Episode Transcript
[00:00:00] Intro music.
[00:00:13] Welcome back to the Stimulating Stuff podcast. I'm your host, Rich Vogel, and this episode is going to be off the charts.
[00:00:21] That right there is a pun, a double entendre, a play on words and a witticism all rolled into one.
[00:00:30] Here's why. Today I'm answering the question, how many neuromonitoring cases are there out there? A lot of people have an idea in their head and the range is all over the place. And that's mostly because it's shockingly difficult to pin down an answer. So I'm going to share some data, some insights, and some graphs or charts.
[00:00:54] That's why it's going to be off the chart.
[00:00:59] Also, this is a very popular topic that few people know how to address, so I think my listenership is really going to pop here across all platforms and services.
[00:01:11] I have like a couple thousand listeners from over 30 different countries and today is my first day broadcasting in video.
[00:01:23] Look who's coming up!
[00:01:25] So how do we address this question about neuromonitoring case volume?
[00:01:30] Well, there are a few ways to go about it and all of them suck. But I think I found a way to zero in on the number and I have some data that I think is going to shock you in more ways than one.
[00:01:46] So let's dive in.
[00:01:48] I think there are a few different ways that we can go about zeroing in or trying to zero in on neuromonitoring case volumes. And the first one is large databases.
[00:02:03] So an example database is the nationwide inpatient sample or the nis.
[00:02:09] And this constitutes really what is the largest all patients payer. So all insurance payer inpatient database in the U.S. and it represents approximately a 20% sample of discharges from U.S. hospitals.
[00:02:29] And it's weighted to provide national estimates.
[00:02:34] And my understanding is that the data come from hospital based coders. So these are people who work in the hospital and their job is to code the services that happen within the hospital and send those codes to insurance companies. And these folks, they are incentivized to maximize reimbursement for the hospital and their physicians using ICD and CPT codes.
[00:03:00] The problem is that hospitals may not code for neuromonitoring because it's not high paying, certainly compared to other codes for other services.
[00:03:13] Also on the academic side. So what we sometimes call in house neuromonitoring, the hospital may not even bill or code for neuromonitoring at all because neurologists may be doing other work at the same time, like in clinic or reading EEGs. And that other work brings in more RBUs. But they are not allowed to bill for neuromonitoring if they're doing other work, because the American Medical association, the AMA, and the definition of the CPT code for neuromonitoring says that they must be solely dedicated to monitoring, at least for the time component. So they probably don't bill for that on the outsourced side. So, you know, hospitals, 75% to 80% of all neuromonitoring is conducted by outsourced companies. Right. There's no incentive for the hospital to code at all.
[00:04:10] So technical services companies who have contracts with neurologists, or they may even employ their own neurologists, those things are unlikely to make their way to the national inpatient sample.
[00:04:25] So the bottom line is there's really no way to estimate the number of neuromonitoring cases using the nis.
[00:04:33] But that certainly hasn't stopped people from trying. And I will tell you that the literature is absolutely fascinating, filled with horseshit. Speaking of which, another example database is called Pearl Diver.
[00:04:46] And this is a database that essentially aggregates de identified insurance claims data from multiple sources, including commercial insurers like Humana and United Healthcare, as well as government programs like Medicare.
[00:05:04] And there's a lot of studies in the literature that use Pearl Diver to make claims about neural monitoring. But the problems with this database are several. I think, you know, the first one is the database has evolved over time with different versions of the database incorporating various data sources, and that limits the consistency and the completeness of the information available.
[00:05:34] And it uses ICD and CPT codes, but it often doesn't include all codes for a procedure.
[00:05:41] So why might that be?
[00:05:45] Well, the database is primarily composed of claims that are paid rather than claims that are submitted for payment. And I think this distinction is really important and it's been the subject of a lot of criticism, particularly in studies where the exclusion of unpaid claims may lead to selection bias.
[00:06:10] So what do I mean by paid and unpaid claims? So paid claims means that. So these are claims that are submitted to the insurance company for, for example, for neuromonitoring.
[00:06:24] So they're, they're submitted to the insurance payers and they have been approved and the service has been reimbursed. So if you work for a company and you provided neuromonitoring, they submitted that claim to the insurance company and the insurance company actually reimbursed them for it.
[00:06:43] Submitted claims is exactly what I just said a second ago. These are claims that the healthcare providers submit to the insurance payers for reimbursement regardless of whether or not they're paid.
[00:06:55] And this would actually be more representative of the actual number of patients receiving neuromonitoring if a database like Pearl Diver actually included them.
[00:07:05] So I'll give you an example from the literature. There's a paper from 2016 that was highly criticized by a lot of people, including myself, with letters to the editor about it. And it's by. I can never say this person's name, but it's Ajiboye A J I B O Y E and colleagues. And they use the Pearl Diver database to identify that number of ACDF that included neural monitoring between the years of 2007 and 2014.
