Latest news with #CurrentProceduralTerminology
Malaysian Reserve
22-05-2025
- Health
- Malaysian Reserve
AMA Establishes CPT Codes for Minimally Invasive ESD Procedure
CENTER VALLEY, Pa., May 22, 2025 /PRNewswire/ — Olympus Corporation, a global medical technology company committed to making people's lives healthier, safer, and more fulfilling, announced today the American Medical Association (AMA) Current Procedural Terminology (CPT®) Editorial Panel has published its Summary of Panel Actions and has agreed to establish two Category I CPT codes for the Endoscopic Submucosal Dissection (ESD) procedure: one code for the upper GI tract and one code for the lower GI tract.i The final code numbers, code descriptors and fee schedules will be published in November 2026, and the codes are anticipated to become effective January 1, 2027. The dedicated CPT codes for the ESD procedure will allow for more widespread clinical adoption of the procedure and remove barriers to patient access. This will be facilitated through a standardized and streamlined reimbursement process for health care providers and payers. 'We applaud the AMA's decision to establish these new CPT codes, which will help more patients and physicians access the ESD procedure for the minimally invasive treatment of pervasive GI diseases and disorders,' said Paul Skodny, Senior Director for Health Economics and Market Access at Olympus Corporation. 'This positive result is the culmination of much hard work and broad support for creating this reimbursement pathway.' ESD is a minimally invasive, organ-sparing endoscopic procedure used to diagnose and treat cancerous and pre-cancerous neoplasms of the gastrointestinal (GI) tract. Rather than surgically removing whole sections of the GI tract through incisions on the skin, physicians remove tumors through natural orifices, via an endoscope, in one piece. This technique enables accurate staging of these lesions by pathologists, leading to less recurrence rates than other endoscopic Without large incisions or having sections of organs removed, patients experience less pain, faster healing and may not suffer the potential consequences of segmental 'We are thrilled to reach this significant reimbursement milestone for the ESD procedure,' said Mike Callaghan, General Manager for EndoTherapy at Olympus Corporation. 'Olympus has been at the forefront of developing ESD solutions since the procedure was first pioneered by Japanese clinicians working collaboratively with Olympus. This decision by the AMA will facilitate broader adoption of this procedure in the U.S., and it will enhance patient care by providing more patients with access to an advanced and novel treatment option.' Visit the Olympus Americas ESD web page for more information about the ESD procedure: About OlympusAt Olympus, we are committed to Our Purpose of making people's lives healthier, safer and more fulfilling. As a global medical technology company, we partner with healthcare professionals to provide solutions and services for early detection, diagnosis and minimally invasive treatment, aiming to improve patient outcomes by elevating the standard of care in targeted disease states. For more than 100 years, Olympus has pursued a goal of contributing to society by producing products designed with the purpose of delivering optimal outcomes for its customers around the world. Olympus Corporation of the Americas, a wholly owned subsidiary of Olympus Corporation, is headquartered in Center Valley, Pennsylvania, USA, and employs more than 4,500 employees throughout locations in North and South America. For more information, visit i Summary of Panel Actions. Updated May 16, 2025. Accessed May 20, 2025. Fukami, N. Endoscopic Submucosal Dissection in the Esophagus: Indications, Techniques, and Outcomes, Gastrointestinal Endoscopy Clinics of North America. 2023;33(1);55-66. doi:10.1016/ Abdelfatah MM, Barakat M, Ahmad D, Ibrahim M, Ahmed Y, Kurdi Y, Grimm IS, Othman MO. Long-term outcomes of endoscopic submucosal dissection versus surgery in early gastric cancer: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2019;31(4):418-424. Doi:10.1097/MEG.0000000000001352. PMID: 30694909iv Qian M, Sheng Y, Wu M, Wang S, Zhang K. Comparison between Endoscopic Submucosal Dissection and Surgery in Patients with Early Gastric Cancer. Cancers. 2022; 14(15):3603.
