The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis.

BACKGROUND: Flap-based breast reconstruction demands greater operative labor and offers superior patient-reported outcomes compared with implants. However, use of implants continues to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments. METHODS: Using the Blue Health Intelligence database from 2009 to 2013, patients were identified who underwent tissue expander (i.e., implant) or free-flap breast reconstruction. The implant-to-flap ratio and physician payments were assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method. RESULTS: A total of 21,259 episodes of breast reconstruction occurred in 122 U.S. markets. The distribution of implant-to-flap ratio varied by market, ranging from the fifth percentile at 1.63 to the ninety-fifth percentile at 43.7 (median, 6.19). Modeling the implant-to-flap ratio versus implant payment showed a more elastic quadratic equation compared with the function for flap-to-implant ratio versus flap payment. Probability modeling demonstrated that switching the reconstructive method from implants to flaps with a 0.75 probability required a $1610 payment increase, whereas switching from flaps to implants at the same certainty occurred at a loss of$960. CONCLUSIONS: There was a correlation between the ratio of flaps to implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a relative value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort

Impact of Contralateral Symmetry Procedures on Long-Term Patient-Reported Outcomes following Unilateral Prosthetic Breast Reconstruction.

BACKGROUND:  One aim of unilateral postmastectomy breast reconstruction (BR) is to restore symmetry with the contralateral breast. As such, unilateral prosthetic reconstruction often requires a contralateral symmetry procedure (CSP). There is sparse literature on the impact of CSPs on long-term patient-reported outcomes (PROs) such as satisfaction and health-related quality of life (HRQoL). This study aims to describe PROs following CSPs, using a validated PRO tool, BREAST-Q. The hypothesis is that CSPs are associated with greater patient-reported satisfaction and HRQoL. METHODS:  This study is a single institutional analysis of prospectively collected BREAST-Q scores of patients who underwent unilateral prosthetic BR during 2011 to 2015. Women 18 years and older with BREAST-Q scores measured ≥ 9months after BR with or without CSP(s) at the time of expander replacement were included. Patients were classified into four subcohorts: augmentation, mastopexy, reduction, and no symmetry procedure (controls). Sociodemographic, clinical characteristics, and BREAST-Q scores were analyzed. Multivariable linear regression was performed. RESULTS:  Of 553 patients, 67 (12%) underwent contralateral augmentation, 68 (12%) mastopexy, 93(17%) reduction, and 325 (59%) were controls. Mean follow-up time was 52 months. Satisfaction with breast and outcomes were higher in the augmentation compared with the control groups ( CONCLUSION:  Prosthetic reconstruction with contralateral breast augmentation was associated with greater satisfaction with breast and reconstructive outcome. In contrast, breast reduction and mastopexy procedures demonstrated equivalent satisfaction with breasts compared with controls but may be associated with lower physical well-being. Such information can be used to improve the shared decision-making process for women who choose unilateral prosthetic BR

Trends in Physician Payments for Breast Reconstruction.

BACKGROUND: Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction. METHODS: The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models. RESULTS: There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p \u3c 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to$2378) compared with -1.8 percent (from $3858 to$3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus$987 for tissue expanders). CONCLUSIONS: The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers

The Impact of the Cosurgeon Model on Bilateral Autologous Breast Reconstruction.

BACKGROUND: Microsurgical breast reconstructions (MBRs) are time and labor intensive procedures. To circumvent these barriers, plastic surgeons have started working together as cosurgeons (CSs). This study aims to evaluate the impact of the CS model (CSM) specifically on bilateral MBR. The hypothesis is that CS procedures reduce operative time and surgical complications. STUDY DESIGN: This was a single institutional retrospective cohort study, which included all consecutive patients who underwent bilateral MBR from 2014 to 2016. Patients were grouped into single surgeon (SS) or CSs based on the number of the attending plastic surgeons present. Demographic and clinical characteristics including age, body mass index, smoking, American Society of Anesthesiologist class, radiation, and the timing of the reconstruction were assessed. Univariate and multivariate analyses were performed for outcomes including operative time and postoperative complications. RESULTS: Of the 136 patients included in the study, 41% had breast reconstruction performed by CSs, whereas 59% had a SS. Sociodemographic features were evenly distributed with the exception of a greater number of delayed reconstructions in the SS group (33 vs. 13%; p <0.01). Pedicle TRAMS (transverse rectus abdominis musculocutaneous flaps) were performed in 5 versus 0% of SS versus CS cases, respectively. Rates of major (4 vs. 16%) and minor (11 vs. 24%) complications were significantly lower in CS procedures. Multivariate analyses demonstrated CS operations required significantly shorter operative time by 73 minutes (p <0.001), and trended toward a reduced postoperative complication rate (p= 0.07). CONCLUSION: The CSM is associated with improved operative efficiency for bilateral MBR. Further evaluation of the CSM may prove useful in other surgical disciplines with time and labor intense procedures