Impact of Physician Payments on Microvascular Breast Reconstruction: An All-Payer Claim Database Analysis

The Use of Unlisted Billing Codes for Microsurgical Breast Reconstruction and Implications for Code Consolidation

BACKGROUND

 Private insurers have considered consolidating the billing codes presently available for microvascular breast reconstruction. There is a need to understand how these different codes are currently distributed and used to help inform how coding consolidation may impact patients and providers.

METHODS

 Using the Massachusetts All-Payer Claims Database between 2016 and 2020, patients who underwent microsurgical breast reconstruction following mastectomy for cancer-related indications were identified. Multivariable logistic regression was used to test whether an S2068 claim was associated with insurance type and median household income by patient ZIP code. The ratio of S2068 to CPT19364 claims for privately insured patients was calculated for providers practicing in each county. Total payments for professional fees were compared between billing codes.

RESULTS

 There were 272 claims for S2068 and 209 claims for CPT19364. An S2068 claim was associated with age < 45 years (OR: 1.89, 95% CI: 1.11-3.20, p = 0.019), more affluent ZIP codes (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004), and private insurance (OR: 16.13, 95% CI: 7.81-33.33, p < 0.001). Median total payments from private insurers were 101% higher for S2068 than for CPT19364. In all but two counties (Worcester and Hampshire), the S-code was used more frequently than CPT19364 for their privately insured patients.

CONCLUSION

 Coding practices for microsurgical breast reconstruction lacked uniformity in Massachusetts, and payments differed greatly between S2068 and CPT19364. Patients from more affluent towns were more likely to have S-code claims. Coding consolidation could impact access, as the majority of providers in Massachusetts might need to adapt their practices if the S-code were discontinued.

Social Determinants of Health and Patient-reported Outcomes Following Autologous Breast Reconstruction, Using Insurance as a Proxy

BACKGROUND

 Insurance type can serve as a surrogate marker for social determinants of health and can influence many aspects of the breast reconstruction experience. We aimed to examine the impact of insurance coverage on patients reported outcomes with the BREAST-Q (patient reported outcome measure for breast reconstruction patients, in patients receiving) in patients receiving deep inferior epigastric artery perforator (DIEP) flap breast reconstruction.

METHODS

 We retrospectively examined patients who received DIEP flaps at our institution from 2010 to 2019. Patients were divided into categories by insurance: commercial, Medicaid, or Medicare. Demographic factors, surgical factors, and complication data were recorded. Descriptive statistics, Fisher's exact, Kruskal-Wallis rank sum tests, and generalized estimating equations were performed to identify associations between insurance status and five domains of the BREAST-Q Reconstructive module.

RESULTS

 A total of 1,285 patients were included, of which 1,011 (78.7%) had commercial, 89 (6.9%) had Medicaid, and 185 (14.4%) had Medicare insurances. Total flap loss rates were significantly higher in the Medicare and Medicaid patients as compared to commercial patients; however, commercial patients had a higher rate of wound dehiscence as compared to Medicare patients. With all other factors controlled for, patients with Medicare had lower Physical Well-being of the Chest (PWBC) than patients with commercial insurance (β = - 3.1, 95% confidence interval (CI): -5.0, -1.2, p = 0.002). There were no significant associations between insurance classification and other domains of the BREAST-Q.

CONCLUSION

 Patients with government-issued insurance had lower success rates of autologous breast reconstruction. Further, patients with Medicare had lower PWBC than patients with commercial insurance regardless of other factors, while other BREAST-Q metrics did not differ. Further investigation as to the causes of such variation is warranted in larger, more diverse cohorts.

Lower Commercial Rates for Breast Surgical Procedures are Associated with Socioeconomic Disadvantage: A Transparency in Coverage Analysis

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) implemented the Transparency in Coverage Rule in 2022, which requires payers to disclose commercial rates for the first time in the history of the US healthcare system. The purpose of this study was to characterize payer-disclosed commercial facility rates and examine the relationship with county-level social disadvantage for common breast surgical procedures.