Yahoo
12-05-2025
- Business
- Yahoo
NeurAxis Reports Strong First Quarter 2025 Financial Results Driven by a 39% Growth in Revenues
Conference call will be held today, Monday, May 12 at 9:00 am ET CARMEL, Ind., May 12, 2025 (GLOBE NEWSWIRE) -- NeurAxis, Inc. ('NeurAxis,' or the 'Company') (NYSE American: NRXS), a medical technology company commercializing neuromodulation therapies for chronic and debilitating conditions in children and adults, today announced results for the first quarter 2025 for the period ended March 31, 2025. 1Q25 Financial highlights Revenues increased 39% year over year to $896 thousand in 1Q25 compared to $647 thousand in 1Q24. Revenues increased 18% quarter over quarter to $896 thousand in 1Q25 compared to $761 thousand in 4Q24. Operating loss (excluding a one-time legal settlement) improved by 9% compared to the first quarter of 2024. Cash balance was $2.0 million as of March 31, 2025. Recent Operational Highlights Expanded total covered lives to approximately 51 million compared to 4 million as of December 31 2023. Received a new Current Procedural Terminology (CPT) Category I code for Percutaneous Electrical Nerve Field Stimulation (PENFS) procedures effective January 1, 2026. Received new FDA clearance for the expansion of IB-Stim label: to allow for a larger patient population beyond 11-18 years of age to 8-21 years. to increase devices per patient to 4 devices. Received 510(k) clearance from the FDA for its rectal expulsion device (RED) product. RED's innovative design simplifies anorectal function testing and can be used without interrupting clinical workflow. The Company has just begun the commercialization process and expects the first meaningful revenues in 2Q25. The Company remains committed to clinical research in the pediatric space, with 16 peer-reviewed publications. All studies were carried out in US children's hospitals using NeurAxis' PENFS technology. This level of evidence puts NeurAxis in a great position to continue expanding payor coverage and increasing adoption of the technology. Management Commentary Brian Carrico, Chief Executive Officer of NeurAxis, commented, 'Q1 2025 marked another strong quarter for NeurAxis, with revenue growing 39% year-over-year, extending the momentum that began in Q3 2024. Our progress is becoming increasingly evident in the numbers. In the first quarter alone, 300 patients were treated through full PO or PAP programs—an annualized rate of 1,200 patients. While this marks important growth, it still represents just 0.2% of the 600,000 severely affected children in the U.S. suffering from IBS who are in urgent need of IB-Stim. This robust growth is driven by physicians gaining greater comfort with billing and coding processes, alongside broader awareness of academic society guidelines that recognize PENFS with the highest GRADE of evidence. Today, positive coverage policies now encompass approximately 51 million lives, and several additional payers are actively engaged in policy development. While our revenue trajectory has accelerated in recent quarters, it's important to recognize we are still reaching only a small fraction of our total addressable market, primarily because national policy coverage and the implementation of the Category I CPT code are still forthcoming. We expect the upcoming publication of academic society guidelines to be a significant catalyst for broader insurance coverage, with the goal of securing treatment access for the majority of affected children in the U.S. These coverage expansions, alongside the Category I code taking effect on January 1, 2026, are the two critical milestones that position us for large-scale national growth. In parallel, we have submitted for FDA clearance to expand IB-Stim's indication to include pediatric Functional Dyspepsia, and we are cautiously optimistic for approval in 2025. A successful clearance would effectively double our pediatric addressable market. Our vision is clear: we are methodically executing against our milestones to drive growth, expand access, and deliver on our revenue expectations. We anticipate meaningful acceleration in revenue growth as we move closer to cash flow breakeven, fueled by two catalysts — the continued expansion of positive payer coverage for IB-Stim (PENFS) and the commercialization of RED, alongside the Category I CPT code becoming effective in early 2026." First Quarter 2025 Financial Results Revenues in the first quarter of 2025 were $896 thousand, up 39% compared to $647 thousand in the first quarter of 2024. Unit sales increased approximately 46% year over year due to growth from patients with full insurance reimbursement and the Company's financial assistance program that offers discounts for patients without insurance coverage. The Company continues to see great improvements in recent months, gaining positive policy coverage for the PENFS technology, and recent results are indicative of that success. Gross margin in the first quarter of 2025 declined to 84.4% from 88.4% in the first quarter of 2024. Despite the increase