State Economics and University Status Drive a Two-Tiered Medicare Reimbursement System for Vascular Surgery.

INTRODUCTION: The financial sustainability of vascular surgery programs relies heavily on Medicare reimbursement, yet structural policies may create significant disparities in payment rates unrelated to clinical care. While geographic variation in spending is well-documented, the specific influence of institutional prestige and regional economics on per-procedure pricing remains under-examined. This study analyzed national payment data to determine if these factors create a policy-driven "two-tiered" reimbursement system independent of patient acuity. METHODS: A cross-sectional analysis of the Fiscal Year 2022 CMS Inpatient Prospective Payment System (IPPS) Provider Summary File was performed. The cohort included 1,402 hospitals performing "Other Vascular Procedures" (MS-DRGs 252-254). Hospitals were classified by institutional status (Academic vs. Community) and rurality (Urban, Large Rural, Small Rural). State-level economic capacity was quantified using Bureau of Economic Analysis Healthcare GDP data. Multivariable linear regression assessed the independent impact of these structural factors on the average Medicare payment per discharge. A sensitivity analysis restricted to MS-DRG 253 was conducted to control for case mix. RESULTS: Significant geographic and institutional disparities in reimbursement were identified. Mean payments varied more than two-fold by state, from a low of $15,652 in Arkansas to $35,873 in Maryland, and correlated strongly with State Healthcare GDP (r = 0.38; p = 0.006). In the multivariable model, Academic status was an independent predictor of higher reimbursement, conferring a $4,501 premium per episode over community hospitals (p < 0.001). This premium persisted at $3,890 (p < 0.001) even when controlling for patient acuity (MS-DRG 253). Conversely, rural status was not a significant predictor of price (p = 0.716), yet rural hospitals were clustered in the ultra-low volume decile (<15 cases/year). CONCLUSIONS: Medicare reimbursement for vascular surgery operates as a two-tiered system defined by regional economics and institutional prestige rather than clinical efficiency. Academic centers enjoy a significant structural premium, whereas rural hospitals face an existential volume crisis despite receiving price parity. Preserving rural limb salvage access will likely require volume-independent funding models rather than standard fee-for-service adjustments.