Incentives and factors impacting costs in the surgical management of carotid disease

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OBJECTIVE: With the proliferation of different carotid interventions, there is a need to understand the costs and reimbursements for different procedures and what perioperative factors drive cost. We evaluated the charges and reimbursements for carotid endarterectomies (CEAs) and transcervical carotid artery revascularization (TCAR) across surgical and payer groups. METHODS: We conducted a single-institution retrospective cohort study, from January 1, 2014, to July 1, 2025. Using Epic Systems reporting tools, procedural charges, reimbursements (hospital and professional), and patient characteristics were extracted. The U.S. Bureau of Labor Statistics inflation calculator was used to standardize prices to January 2025 levels. RESULTS: We performed 811 CEAs (31 with jaw subluxation) and 159 TCAR on 931 unique patients at our institution. Hospital reimbursements favored TCAR (TCAR $66,113.57 > endarterectomy $38,323) and professional reimbursements favored endarterectomy (endarterectomy $1707 > TCAR $1397). Higher TCAR operating room (OR) charges are driven by the higher cost of the TCAR system. The average TCAR system charge was $13,319 with an additional $9147 charge per stent ($22,466 total). The TCAR system outweighs the cost savings from shorter TCAR OR cases (TCAR 164.60 minutes vs endarterectomy 221.79 minutes), with cost savings of $10,809 at an average TCAR OR time of $189 per minute after the first 60 minutes. In comparison, adjuncts for complex endarterectomies such as jaw subluxation, are a fraction of the cost of a TCAR system. Different practice patterns can also affect billing and reimbursements, where neurosurgery endarterectomy charges and reimbursements were significantly different from those of vascular surgery. CONCLUSIONS: The choice of intervention option (TCAR or endarterectomy) and local practice patterns are the major drivers of charges and reimbursements for carotid interventions. Our institution is incentivized to perform TCARs due to reimbursements greatly outstripping endarterectomy. However, device costs greatly outweigh OR time savings. CEA remains a significantly less expensive means of managing carotid stenosis compared with TCAR, even with adjuncts such as jaw subluxation or neuromonitoring. Notably, charges differed dramatically from reimbursements, underscoring the divergence of charges from true payments.

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