The Costs of Breast Reconstruction and Implications for Episode-Based Bundled Payment Models
Nicholas L. Berlin, MD, MPH1, Evan Matros, MD, MMSc, MPH2, Kevin C. Chung, MD, MS1, Adeyiza O. Momoh, MD1.
1University of Michigan, Ann Arbor, MI, USA, 2Memorial Sloan-Kettering Cancer Center, New York City, NY, USA.
Purpose: Implementation of episode-based bundled payment models is imminent in the United States. Bundled payments for multidisciplinary care of women with breast cancer will profoundly impact reimbursement and access to breast reconstruction. Our objectives were to determine the contribution of cancer therapies, revisions, and complications to costs following immediate reconstruction and the optimal duration of episodes to incentivize cost containment.
Methods:The cohort was comprised of women who underwent immediate breast reconstruction between years 2009 to 2016 from the MarketScan Commercial Claims and Encounters database. Continuous enrollment for three months prior and 24 months following reconstruction was required. Total costs were calculated within predefined episodes (30 days, 90 days, one year, and two years). Multivariable models were built to assess predictors of costs.
Results: Among 15,377 women in the analytic cohort, 11,592 (75%) underwent tissue-expander (TE), 1,279 (8%) underwent direct to implant (DTI), and 2,506 (16%) underwent autologous reconstruction. Neo/adjuvant therapies increased costs at one year [TE +$40,571 (p=0.003), DTI +$40,535 (p=0.007), and autologous +$35,233 (p=0.011)]. At one year, most patients had undergone TE exchange (76%) and revisions (81%), and a majority of complications had occurred (87%). Comorbidities, revisions, and complications increased costs for all episode scenarios.
Conclusions: Given the complexity of reconstruction pathways, our findings suggest that a one-year episode time horizon would optimally capture reconstruction events and complications. Policy-makers should consider separate bundles for medical and surgical care with adjustment for procedure type and cancer therapies to limit the adverse impact of bundled payments on access to reconstruction.
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