MATERIALS AND METHODS

We performed a cross-sectional study of 2023 pricing data for 14 ablative and reconstructive breast procedures from Turquoise Health. Socioeconomic disadvantage was quantified using the Social Vulnerability Index (SVI). Within- and across-payer ratios quantified rate variation. Linear regression assessed the relationship between relative value unit (RVU)-adjusted median commercial rates and facility-level variables including SVI quartile.

RESULTS

There were 4,748,074 unique commercial rates disclosed by four payers from negotiations with 10,023 hospitals. Rates varied by a factor of 9.8-15.6 within and 10.0-18.1 across payers. RVU-adjusted commercial rate decreased in a stepwise fashion as SVI quartile increased and varied by payer (p < 0.001). Higher RVU-adjusted rates were associated with hospitals compared with ambulatory facilities (β = 138, 95% CI 138-139, p < 0.001). Lower rates were associated with areas of less healthcare infrastructure (β = - 37, 95% CI - 38 to - 37, p < 0.001).

CONCLUSIONS

Facility rates for breast surgical procedures varied significantly within and between payers and were higher for hospitals compared with ambulatory surgery centers. Facilities in areas of higher social vulnerability were associated with lower negotiated rates. The health equity implications of lower payment in areas of higher disadvantage, particularly in terms of access to care, deserve further investigation.

Microsurgeon Development, Attrition, and Hope for the Future: A Qualitative Analysis

BACKGROUND

 The field of microsurgery continues to grow, yet barriers to practice still exist. This qualitative study aims to elucidate factors both strengthening and threatening this subspecialty through structured interviews with fellowship-trained microsurgeons.

METHODS

 An interview guide was designed, and structured interviews were conducted with practicing fellowship-trained microsurgeon members of the American Society of Reconstructive Microsurgeons between August 2021 and May 2022. Three independent reviewers transcribed, content-coded, and thematically analyzed the interviews. Themes and subthemes were discussed and finalized.

RESULTS

 Twenty-one practicing microsurgeons were interviewed, hailing from all four Census geographical regions of the United States. The most common practice model was academic (43%, n = 9). Five overarching themes emerged: a passion for microsurgery, training and mentorship, practical considerations, team support, and hope for the future. Microsurgeons reported early exposure to microsurgery as catalyzing their passion, whereas a strong training foundation and lifelong mentors sustained it. Practical challenges arose when establishing and maintaining a microsurgery practice, such as poor reimbursement and unfavorable referral patterns. Team support from staff and other microsurgeons (e.g., a co-surgeon model) was crucial to success. Finally, microsurgeons hoped that future advances would expand access to microsurgical reconstruction for patients and plastic surgeons.

CONCLUSION

 This unique, qualitative description of the current landscape of microsurgery revealed that though practical barriers exist, team-based models can alleviate some difficulties. Future advances that increase accessibility may further strengthen this unique and versatile field.

Impact of Insurance Status on Postoperative Recovery after Microsurgical Breast Reconstruction

BACKGROUND

 Persistent disparities in breast reconstruction access have been widely documented, yet a significant research gap remains in understanding the impact of social determinants of health (SDOH) on postoperative outcomes and complications.

METHODS

 A retrospective chart review was performed on all patients who underwent abdominal-based free-flap breast reconstruction between August 2018 and December 2022 at a racially, ethnically, and socioeconomically diverse urban academic institute with a historically underserved patient population. Patients were stratified by the public (Medicare and Medicaid) versus private insurance as a proxy for SDOH. Patient demographics, length of stay (LOS), timing in progression through postoperative recovery milestones, and complications were compared.