in sales volume, the decline in gross margin is the result of higher growth from financial assistance customers with discounted pricing due to lack of insurance coverage compared to full reimbursement customers with insurance coverage and higher device manufacturing and shipping costs. Operating expenses in the first quarter of 2025 were $3.1 million, an increase of 27% compared to $2.4 million in the first quarter of 2024. The increase is due to (i) the settlement of a lawsuit, (ii) higher selling expenses corresponding directly with sales volume and (iii) higher research and development costs as the Company completed RED development and initiated expenditures on a new medical research project. Excluding the one-time legal settlement charge, the Company's operating expenses in the first quarter of 2025 would have remained relatively flat compared to the first quarter of 2024. Operating loss in the first quarter of 2025 was $2.3 million, an increase of 25% compared to $1.8 million in the first quarter of 2024. Excluding the one-time legal settlement charge, the Company's operating loss in the first quarter of 2025 would have improved 9% compared to the first quarter of 2024. Net loss in the first quarter of 2025 was $2.3 million, an increase of 8% compared to $2.1 million in the first quarter of 2024. Excluding the one-time legal settlement charge, the Company's net loss in the first quarter of 2025 would have improved 22% compared to the first quarter of 2024. Cash on hand as of March 31, 2025, was $2.0 million. Cash used in operations in the first quarter of 2025 was $271 thousand higher than in the first quarter of 2024 primarily due to past due payables in the first quarter of 2024 that was a function of the Company's liquidity position at the time. The Company has no long-term debt. Conference Call Details Date and Time: Monday, May 12, 2025, at 9:00am ET Live Webcast Information: Interested parties can access the conference call via a live webcast, which is available in the Investor Relations section of the Company's website at or For participants listening through the webcast, questions can be sent in through the portal using the 'Ask a Question' link or by emailing questions to NRXS@ Call-in Information: Interested parties can also access the live conference call by initially registering at the following link. Upon completion of the registration link, call-in participants will receive the dial-in info and a unique PIN to join the call as well as an email confirmation with the details. Replay: A webcast replay will be available in the Investor Relations section of the Company's website at orhttps:// About NeurAxis, Inc., is a medical technology company focused on neuromodulation therapies to address chronic and debilitating conditions in children and adults. NeurAxis is dedicated to advancing science and leveraging evidence-based medicine to drive the adoption of its IB-Stim™ therapy, which is its proprietary Percutaneous Electrical Nerve Field Stimulation (PENFS) technology, by the medical, scientific, and patient communities. IB-Stim™ is FDA-cleared for functional abdominal pain associated with irritable bowel syndrome (IBS) in adolescents 8-21 years old. Additional clinical trials of PENFS in multiple pediatric and adult conditions with large unmet healthcare needs are underway. For more information, please visit Forward-Looking StatementsCertain statements in this press release are forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended. All statements other than statements of historical fact are forward-looking statements. Forward-looking statements are based on management's current assumptions and expectations of future events and trends, which affect or may affect the Company's business, strategy, operations or financial performance, and actual results and other events may differ materially from those expressed or implied in such statements due to numerous risks and uncertainties. Forward-looking statements are inherently subject to risks and uncertainties, some of which cannot be predicted or quantified. There are a number of important factors that could cause actual results, developments, business decisions or other events to differ materially from those contemplated by the forward-looking statements in this press release. These factors include, among other things, the conditions in the U.S. and global economy, the trading price and volatility of the Company's stock, public health issues or other events, the Company's compliance with applicable laws, the results of the Company's clinical trials and perceptions thereof, the results of submissions to the FDA, the results of the shareholder vote to enable the issuance of the Preferred Stock, and factors described in the Risk Factors section of NeurAxis's public filings with the Securities and Exchange Commission (SEC). Because forward-looking statements are inherently subject to risks and uncertainties, you should not rely on these forward-looking statements as predictions of future events. These forward-looking statements