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The Impact of Declining Reimbursements on Women’s Choices for Breast Reconstruction: National Trends and Healthcare Implications
Kamakshi R. Zeidler, MD, Tina Hernandez-Boussard, PhD MPH, Ario Barzin, MD, Gordon K. Lee, MD, Catherine Curtin, MD.
Stanford University, Palo Alto, CA, USA.
Breast cancer affects many American women. Post-mastectomy breast reconstruction has been shown to improve quality-of-life. The options for breast reconstruction are separated into two main categories, with autologous reconstruction being a technically more demanding operation but offering a better aesthetic outcome and implant based reconstruction being technically easy to perform, but associated with complications leading to implant failure. The reimbursement for autologus recontruction has been declining over time, and we hypothesized that more women would receive implant reconstruction as reimbursement declined for autologus reconstruction.
This was a retrospective review of data from the Nationwide Inpatient Sample (NIS) from January 1, 1998 to December 31, 2007. Breast reconstruction was identified from the NIS database, and categorized into two groups: autologous (including pedicled and microsurgical flaps) or expander (implant) reconstruction. Comparison of means between autologous and expander reconstruction was performed using Rao-Scott Chi-squared analyses and Student's t-test. A time trend analysis assessed changes in breast reconstruction over time. Medicare physician fee schedule from 2000 to 2010 provided physician reimbursement rates for the procedures of interest. A logistic regression model was designed using variables that were significant in dichotomous analysis. A p-value less than 0.05 indicates statistical significance.
During the ten year study period 307,016 breast reconstructions were performed. Over time, autologous reconstruction decreased at a rate of 3.43% per year, while expander reconstructions increased at a rate of 9.97% per year. Medicare reimbursement also changed, with expander reconstruction reimbursement remaining unchanged while autologous reconstruction reimbursement decreased. The differences between the autologous and expander groups included:. expander recipients had a higher mean age (50.4 vs autologous 49.6 years old, p<0.0001); there was no change in the mean ages over time; autologous reconstructions had a longer length of stay (4.2 vs expander 2.1 days, p<0.0001); expander recipients were more likely to be Caucasian (64.8% vs autologous 56.3%, p<0.0001); autologous patients had a lower Charlson Co-morbidity Index (47% vs expander 34.5% having a score less than 2, p<0.0001); and autologous reconstructions were more likely to be performed at a teaching hospital (67.3% vs expander 62.2%, p=0.0469). A logistic regression model was used to predict the probability of having an expander reconstruction (variables included age, payer, hospital location, medical co-morbidities, and race). The model showed that the odds of having an expander vs an autologous reconstruction between 1998 and 2007 can be predicted by Medicare enrollment, race, hospital location, medical co-morbidities, and year of procedure. Of these predictors, Medicare enrolment most strongly increased the odds of having an expander reconstruction (OR 1.9)
This study suggests that declining reimbursement for autologous reconstruction is limiting access to this procedure. The Women's Health and Cancer Rights Act, passed in 1998, ensures that all health care payers provide coverage for post-mastectomy breast reconstruction, but it does not set benchmarks for reimbursement. As reimbursement declines, breast reconstruction choices may be limited.
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