RESULTS

 A total of 162 patients were included, and 57% of patients had public insurance, with this group more likely to be Hispanic (odds ratio [OR] 2.7; p = 0.003) and Spanish-speaking (OR 3.4; p = 0.003). Privately insured patients were more likely to be non-Hispanic Black (OR 2.7; p = 0.006). Patients with public insurance had a higher rate of unplanned return to the operating room within 90 days and a higher incidence of complications, though not statistically significant. They also experienced a significantly longer LOS than privately insured patients (3.6 ± 1.0 vs. 3.0 ± 0.7 days; p < 0.0001). Logistic regression identified an LOS exceeding 3 days as independently associated with public insurance status (OR 3.0; p = 0.03), bilateral procedure (OR 5.6; p = 0.0007), preoperative functional-dependent status (OR 7.0; p = 0.04), and higher body mass index (BMI; OR 1.1; p = 0.03). Patients with public insurance were more likely to encounter delays in achieving recovery milestones.

CONCLUSION

 Public insurance status, serving as a proxy for a disadvantage in SDOH, is predictive of extended LOS and postoperative recovery delays following microsurgical breast reconstruction. This underscores the need for future quality improvement efforts to address and mitigate these disparities.

Local practice variations and payer differences underlie state-wide disparities in oncoplastic breast surgery

BACKGROUND

Little is known about disparities in oncoplastic breast surgery delivery.

METHODS

The Massachusetts All-Payer Claims Database was queried for patients who received lumpectomy for a diagnosis of breast cancer. Oncoplastic surgery was defined as adjacent tissue transfer, complex trunk repair, reduction mammoplasty, mastopexy, flap-based reconstruction, prosthesis insertion, or unspecified breast reconstruction after lumpectomy.

RESULTS

We identified 18 748 patients who underwent lumpectomy between 2016 and 2020. Among those, 3140 patients underwent immediate oncoplastic surgery and 436 patients underwent delayed oncoplastic surgery. Eighty-one percent of patients who underwent oncoplastic surgery did so in the same county as they underwent a lumpectomy. However, the relative frequency of oncoplastic surgery varied significantly among counties. In multivariable regression, public insurance status (odds ratio: 0.87, 95% confidence interval: 0.80-0.95, p = 0.002) was associated with lower odds of undergoing oncoplastic surgery, even after adjusting for macromastia, other comorbidities, and county of lumpectomy. Average payments for lumpectomy with oncoplastic surgery were more than twice as high from private insurers ($840 vs. $1942, p < 0.001).

CONCLUSION

Disparities in the receipt of oncoplastic surgery were related to differences in local practice patterns and the type of insurance patients held. Expanding services across counties and considering billing reform may help reduce these disparities.

Financial (dis)incentives to surgical management of head and neck cancer care

BACKGROUND

Patients with head and neck cancer (HNC) often require complex surgical reconstruction. This retrospective, cross-sectional study compares financial factors influencing HNC and breast cancer (BC) care to examine care disparities.

METHODS

Pricing data from 2012 to 2021 was abstracted from the CMS Physician Fee Schedule Look-Up Tool. Nonprofit and research support was quantified by searching the NIH, IRS, and GuideStar databases. New York State Department of Health data from 2015 to 2019 was analyzed to compare costs, charges, and payer mix.

RESULTS

HNC reconstructive procedures reimburse lower than comparable breast procedures (p < 0.05). Nonprofit and research support for HNC is disproportionately low relative to disease burden. Patients hospitalized for HNC surgical procedures generated higher costs and lower charges than patients with BC (p < 0.05).

CONCLUSION

Comparatively low procedure reimbursement, low nonprofit support, and high cost of care for patients with HNC relative to patients with BC may contribute to care disparities for patients with HNC.