speak only as of the date of this press release and, except to the extent required by applicable law, the Company undertakes no obligation to update or revise these statements, whether as a result of any new information, future events and developments or otherwise. For contraindications, precaution, warnings, and IFU, please see: For important RED information, including indications, precautions, and contraindications, visit: Contacts: CompanyNeurAxis, Investor Relations Lytham PartnersBen Shamsian646-829-9701shamsian@ (Unaudited) For the Three Months EndedMarch 31, 2025 2024 Net Sales $ 895,655 $ 646,635 Cost of Goods Sold 139,475 75,081 Gross Profit 756,180 571,554 Selling Expenses 133,954 80,030 Research and Development 60,556 5,570 General and Administrative 2,856,768 2,318,074 Operating Loss (2,295,098 ) (1,832,120 ) Other income (expense): Financing charges — (230,824 ) Interest expense (2,237 ) (26,560 ) Change in fair value of warrant liability 1,831 (9,284 ) Amortization of debt discount and issuance cost — (21,683 ) Other income 16,820 — Other expense — (180 ) Total other income (expense), net 16,414 (288,531 ) Net loss (2,278,684 ) (2,120,651 ) Preferred stock dividends (213,543 ) — Net loss available to common stockholders $ (2,492,227 ) $ (2,120,651 ) Per-Share Data Basic and diluted loss per share $ (0.33 ) $ (0.32 ) Weighted Average Common Shares Outstanding Basic and diluted 7,463,578 6,550,567
Yahoo
03-04-2025
- Business
- Yahoo
Massachusetts man sentenced in healthcare fraud case
BOSTON (WWLP) – A healthcare company executive has been sentenced to prison in a health benefit program fraud case. In a news release from the Department of Justice in Boston, 42-year-old Miguel Saravia of Hanson pleaded guilty to six counts of healthcare fraud in federal court. Saravia is the CEO of Dana Group Associates and also the former COO of Prime Behavioral Health. Massachusetts pizza chain owner sentenced for defrauding the U.S. Small Business Administration Investigators say that from 2017-2022, Saravia had persons with no billing or medical training enter Current Procedural Terminology codes (CPT) for therapy services that were not provided and to upcode CPT codes used for psychotherapy visits. He submitted, or directed the submission of, false claims for treatment that was not provided or for more complex and expensive treatment than was provided. Last week, Saravia was sentenced to three and a half months in prison, followed by one year of supervised release, and ordered to pay $561,141.89 in restitution. WWLP-22News, an NBC affiliate, began broadcasting in March 1953 to provide local news, network, syndicated, and local programming to western Massachusetts. Watch the 22News Digital Edition weekdays at 4 p.m. on Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
Yahoo
20-03-2025
- Business
- Yahoo
NeurAxis Reports Strong Fourth Quarter 2024 Financial Results Driven by a 43% Increase in Revenues
Conference call will be held today, Thursday, March 20 at 9:00 am ET CARMEL, Ind., March 20, 2025 (GLOBE NEWSWIRE) -- NeurAxis, Inc. ('NeurAxis,' or the 'Company') (NYSE American: NRXS), a medical technology company commercializing neuromodulation therapies for chronic and debilitating conditions in children and adults, today announced results for the fourth quarter and fiscal year 2024 for the period ended December 31, 2024. 4Q24 Financial highlights Revenues increased 43% to $761 thousand in 4Q24 compared to $531 thousand in 4Q23. Operating loss improved by 10% compared to the fourth quarter of 2023. Cash balance was $3.7 million as of December 31, 2024. Recent Operational Highlights Expanded total covered lives to approximately 51 million compared to 4 million as of December 31 2023. Received a new Current Procedural Terminology (CPT) Category I code for Percutaneous Electrical Nerve Field Stimulation (PENFS) procedures effective January 1, 2026. Received new FDA clearance for the expansion of IB-Stim label: to allow for a larger patient population beyond 11-18 years of age to 8-21 years. to increase devices per patient to 4 devices. Received 510(k) clearance from the FDA for its rectal expulsion device (RED) product. RED's innovative design simplifies anorectal function testing and can be used without interrupting clinical workflow. The Company has just begun the commercialization process and expects the first meaningful revenues in 2Q25. The Company remains committed to clinical research in the pediatric space, with 16 peer-reviewed publications. All studies were carried out in US children's hospitals using NeurAxis' PENFS technology. This level of evidence puts NeurAxis in a great position to continue expanding payor coverage and increasing adoption of the technology. Management Commentary Brian Carrico, Chief Executive Officer of NeurAxis, commented, 'Our strong performance in 4Q24 capped off a transformational year, as we significantly expanded insurance coverage for IB Stim, received a CPT Category I code for PENFS, nearly doubled our TAM for Pediatric FAB/IBS, and received 510(k) clearance for our RED device. These important accomplishments put us in an exceptional position to continue the outsized growth we have achieved in the last two quarters. Our growth prospects in the near and medium term are robust and extend across multiple products and indications, and combined with disciplined cost management, have set the stage for achieving cash flow breakeven. Notably, recent investments from life science-focused funds have bolstered our balance sheet, providing the financial strength to accomplish our objectives. 