Discussion: Conceptual Considerations for Payment Bundling in Breast Reconstruction

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This article discusses the ongoing trend by the Centers for Medicare and Medicaid Services and the private sector to use payment reform as a means to combat ballooning health care costs by shifting financial risk from the insurance company to health care delivery systems and providers. As the authors point out, bundled and capitated payments are already being implemented for procedures such as total joint arthroplasty, and we should prepare for procedures such as breast reconstruction to be next. However, bundled payment for breast reconstruction is a more complicated undertaking, and the authors do an excellent job discussing the conceptual considerations needed to make this a reality: defining an episode of care for breast reconstruction, defining the duration of this episode, and organizing payments so that clinical decisions such as type of reconstruction and number of stages are made with patient outcome in mind and independent of remuneration. As plastic surgeons, we should be involved in this conversation early, as we are the most qualified individuals to guide implementation of bundled payment for breast reconstruction.
We agree with the authors that because of the variability in practice and cost of managing breast cancer, breast reconstruction must be bundled separately from the diagnosis and treatment of breast cancer. The majority of breast cancer patients undergoing mastectomy do not undergo reconstruction, and among the women that undergo reconstruction, only 40 percent undergo reconstruction immediately.1 Separate bundling would incentivize health systems to redesign care pathways such that every breast cancer patient that desires reconstruction is offered the option, and every woman who is a candidate undergoes immediate reconstruction. In addition, there would be no penalty to the health system if delayed reconstruction was deemed a more appropriate clinical course or personal choice.
As the authors discuss, defining an episode of care for breast reconstruction is a difficult task. How long should the risk period be? Should only true complications be included, or should revision operations be included as well? It is important to note that the study by Fischer et al. cited in the article is based on a retrospective review of practice patterns that were likely influenced by existing payment structures where revision procedures result in additional payments to health systems and providers.2 The inclusion of both complications and revision procedures in bundled payment will likely change behavior—surgeons will seek the best initial reconstruction and limit revisions to what is truly necessary.3,4 With the emergence of direct-to-implant reconstruction and its potential cost-benefits compared with tissue expander reconstruction,5 growing numbers of autologous reconstructive options,6 and emerging evidence that autologous may be the most cost-effective reconstructive option in selected patients,7 an episode of care long enough to include revision procedures will encourage providers to personalize breast reconstruction care plans and use newer techniques. This will benefit patients and the system as a whole. We know that plastic surgeons are better at resource use in breast reconstruction compared with other specialties8—the added pressures of bundled payment will accentuate that difference and further incentivize health systems to use only well-trained, board-certified plastic surgeons in breast reconstruction.
The authors wisely include other important considerations for bundling breast reconstruction: adjustments of payments based on type of reconstruction, risk adjustment, and effect of bundling on use of technology. Autologous and prosthetic reconstructions have different associated costs and will require separate bundles. These bundles must be carefully balanced such that the type of reconstruction recommended for a patient is based on evidence and separated from remuneration.

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