The Practice Implications of Third-Party Reimbursement for Breast Reconstruction: A National Survey of Plastic Surgeons
Amy K. Alderman, MD, MPH1, Rachel Streu, MD, MS2, Dunya Atisha, MD3.
1University of Michigan, Ann Arbor, MI, USA, 2University of Michigan, St. Joseph Mercy Hospital, Ann Arbor, MI, USA, 3University of Iowa, Iowa City, IA, USA.
PURPOSE: Less than 20% of breast cancer patients receive reconstruction at the time of the mastectomy despite federally mandated coverage. A large proportion of general surgeons do not refer patients to plastic surgeons prior to the mastectomy, and general surgeons are showing increased interest in oncoplastic surgery. This project will evaluate plastic surgeons’ interest and perceived barriers to providing post-mastectomy breast reconstruction, especially related to economic challenges imposed by third- party payers.
METHODS: A mailed, self-administered survey was sent to a national sample of 500 randomly selected members of the American Society of Plastic Surgeons (77% response rate). The dependent variable was surgeon report of the number of breast reconstructions performed annually. Surgeon volume was collapsed into three categories (<25, 25-50, >50 cases/year) and regressed on the following covariates using logistic regression: surgeon age, surgeon gender, fellowship training, hospital setting, resident availability, and attitudes about reimbursement for breast reconstruction.
RESULTS: Nearly all surgeons (90%) found breast reconstruction personally rewarding, and 94% enjoyed the technical aspects of these procedures. However, 85% of the sample were considered as low or moderate volume surgeons, performing <50 breast reconstructions/year. Nearly half of the surgeons (43%) reported decreasing their volume of breast reconstruction cases due to poor reimbursement, and more than 80% reported inadequate reimbursement for autogenous tissue procedures (Table 1). Low volume practices were independently associated with increased surgeon age (p = 0.03), lack of resident availability (p < 0.0001), and belief that reimbursement limits reconstructive practice (p < 0.001). In addition, surgeons reported difficulty in obtaining insurance coverage for post-mastectomy reconstruction (15%), symmetry procedures (33%), and nipple areolar reconstruction (19%).
CONCLUSIONS: Third- party payers are limiting women’s access to post-mastectomy breast reconstruction through inadequate professional reimbursement and non-compliance with the Women’s Health and Cancer Rights Act. Advocacy efforts must be directed at ensuring appropriate coverage for these procedures. Equally important, the reimbursement rate must match the intensity of services for these reconstructive procedures to encourage plastic surgeons’ services for women needing breast reconstruction.
Table 1. Plastic Surgeons' Attitudes Towards Third-Party Reimbursement for Post-Mastectomy Breast Reconstruction
|Reconstructive Procedure||% Surgeons Who Believe that Reimbursement is Inadequate|
|*responders chose 4 or 5 on a 5 point Likert scale|