[00:07:37] Okay, keep that in mind. So we're talking about eight years total.
[00:07:42] That includes 2007 and includes 2014. So that's why it's eight years. And they found across the country the total number of ACDF that they said were monitored was 2600.
[00:07:58] Now we know that that's basically a joke because a single large neural monitoring company would likely have monitored over 20,000 ACDFs in 2014 alone. So that shows how bad that database is. And they use these data to argue that neuromonitoring was on a significant decline, which we also know is they. This is a prime example of selection bias.
[00:08:25] We all know that reimbursement for neural monitoring from insurance companies has been on the decline and insurance simply doesn't pay for neuromonitoring in some cases.
[00:08:35] So basically Pearl Diver is no help. Again, horseshit.
[00:08:41] Another example of a database is called MarketScan. It's very similar to Pearl Diver, but it has a wider scope. And I only mentioned this database because there's a new publication out just a couple months ago. I'm recording this June 11, 2025. And I think within the last two or three months this new paper came out and it is looking at the utilization of neuromonitoring. It's actually a pretty good paper. The data are in this database, they're quality controlled during the database creation and the data are based on fully paid and adjudicated claims. So it has the same problem as Pearl Diver. Isn't that interesting? So this paper that came out, it was by Ivan Sanchez Fernandez and colleagues out of Boston University and they looked at neuromonitoring utilization in several surgical categories in the US during a period from 2006 to 2022.
[00:09:44] So they use MarketScan and that consists of information from patients who have essentially employer sponsored private insurance.
[00:09:56] So here's a few interesting things that came from this paper. And I want to go through the surgical categories and look at my notes here. So looking at the year 2022, so that we're just going back like three years here and a few different surgical categories. The first one is cerebella pontine angle tumors. They found that 50% of those included neural monitoring, carotid endoterectomies, 20% of those included neural monitoring, tethered cord 50%, spinal fusion 70%, and aortic aneurysm repair, less than 5%.
[00:10:37] Now, remember, these are commercial claims, doesn't include Medicare.
[00:10:41] So that likely means that surgeries like carotid endarterectomies and aortic aneurysm repairs that tend to be older patients are probably highly underreported. So that's why CEA was 20% and aortic aneurysms was like less than 5%. But in general, they found that the proportion of patients with any neuromonitoring has been increasing significantly over the years, except for those aortic aneurysms, in which case they argue that it's been decreasing. But anyway, so there was, by their report, substantial variability in the technique, in the techniques used in each surgery. And by this I mean the combination of modalities. And only a minority of patients, they said, Sorry. Only a minority of patients, they said, received a multimodality combination of neuromonitoring tests that would be considered optimal for each surgery. So I thought that was really interesting.
[00:11:51] So overall, we can use these large databases to get a sense of utilization in certain classes of patients under certain conditions. But it's really difficult to rely on these databases to understand neuromonitoring case volume in the United States.
[00:12:09] So where else can we get data?
[00:12:12] Well, one of them is from neuromonitoring specific databases.
[00:12:17] So you all know us, Mon and Zinia X, and we can go to them, for example, and we could say, how many patients are in your database from this year?
[00:12:27] And that would give us a pretty good cross section, mostly from outsourced companies. Not all of them use it. Some of them have their own proprietary databases.
[00:12:37] But even so, those companies would be need to be willing to share their data and their information.
[00:12:44] And it wouldn't include large academic centers and like I said, other private companies that have their own proprietary database.
[00:12:55] We could also go to neuromonitoring companies and we could ask them, how many patients did you monitor last year? I can tell you that very few would be truthful or even share that information.
[00:13:09] Hospital employees, in talking to them, they rarely know how many patients they monitored in the last year. And from private company perspective, there are so many of them.
[00:13:21] I mean, I know this field pretty well and I don't even know all the companies out there, probably hundreds of them. I just learned of a new one yesterday, so that's a problem.
[00:13:33] Excuse me.
[00:13:35] We could also ask device companies, how many neural monitoring devices did you sell last year or are out there in the field?
[00:13:45] Or if they, if they had a per click license instead of an annual license, we'd be able to ask that. But I'm not sure that we would really get the information that we're looking for from that. There's probably more systems are there, there's probably more systems out there than there are technologists.
[00:14:05] So it would be hard to kind of capture that information from device companies.
[00:14:12] But another way that we can do this is we can count the number of semens.
[00:14:19] So I asked the question and I'm going to walk you through this because I think the data that I'm about to show you is just absolutely fascinating.
[00:14:30] So I started by asking the question, how many active CNIMs are there right now in June of 2025?
[00:14:41] And these are people who are not expired and they are not emeritus status, which there are very few emeritus and all of them are retired.
[00:14:53] And I'm going to show you a graph here.