'Positive policy coverage for approximately 51 million lives now exists, with numerous payers actively engaged in the review and policy development process. Our progress is increasingly reflected in the numbers. Over the past 12 months, more than 1,000 pediatric patients have been treated, representing just over 0.1% of the 600,000 children in the U.S. suffering from debilitating IBS and in urgent need of IB-Stim. Revenue growth has been robust, with a 43% year-over-year increase in 4Q24, building on the strong momentum of Q3's 40% sales surge. This upward trajectory has continued into 1Q25. 'Looking ahead, we expect the upcoming publication of academic society guidelines to drive significant insurance policy coverage as we look to have the majority of children in the US covered for treatment. This remaining policy coverage, coupled with the implementation of the Category I code on January 1, 2026, are the two milestones we have been working toward since the beginning to allow large-scale growth nationally. Additionally, we have submitted for FDA clearance for Functional Dyspepsia in children and we are cautiously optimistic in receiving this expanded indication for our PENFS technology in 2025. If successful, this will double our total addressable market in the pediatric market. Our vision is clear, and we will continue to hit the remaining milestones in order to achieve our growth and revenue expectations.' Fourth Quarter and Fiscal Year 2024 Financial Results Revenues in the fourth quarter of 2024 were $761 thousand, up 43% compared to $531 thousand in the fourth quarter of 2023. Unit sales increased approximately 45% due to growth from patients with full insurance reimbursement and the Company's financial assistance program that offers discounts for patients without insurance coverage. The Company continues to see great improvements in recent months, gaining positive policy coverage for the PENFS technology, and recent results are indicative of that success. Revenue in fiscal year 2024 was $2.7 million, an increase of 9% compared to $2.5 million in fiscal year 2023. Unit sales increased approximately 19% due to continued growth of the Company's financial assistance program. Gross margin in the fourth quarter of 2024 remained steady at 86.4% during the fourth quarters ended December 31, 2024 and 2023. The Company maintained its gross margin by growing its higher margin full insurance reimbursement program to offset the growth of devices delivered through the discounted financial assistance program. Gross margin in fiscal year 2024 of 86.5% declined 120 basis points compared to 87.7% in fiscal year 2023 due to growth in device deliveries from the Company's financial assistant programs. Selling, general and administrative expenses in the fourth quarter of 2024 were $2.1 million, an increase of 2% compared to $2.0 million in the fourth quarter of 2023. The increase was due to the hiring of key personnel and the introduction of a short-term incentive plan in fiscal 2024, mostly offset by lower third party service costs. Selling, general and administrative expenses in fiscal year 2024 were $9.5 million, an increase of 7% compared to $8.8 million in fiscal year 2023. The increase was due to the hiring of key personnel, the introduction of a short-term incentive plan and the annualization of public company costs, one-time severance and advisory costs, partly offset by post-IPO consulting and recruiting fee and IPO bonuses that did not recur in 2024 as well as lower third party service costs in 2024. Operating loss in the fourth quarter of 2024 was $1.5 million, an improvement of 10% compared to $1.6 million in the fourth quarter of 2023. Operating loss in fiscal year 2024 was $7.2 million, an increase of 7% compared to the $6.7 million for the full year of 2023. Net loss in the fourth quarter of 2024 was $1.5 million, a decrease of 73% compared to $5.3 million in the fourth quarter of 2023 primarily due to a lower operating loss and a $3.7 million charge related to the extinguishment of debt upon the Company's IPO in 2023. Net loss for the full year 2024 was $8.2 million, a decrease of 44% compared to the $14.6 million for the full year of 2023 primarily due to the absence of debt discount, issuance cost and debt extinguishment charges triggered by the Company's IPO in 2023 partially offset by a higher operating loss. Cash on hand as of December 31, 2024, was $3.7 million. Although the Company had no long-term debt as of December 31, 2024, short-term debt of $154 thousand