability for surgical cleft care, indicating the need for healthcare policy reform.