[00:14:56] And as you can see, the number of active semens has increased pretty steadily since inception of the CNIM exam back in 1996. And today there are 4274 active semens.
[00:15:17] So with this information in mind, we can ask how many cases were monitored this year or last year by the average cnm?
[00:15:30] Now we have to make a few assumptions in order to do this.
[00:15:34] Assumption number one is that the number of non certified technologists that are out there monitoring in a given year is approximately equal to the number of CNM certified technologists who no longer monitor cases either because they left the field or they were promoted to management. And hey, I'm one of them. I have a cnim, I haven't monitored a patient in eight years, seven years.
[00:16:07] Assumption number two is that the number of sea names outside the United States is negligible.
[00:16:16] And after doing a ton of research, I basically identified that there's less than 100.
[00:16:22] So I, I, I did searches for example for Sinims working in Canada, Mexico, Brazil, the UK, France, Germany, Australia, China, India, Singapore, Thailand, United Arab Emirates and Saudi Arabia. And the Results revealed less than 100.
[00:16:46] Okay.
[00:16:47] And then another assumption that we have to make is that there are high and low estimates.
[00:16:55] So I think generally if you talk to a neuromonitoring company about where they like their utilization to be, it's somewhere between 15 and 16 to 20 surgeries per month per tech.
[00:17:12] So what I did was essentially I took a high and low range of 180 to 240 annual cases per technologist per certified CNM technologist.
[00:17:28] Okay. Then I did some market research which, you know, I guess technically I've been doing for like 15 years now, acquiring personal knowledges, knowledge of cases monitored by major corporate and academic institutions.
[00:17:46] And then I also had to do a couple of adjustments for like 2020 and 2021 because of lost volume due to COVID 19.
[00:17:58] But basically I can use this information to build a graph with high and low estimates the total number of cases monitored in the US And I can go back in time with these data to estimate the growth of neuromonitoring. And I'm going to show you a graph here. I did this for 2014 through 2024 and this is what it looks like.
[00:18:25] So using this method, I found the 2024 volume to be between 750,000 and just over 1 million monitored cases in the United States in 2024.
[00:18:44] Now this does not include at least 50,000 spine surgeries using surgeon directed monitoring in the US an unknown number of ENT procedures where the surgeon is essentially doing their own monitoring.
[00:18:59] And obviously it doesn't include the rest of the world outside of the U.S. but hey, let me stop here and say this.
[00:19:06] If you live in a country outside the United States and you have a pretty darn good understand of the number of cases that are monitored in your country, please shoot me an email. I would love to be able to include this in a worldwide demographic email address.
[00:19:26] Stimulating stuff. Podcast gmail.com okay, so here's where the data get really interesting because I can start to forecast projections for growth of neuromonitoring over time and how it's going to impact the CNN workforce.
[00:19:44] So the growth of neuromonitoring case volumes from 2014 to 2024.
[00:19:50] If, if I.
[00:19:53] So if I look at 2014 and I look at 2024 and I calculate essentially on average how much should it grow per year, that comes out to about 4.87%. So that is the compound annual growth rate or CAGR.
[00:20:12] And then I can look at external resources. So a 2016 neuromonitoring market report by Grandview Research projected that the US neuromonitoring market would grow at a CAGR of 4.79%.
[00:20:27] Isn't that interesting? So I based my data on the number of sinims and the average number of cases or range of cases that they monitor per year. And then I went back in time looking at the number of sinims. And I built what I thought was the number of cases and the growth of volume over time.
[00:20:47] And then I went back in time and I looked at this market report from 2016 that predicted that the volume would grow over the next 10 years to 2025 at a rate that was almost identical to the one that I found going back in time with a number of SEMs.
[00:21:09] Okay, so now we can bring in new data.
[00:21:13] So looking at recent market reports that are out there, for example, there's one from 2023 by the Allied Market Research and another one from 2025. This is brand new from Grandview Research.
[00:21:29] They projected that the neuromonitoring market would grow at an annual rate of between 5.97 and 6.1 respectively.
[00:21:43] So right around 6%.
[00:21:46] And then I can. So taking the case volumes that I believe we're at today and the high and low estimates of the number of cases that an average CNM certified technologist monitors in a year between 180 and 240, I can start to build projections. Right.
[00:22:07] And then I also did some market research, you know, personal knowledge, everything that I said before.
[00:22:14] And then I can also include some potentially relevant data.
[00:22:20] For example, spine surgery.
[00:22:23] Spine surgery comprises somewhere between 70 and 80% of neuromonitoring volume in the U.S.
[00:22:30] multiple reports, and again, these are third party market reports suggest that spine surgery volume in the US will increase 30, 40% over the next 10 years.