represented a note payable related to the financing of business insurance premiums. Cash used in operations in fiscal year 2024 of $6.1 million was $595 thousand lower than in fiscal year 2023 primarily due to more issuances of common stock instead of cash for certain services and lower interest payments. Conference Call Details Date and Time: Thursday, March 20, 2025, at 9:00am ET Live Webcast Information: Interested parties can access the conference call via a live webcast, which is available in the Investor Relations section of the Company's website at or For participants listening through the webcast, questions can be sent in through the portal using the 'Ask a Question' link or by emailing questions to NRXS@ Call-in Information: Interested parties can also access the live conference call by initially registering at the following link. Upon completion of the registration link, call-in participants will receive the dial-in info and a unique PIN to join the call as well as an email confirmation with the details. Replay: A webcast replay will be available in the Investor Relations section of the Company's website at or About NeurAxis, Inc. NeurAxis, Inc., is a medical technology company focused on neuromodulation therapies to address chronic and debilitating conditions in children and adults. NeurAxis is dedicated to advancing science and leveraging evidence-based medicine to drive the adoption of its IB-Stim™ therapy, which is its proprietary Percutaneous Electrical Nerve Field Stimulation (PENFS) technology, by the medical, scientific, and patient communities. IB-Stim™ is FDA-cleared for functional abdominal pain associated with irritable bowel syndrome (IBS) in adolescents 8-21 years old. Additional clinical trials of PENFS in multiple pediatric and adult conditions with large unmet healthcare needs are underway. For more information, please visit Forward-Looking Statements Certain statements in this press release are forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended. All statements other than statements of historical fact are forward-looking statements. Forward-looking statements are based on management's current assumptions and expectations of future events and trends, which affect or may affect the Company's business, strategy, operations or financial performance, and actual results and other events may differ materially from those expressed or implied in such statements due to numerous risks and uncertainties. Forward-looking statements are inherently subject to risks and uncertainties, some of which cannot be predicted or quantified. There are a number of important factors that could cause actual results, developments, business decisions or other events to differ materially from those contemplated by the forward-looking statements in this press release. These factors include, among other things, the conditions in the U.S. and global economy, the trading price and volatility of the Company's stock, public health issues or other events, the Company's compliance with applicable laws, the results of the Company's clinical trials and perceptions thereof, the results of submissions to the FDA, the results of the shareholder vote to enable the issuance of the Preferred Stock, and factors described in the Risk Factors section of NeurAxis's public filings with the Securities and Exchange Commission (SEC). Because forward-looking statements are inherently subject to risks and uncertainties, you should not rely on these forward-looking statements as predictions of future events. These forward-looking statements speak only as of the date of this press release and, except to the extent required by applicable law, the Company undertakes no obligation to update or revise these statements, whether as a result of any new information, future events and developments or otherwise. For contraindications, precaution, warnings, and IFU, please see: For important RED information, including indications, precautions, and contraindications, visit: Contacts: CompanyNeurAxis, Investor Relations Lytham PartnersBen Shamsian646-829-9701shamsian@ NeurAxis, Inc. Condensed Statements of Operations Twelve Months Ended December 31, 2024 2023 Net sales $ 2,685,925 $ 2,460,049 Cost of goods sold 362,002 303,345 Gross profit 2,323,923 2,156,704 Selling expenses 324,708 323,569 Research and development 206,107 169,315 General and administrative 8,949,925 8,328,315 Operating loss (7,156,817 ) (6,664,495 ) Other (expense) income: Financing charges (230,824 ) (2,772 ) Interest expense, net (174,328 ) (476,416 ) Change in fair value of warrant liability (941 ) 844,854 Change in fair value of derivative financial instruments - 198,551 Amortization of debt discount and issuance costs (126,387 ) (4,881,622 ) Extinguishment of debt liabilities - (3,649,561 ) Other (expense) income, net (552,204 ) 4,778 Total other (expense) income, net (1,084,684 ) (7,962,188 ) Net loss $ (8,241,501 ) $ (14,626,683 )
Yahoo
11-03-2025
- Health
- Yahoo
Opinion - Want to reduce the cost of healthcare? Start with our billing practices.