Health Care Value in Plastic Surgery Practice

SUMMARY

As value-based care gains traction in response to towering health care expenditures and issues of health care inequity, hospital capacity, and labor shortages, it is important to consider how a value-based approach can be achieved in plastic surgery. Value is defined as outcomes divided by costs across entire cycles of care. Drawing on previous studies and policies, this article identifies key opportunities in plastic surgery to move the levers of costs and outcomes to deliver higher value care. Specifically, outcomes in plastic surgery should include conventional measures of complication rates and patient-reported outcome measures to drive quality improvement and benchmark payments. Meanwhile, cost reduction in plastic surgery can be achieved through value-based payment reform, efficient workflows, evidence-based and cost-conscious selection of medical devices, and greater use of outpatient surgical facilities. Lastly, the authors discuss how the diminished presence of third-party payers in aesthetic surgery exemplifies the cost-conscious and patient-centered nature of value-based plastic surgery. To lead in future health policy and care delivery reform, plastic surgeons should strive for high-value care, remain open to new ways of care delivery, and understand how plastic surgery fits into overall health care delivery.

The Insurance Landscape for Implant- and Autologous-based Breast Reconstruction in the United States

Insurance coverage of postmastectomy breast reconstruction is mandated in America, regardless of reconstructive modality. Despite enhanced patient-reported outcomes, autologous reconstruction is utilized less than nonautologous reconstruction nationally. Lower reimbursement from Medicare and Medicaid may disincentivize autologous-based reconstruction. This study examines the impact of insurance and sociodemographic factors on breast reconstruction.

Methods

A retrospective analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database from 2014 to 2017 was performed. International Classification of Diseases Clinical Modification and Procedure Coding System codes were used to identify patients for inclusion. De-identified sociodemographic and insurance data were analyzed using χ ², least absolute shrinkage and selection operator regression analysis, and classification trees.

Results

In total, 31,468 patients were identified for analysis and stratified by reconstructive modality, sociodemographics, insurance, and hospital characteristics. Most patients underwent nonautologous reconstruction (63.2%). Deep inferior epigastric perforator flaps were the most common autologous modality (46.7%). Least absolute shrinkage and selection operator regression identified Black race, urban-teaching hospitals, nonsmoking status, and obesity to be associated with autologous reconstruction. Publicly-insured patients were less likely to undergo autologous reconstruction than privately-insured patients. Within autologous reconstruction, publicly-insured patients were 1.97 (P < 0.001) times as likely to obtain pedicled flaps than free flaps. Black patients were 33% (P < 0.001) less likely to obtain free flaps than White patients.

Conclusions

Breast reconstruction is influenced by insurance, hospital demographics, and sociodemographic factors. Action to mitigate this health disparity should be undertaken so that surgical decision-making is solely dependent upon medical and anatomic factors.

Commercial Price Variation for Breast Reconstruction in the Era of Price Transparency

Importance

Breast reconstruction is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule was enacted in 2021 to facilitate market competition and lower health care costs. Breast reconstruction pricing should be analyzed to evaluate for market effectiveness and opportunities to lower the cost of health care.

Objective

To evaluate the extent of commercial price variation for breast reconstruction. The secondary objective was to characterize the price of breast reconstruction in relation to market concentration and payer mix.

Design, Setting, and Participants

This was a cross-sectional study conducted from January to April 2022 using 2021 pricing data made available after the Hospital Price Transparency Rule. National data were obtained from Turquoise Health, a data service platform that aggregates price disclosures from hospital websites. Participants were included from all hospitals with disclosed pricing data for breast reconstructive procedures, identified by Current Procedural Terminology (CPT) code.

Main Outcomes and Measures

Price variation was measured via within- and across-hospital ratios. A mixed-effects linear model evaluated commercial rates relative to governmental rates and the Herfindahl-Hirschman Index (health care market concentration) at the facility level. Linear regression was used to evaluate commercial rates as a function of facility characteristics.

Results

A total of 69 834 unique commercial rates were extracted from 978 facilities across 335 metropolitan areas. Commercial rates increased as health care markets became less competitive (coefficient, $4037.52; 95% CI, $700.12 to $7374.92; P = .02; for Herfindahl-Hirschman Index [HHI] 1501-2500, coefficient $3290.21; 95% CI, $878.08 to $5702.34; P = .01; both compared with HHI ≤1500). Commercial rates demonstrated economically insignificant associations with Medicare and Medicaid rates (Medicare coefficient, -$0.05; 95% CI, -$0.14 to $0.03; P = .23; Medicaid coefficient, $0.14; 95% CI, $0.07 to $0.22; P < .001). Safety-net and nonprofit hospitals reported lower commercial rates (coefficient, -$3269.58; 95% CI, -$3815.42 to -$2723.74; P < .001 and coefficient, -$1892.79; -$2519.61 to -$1265.97; P < .001, respectively). Extra-large hospitals (400+ beds) reported higher commercial rates compared with their smaller counterparts (coefficient, $1036.07; 95% CI, $198.29 to $1873.85, P = .02).