[00:22:44] The US spine market is expected to grow at a compound annual growth rate of 4.19% from 2024 to 2031. I can also look at brain surgery, which comprises, I don't know, maybe about 10% of neural monitoring volume in the U.S. and again, multiple reports suggest that brain surgery in the US will increase by 25 to 30% over the next 10 years and that CAGR is 4.5% going from 2024 to 2034. And then I can also think of other things. For example, there's more knowledge today that neuromonitoring is actually improves patient safety. There are aging surgeons who don't historically use neuromonitoring that are retiring and essentially being replaced by younger surgeons who have never gone without it.
[00:23:42] And there's also increased medical legal scrutiny of surgeons who don't use neuromonitoring. So I can kind of put all of these things together, right? But basically I didn't include those specific numbers in my analysis. But what I did was I built forecasts for the next 10 years using annual growth rates of 4.87%, which is essentially where we have been over the last 10 years, and 6%, which is where market reports suggest we will be. And here are the graphs.
[00:24:19] So first here is the 4.87% graph. And you can see that by 2035, starting where we are now, we'll be somewhere between 120 and 160 ish thousand cases per year. By 2035 when I use the 6% CAGR.
[00:24:41] Let's look at this graph here.
[00:24:44] You can see that by 2035 we could be close to 2 million cases.
[00:24:53] So that I think is really interesting alone. But then I started to think, you know, I know there's a bunch of people out there getting CNIMs each year, right? But I also don't really know how many people are letting their credentials expire.
[00:25:14] And so I wondered how many new CNMs. So what's the delta? How many new CNMs are being added to the pool in order to cover the anticipated volume, the anticipated increase in surgical volume that's coming.
[00:25:32] And as it turns out, the numbers have been declining.
[00:25:37] So for example, in 2016 we added just over 250 new CNIMs to the pool. So remember, this is the delta. This, this accounts for those who expired 250 new ones in 2016.
[00:25:54] And I'm going to show you a graph here.
[00:25:57] But in 2024 we only added 100.
[00:26:02] So the Delta is decreasing. And this graph shows a trend line that if we stay on this path, we will be losing more sinims than we add by 2029.
[00:26:15] And by 2035 we'll have 150 less credentialed technologists than we do today if this trend continues.
[00:26:28] So actually I want to show you another graph here. This just shows the projected CNM workforce based on the linear delta trend that I showed you in the last graph. And you can see that we will see, we will continue to see the new, the, the pool of CNIMs increasing over time to about 2028 or 2029. And then it's going to start to decrease, as you can see here.
[00:27:02] So then I asked what I think is probably the most important or interesting question that our field needs to consider.
[00:27:13] So with the anticipated increase in neuromonitoring case volume and considering the anticipated number of available credentialed technologists, when are we going to hit our inflection point? When we don't have enough CNIMs to monitor the volume of cases?
[00:27:33] Or another way to think about it is at what point is the average CNIM going to have to start monitoring well over 240 cases per year, like significantly increase their volume? And the answer is 2027. Look at this graph.
[00:27:50] So basically what you're seeing here is that there's this red area, this pink area is where the unmet demand is.
[00:27:59] And so you can see that the black line is the projected case volume, the dotted blue line is the workforce. So the number of credentialed technologists and or essentially not the number of technologists, but their capacity, their annual capacity for monitoring cases with a cap of 240 and the green shows where we're basically meeting the demand, and the pink shows where the demand is unmet. And we have two options. We can basically significantly ramp up the number of texts that are out there, or we can find other resources to, to, to, to supplant them or to support them, whatever it is. So finally, I wondered how many new technologists are going to need to be credentialed to enter the field to keep up with the demand.
[00:29:02] And the results were shocking.
[00:29:06] Look at this graph.
[00:29:08] By 2036, we will need to be adding 3,000 new technologists every year if we want to stay within that sweet spot of 180 to 240 cases per year. Basically the workforce needs to double in the next 10 years.
[00:29:29] So as I was working through this, I just thought, man, I got to share this with my podcast audience and I thought you'd find it really interesting. But here's my ask number one, challenge me on these data if you think I'm wrong. Tell me why, Tell me what information you have. Let's get this right. The second one is, and I said it before, but if you work outside the US and you have a good idea, I mean a really good idea of the number of monitored surgeries in your country, and I'm talking about by people, not by surgeon directed systems. Although I'll take that too.
[00:30:07] Please email me and let me know. I'd like to compile a database and just keep updating you all on these numbers.
[00:30:15] And yeah, I mean, I just want to be challenged on this. If you have real solid information or if you have a different way of thinking, about it, please let me know. I'd love to hear from you.
[00:30:30] Okay, so that's it for today. Thank you so much for listening. Please continue sending me your comments, insights and thought provoking questions to stimulating stuff. Podcastmail.com I always love hearing from you. I'm Rich Vogel and I do believe that was stimulating stuff.
[00:30:56] Sa.