Robert F. Kennedy Jr., as the new secretary of Health and Human Services, is the nation's de facto healthcare czar. He will have influence over numerous highly visible agencies, including the Centers for Disease Control and Prevention, the National Institutes of Health and the Food and Drug Administration, among others. Given that healthcare is something that touches everyone's life, his footprint of influence will be expansive. Our nation's healthcare system is fragile, in a constant state of teetering on the edge between precarious functionality, financial insolvency and, for some clinics, operational collapse. As with many large systems in our country, finances rule the roost. 'No margin, no mission' is the mantra of many healthcare organizations. This means that every patient interaction with a healthcare provider ultimately includes the omnipresent hand of health insurance policy rules, inconspicuously but persistently imposing its influence in how they authorize any recommended or prescribed treatments by healthcare providers. In some healthcare organizations, providers are required by their clinic to generate as much revenue as possible. Revenue is earned based on the classification of healthcare services and products, which are mapped into Current Procedural Terminology or CPT codes. These codes are in turn measured by relative value units — the more units billed, the more revenue accrued by clinicians and their employers. There were more than 11,000 CPT codes available in 2024. The way clinicians code each service during patient interactions ultimately determines how much they can bill and how much patients' health insurance will pay. Such a system implicitly provides a structure to value medical skills and services. It is impossible to evaluate a screening for prostate cancer (code 84153), an X-ray exam of an infant's arm (code 73092) or a cardiac shunt imaging (code 78428) on the same scale. Yet the Relative Value Unit system effectively creates such standardization, taking a basket of bananas, oranges and apples and assigning each a value as if they were all grapes. How is this achieved? An American Medical Association committee creates a single financial measure across the diverse swath of medical treatments, determined by factors including time, intensity and cost. The benefit of such standardization is that health insurance companies and the Centers for Medicare and Medicaid Services can pay for services based on it. Such a payment model unfortunately encourages some clinicians to find ways to bill certain procedures, even if they have limited healthcare value. Good medicine for patients should drive billing, not the other way around. Moreover, every type of physician has its own set of codes and values. For example, surgeons perform surgery, cardiologists perform cardiac catheterizations, and primary care physicians perform wellness visits. The value assigned to activities associated with each specialty may contribute to physician satisfaction, or dissatisfaction. It may also influence how medical students choose their specialties. The assigned values may even be a factor driving the looming shortage of all physicians and specialists. Healthcare is big business in our nation. Given that the per capita cost of healthcare in the United States is higher than any other country, yet our health outcomes are middling or poor, by several measures, one must ask whether all those healthcare dollars are delivering better population health. The data suggest that they are not. Unraveling financial motives from medical decision-making is a challenge. Indeed, CPT codes should be used to classify health services, their intended purpose. A focus on creating wellness rather than treating sickness would incentivize healthcare providers to grow their prevention practices and reduce the necessity for treatment. This can be captured in the value assigned for such efforts. The current state of healthcare in our nation is unsustainable. Simply injecting more money into the system is bad for medicine and bad for the economy. Secretary Kennedy has an opportunity to make a difference. One place to look is the CPT codes and how the relative values are set, to determine if they are placing 'carrots' for healthy living in the appropriate places within our healthcare system or paying for services and products that treat disease without encouraging wellness. Changing the compensation model for healthcare providers will not be easy. The Centers for Medicare and Medicaid Services rely on CPT codes. Many countries around the world also use them, with claims that they reduce costs. Yet per capita healthcare costs in the United States are at least 40 percent higher than in other wealthy countries. The U.S. also spends at least 2.5 times more on the cost of administration than such countries. Clearly, something is not working. The CPT codes may be innocent bystanders, given how they are being used and valued. Without new models for compensation, every person who receives healthcare services will be affected at some point in their life. If Secretary Kennedy can revamp procedures' valuations in this way — perhaps even by taking ownership of committee that assigns them — the healthcare system may even heal. The best path forward may not always be the easiest. However, a new path forward is imperative. Sheldon H. Jacobson, Ph.D., is a computer science professor in the Grainger College of Engineering and the Carle Illinois College of Medicine at the University of Illinois Urbana-Champaign. He applies his expertise in data-driven risk-based decision-making to evaluate and inform public policy and public health. Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