Conclusions and Relevance

Study results suggest that commercial rates for breast reconstruction demonstrated large nationwide variation. Higher commercial rates were associated with less competitive markets and facilities that were large, for-profit, and nonsafety net. Privately insured patients with breast cancer may experience higher premiums and deductibles as US hospital market consolidation and for-profit hospitals continue to grow. Transparency policies should be continued along with actions that facilitate greater health care market competition. There was no evidence that facilities increase commercial rates in response to lower governmental rates.

Breaking Barriers to Breast Reconstruction among Socioeconomically Disadvantaged Patients at a Large Safety-net Hospital

Socioeconomic disparities remain prevalent among those who undergo breast reconstruction. At our institution, patients must meet certain criteria to become eligible for breast reconstruction. The purpose of this study was to determine the impact of socioeconomic factors on breast reconstruction eligibility, enrollment, choice, and completion at our large safety-net institution.

Procedural Trends in Medicare Reimbursement and Utilization for Breast Reconstruction: 2000-2019

PURPOSE

Development of appropriate reimbursement models for breast reconstruction in the United States requires an understanding of relevant economic trends. The purpose of this study is to evaluate longitudinal patterns in Medicare reimbursement for frequently performed breast reconstruction procedures between 2000 and 2019.

METHODS

Reimbursement data for 15 commonly performed breast reconstruction procedures were analyzed using the Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool for each Current Procedural Terminology code. By utilizing changes to the US consumer price index, monetary data were adjusted for inflation to 2019 US dollars. Inflation-adjusted trends were used to calculate average annual and total percentage changes in reimbursement over time.

RESULTS

From 2000 to 2019, average adjusted reimbursement for all procedures fell by 13.32%. All procedures demonstrated a negative adjusted reimbursement rate other than immediate insertion of breast prosthesis, which increased by 55.37%. The largest mean decrease was observed in breast reconstruction with other technique (-28.63%), followed by single pedicle transverse rectus abdominis myocutaneous flap (-26.02%), single pedicle transverse rectus abdominis myocutaneous flap with microvascular anastomosis (-23.33%), latissimus dorsi flap (-19.65%), and free flap reconstruction (-19.36%).

CONCLUSIONS

There has been a steady yet substantial decline in Medicare reimbursement for the majority of breast reconstruction procedures over the last 20 years. Given increasing medical costs and the financial uncertainty of the US health care system, an understanding of Medicare reimbursement trends is vital for policymakers, administrators, and physicians to develop agreeable reimbursement models that facilitate growth and economic vitality of breast reconstruction in the United States.

Autologous Breast Reconstruction Trends in the United States: Using the Nationwide Inpatient Sample Database

BACKGROUND

Autologous tissue is the criterion standard in breast reconstruction, but traditionally has been used as a secondary option after implant-based options because of reduced reimbursement relative to effort and required additional technical skill. We intended to evaluate the overall frequency and trends of autologous breast reconstruction (ABR), the trends of ABR in teaching versus nonteaching hospitals and the trends of ABR in different hospital regions in the United States.

METHODS

Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent immediate or delayed ABR from 2009 to 2016 in the United States.

