Surgeries getting longer as cases grow more complex

Despite advances in surgical techniques, operating times have grown longer as surgeons care for more difficult, high-risk patients, new research shows. 

The finding contradicts the Centers for Medicare & Medicaid Services claim that surgery times have gotten shorter — a justification the agency has put forth for proposed cuts in reimbursements to surgeons. (See proposed rule in the Federal Register, starting on page 196).

The proposed payment cuts, which CMS calls an “efficiency adjustment,” would reduce reimbursement for many physician services, including all surgical procedures, by 2.5% starting in 2026.

“We found no evidence that operative times have decreased over the past five years,” said lead author Dr. Christopher Childers, an assistant professor of surgery at the University of Washington School of Medicine. “In fact, we found the opposite: Overall operative times have gone up by about 3%.”

Childers is a cancer surgeon who specializes in liver, pancreas and biliary surgery.

The longer operations are a likely result of surgeons taking on more difficult cases, he said. “Our cases are getting more complex and our patients older and with more chronic diseases.”

The paper was published Aug. 13 in the Journal of the American College of Surgeons. 

Childers and colleagues analyzed data from 1.7 million surgical procedures performed from 2019 to 2023. The data, from about 700 U.S. institutions, was collected by the American College of Surgeons’ National Surgical Quality Improvement Program. The analyses of 11 surgical specialties included such common procedures as appendectomies, hernia repairs and hysterectomies.

The complexity of cases was determined by factors such as age, obesity and chronic conditions, including high blood pressure, diabetes and heart disease.

The researchers found that, from 2019 to 2023, overall operative times rose, not fell, increasing by about 3.1%, on average. For 90% of the procedures studied, operative times were the same or longer than they had been five years prior.

Over the same five-year period, case complexity increased as surgeons cared for more patients who were older and sicker.

“Advances in surgical care have allowed surgeons to successfully operate on patients who in earlier eras might have been deemed too risky to undergo surgery,” Childers said. “Despite this, we’re seeing reduced mortality and fewer readmissions to the hospital.”

The current CMS proposal is in line with the agency’s recent efforts to increase payments for primary-care providers. However, because the reimbursement fee schedule has a fixed budget, an increase for one group requires a decrease for another.

“This unfortunately pits every specialty against one another,” Childers said. “The current proposal is another attempt to take from specialists and give to primary-care providers.”

CMS has argued that improved efficiency has sped and simplified many procedures in justifying the proposal to lower reimbursements for specialists who perform high-cost procedures. Childers suggested, however, that payments to physicians, unlike those to healthcare organizations, already have a built-in reduction: they are not adjusted for inflation.

“Physician payments have never been indexed to inflation, and so we already take a pay cut every year,” he said. For example, in 1998 a surgeon got paid around $320 to remove an appendix. In 2025, surgeons get paid $305, Childers said. 

“Do I think improvement should be made to the physician fee schedule? Sure, absolutely,” he added. “But to make blanket, across-the-board cuts without any empiric evidence to justify it doesn’t make any sense.”

The paper’s senior author is Dr. Thomas C. Tsai, associate professor in the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health in Boston.

Written by Michael McCarthy.

For details about UW Medicine, please visit http://uwmedicine.org/about.