A Cross-Sectional Study of Variations in Reimbursement for Breast Reconstruction: Is A Healthcare Disparity On the Horizon?

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Abstract

Background

Despite growing demand for breast reconstruction, financial disincentives to perform breast reconstruction in patients with government-sponsored insurance plans may lead to longer wait times and decreased access to care. We identify the variation in reimbursement for implant and autologous reconstruction as a step toward understanding these financial implications, to develop safeguards to minimize effects on access to care.

Methods

Billing data were collected over a 10-year period for patients undergoing implant-based (19357) or free-flap (19364) breast reconstruction. Patients were placed into cohorts according to insurance type—Medicare, Medicaid, or private insurance, and these were directly compared.

Results

A total of 2691 women underwent breast reconstruction between 2003 and 2013; 71.2% had private insurance, 13.3% had Medicaid, and 14.49% had Medicare. For implant-based reconstructions, the average reimbursement of total charges was 16.3% for Medicaid, 28.3% for Medicare, and 67.2% for private insurance. For autologous reconstruction, average reimbursement was 12.37% for Medicaid, 22.9% for Medicare, and 35.35% for private insurance. Hourly reimbursement estimates for Medicaid patients undergoing autologous reconstruction were lowest. The highest hourly reimbursement estimate was for privately insured patients undergoing implant-based reconstruction. Over time, reimbursement for autologous reconstruction has declined significantly for all payor types, whereas implant-based reimbursement disparities are narrowing.

Conclusions

We found that wide variations in reimbursement for breast reconstruction procedures exist and may preclude some surgeons from offering certain reconstructive options to a subset of patients. Understanding these discrepancies is a key first step in minimizing a potential care delivery disparity for this patient population.

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