RESULTS

A total of 146,185 patients underwent ABR during this period. The overall rate of ABR increased 112%, from 26.6% to 56.5%. The majority of ABR were delayed reconstructions (62.3%), which increased gradually from 54.9% to 80% during the study period. The overall frequency of flaps included the deep inferior epigastric perforator (32.1%), latissimus dorsi myocutaneous (28.4%), free transvers rectus abdominus myocutaneous (15.9%), pedicled transvers rectus abdominus myocutaneous flap (14.5%), gluteal artery perforator (0.6%), superficial inferior epigastric artery (0.6%), and unspecified-ABR (7.2%). Most ABRs were performed in teaching hospitals (78.6%) versus nonteaching hospitals (21.4%). The teaching hospitals' ABR rate increased from 70.5% to 88.7%. The greatest proportion of ABRs were performed in the south (39.6%) followed by northeast (23.0%), midwest (18.9%), and west (18.5%).

CONCLUSIONS

The deep inferior epigastric perforator flap has become the predominant ABR method in the United States. In addition to more delayed reconstructions being performed in recent years, ABR rates are increasing overall and shifting from pedicled flaps to free flaps.

Are "Free Flaps" "Free" Flaps?

BACKGROUND

 Even standard microvascular tissue transfers are time consuming, require great skill and intensity, and can be stressful. Not surprisingly, work-related relative value units are considered by many microsurgeons to be suboptimal. Some might even say that "free flaps" indeed really are "free" flaps.

METHODS

 A retrospective review of related finances was undertaken for all free flaps performed in a single surgeon private practice during the latest possible year (2014) that included a complete 5-year follow-up to insure receipt of all expected reimbursements from accounts receivable. There were 61 free flaps available; but arbitrarily 12 free flaps were excluded since postmastectomy breast reconstruction always received mandatory insurance payment, as were additional two cases done pro bono as part of an international educational service. This left 47 free flaps to permit determination of gross payments, if any.

RESULTS

 Compensation summated for three distinct time intervals for all free flaps was preoperative: $10,855.92 (mean: $230.98/flap); intraoperative: $117,015.46 (mean: $2,489.69/flap); and postoperative: $45,296.28 (mean: $963.75/flap). Range of gross payment for the free flap portion only was 529.65 to $4,503.71. Total overall revenue received was $173,167.66 (mean: $3,684.42/flap).

CONCLUSION

 A true benefit cost-analysis even if microsurgery specific expenses could be estimated would be inaccurate, so that mean net income for each free flap could not be determined. Albeit a minimal gross payment was obtained for some free flap procedures, in no instance was there zero reimbursement. Based on that fact, there were no truly "free" free flaps in this private practice experience, which should encourage the younger surgeon to realize that economic viability is possible so that their enthusiasm for reconstructive microsurgery can be sustained.

Learning From Those who Learned: A Survey of Fellowship Trained HoLEP Surgeons and Their Current Practice Patterns

OBJECTIVE

To gain insight from the experience of learning Holmium laser enucleation of the prostate (HoLEP), teaching HoLEP, and the current HoLEP practice patterns of fellowship-trained endourologists.

METHODS

Surveys were electronically distributed to United States (U.S.) practicing urologists who completed American Endourology fellowships (that included HoLEP) within the past 6 years. Questions focused on HoLEP training and current practice patterns.

RESULTS

As of September 2019, 12% (6/49) of U.S. endourology fellowships reported including HoLEP as a component of training. With a 73% response rate (16 of 22), 81% participated in over 20 cases during training, while 50% participated in over 50. A total of 25% independently completed over 50 cases from start to finish. At training completion, most (80%) felt comfortable/somewhat comfortable completing an entire HoLEP independently and managing post-op complications. Seventy-five percent practice HoLEP currently, and 25% teach to trainees. When asked "What is most challenging about HoLEP in current practice?" common responses were: efficiency/profitability concerns, poor reimbursement, educating OR/hospital staff, establishing case volume, minimizing sphincter trauma, and large glands (>200gm).

CONCLUSION

With diverse exposure in fellowship, most incorporate HoLEP into their practice after training. Aspects of the procedure remain challenging after several years of experience. Profitability/reimbursement concerns should be further explored to increase HoLEP adoption.