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Purpose
Immediate breast reconstruction has been accepted as a method to assist help many breast cancer patients minimize the physical and psychological impact of mastectomy. We postulate that the availability of immediate reconstruction is limited by socioeconomic status. This study investigates the impact of public versus private insurance on the evolution of immediate breast reconstruction.
Methods
This study utilized the Nationwide Inpatient Sample, the largest available all-payer database in the US, with data approximating a 20-percent sample of hospital stays at US community hospitals. Data from the years 2000 and 2009 were reviewed. Patients with breast cancer undergoing immediate breast reconstruction were identified using CPT codes for both mastectomy and breast reconstruction, either with autologous tissue or tissue expander, occurring during the same hospital visit. Medicaid and privately-insured patients were identified via primary payer information. Statistical significance was determined using a two-tailed Fisher’s exact test.
Results
A total of 63038 (2000) and 48588 (2009) hospital admissions involving mastectomy were examined. In 2000, 9.5% of Medicaid patients undergoing mastectomy received immediate breast reconstruction compared to 40.2% of privately insured patients (p < 0.0001). In 2009, the rates were 19.3% for Medicaid and 54.5% for private insurance (p < 0.0001 for disparity) (See Fig. 1). In 2009, Privately-insured patients were more likely to be reconstructed with autologous tissue than Medicaid patients. (2000: Private insurance: 17.1% undergoing mastectomy had reconstruction with tissue expander, 3.0% with autologous tissue, Medicaid: 2.8% tissue expander, 0.4% autologous tissue, ns; 2009: private insurance: 40.4% tissue expander, 18.4% autologous tissue, Medicaid: 15.1% tissue expander, 5.6% autologous tissue p = 0.012) (See Fig. 2). In 2009, significant predictors of immediate reconstruction were white race and private insurance, significant predictors of no reconstruction were diabetes, obesity, black race and Medicaid (p < 0.001 in all cases). These effects were independent of age.
Conclusions
This study demonstrates a persistent disparity, based upon insurance carrier, in the performance of immediate breast reconstruction after mastectomy but does not demonstrate an effect on the method of immediate reconstruction performed. Despite available data regarding the safety, efficacy, and therapeutic psychological benefit of immediate reconstruction, patients with public insurance continue to demonstrate significant differences in the use of immediate reconstruction following mastectomy. Factors may include significantly lower reimbursement from Medicaid, additional comorbidities, lack of available surgeons accepting Medicaid, as well as the lack of information available to low income patients regarding reconstructive options. Further research will investigate more recent trends, contributing factors, and institutional experience.