Immediate Lymphatic Reconstruction and the Current Value Problem

Lymphedema is the most common long-term complication of cancer treatment. Incidence varies based on the site of lymphadenectomy and cancer type, approximating 19% to 23% following axillary lymph node dissection (ALND) for breast cancer, and 18% following inguinal lymph node dissection for melanoma.^1,2 Once developed, lymphedema is a chronic, progressive condition that places affected patients at risk for cellulitis, disseminated infection, painful swelling, impaired function, physical disfigurement, and reduced quality of life.³ Given its chronicity, lymphedema is associated with increased health care utilization and costs that persist throughout a patient’s lifetime. Accordingly, patients with breast cancer-related lymphedema (BCRL) incur 7-fold greater health care charges compared with unaffected patients, largely reflective of disproportionate all-cause hospitalizations.³

Immediate lymphatic reconstruction (ILR) may prevent lymphedema and decrease costs. This approach involves microsurgical anastomoses of transected lymphatic channels to nearby veins at the time of nodal dissection. This procedure can be applied to both upper and lower extremity lymphadenectomy, but has been most rigorously examined in the context of BCRL. Retrospective studies demonstrate lower rates of BCRL among high-risk patients treated with ILR (grade IB evidence),⁴ with prospective trials ongoing. On meta-analysis, the pooled cumulative incidence of lymphedema among patients who underwent ALND without ILR was 14.1% compared with 2.1% in patients treated with ILR; similar trends were found in patients treated with ALND and regional lymph node radiation (33.4% lymphedema rate without ILR vs. 10.3% with ILR; median follow up time of 25.7 months).⁵ In addition to clinical effectiveness, ILR is cost-effective based on cost-utility analysis from the third-party payer perspective. Compared with patients who underwent ALND without ILR, patients treated with ILR had an incremental cost-utility ratio of $1587.73 per quality-adjusted life year in the setting of ALND without radiation and $699.84 per quality-adjusted life year when treated with ALND and radiation.⁶ In an independent analysis from the societal perspective, ILR was projected to yield an average of $7646.65 (45.2%) lifetime cost savings per patient.⁷

It is currently unknown whether the codes used to bill for ILR incentivize hospital systems and surgeons to offer this procedure. In contrast to economic analyses from a third-party payer or societal perspective, from the perspective of a health system and its surgeons, the value of ILR largely reflects the relative value units (RVUs) assigned to corresponding Current Procedural Terminology (CPT) codes. As with all procedural care, Medicare bases reimbursements on the quantity of RVUs assigned to a given service (eg, Medicare payment is a geographically adjusted RVU total multiplied by a dollar conversion factor), and many private insurers have followed suit. Work RVUs are a component of the RVU that are intended to reflect the “time, mental effort and judgment, technical skill and physical effort, and stress” required for a physician to provide a given clinical service.⁸ Increasingly, group practices, integrated health systems, and academic medical centers utilize work relative value units (wRVUs) as a benchmark for physician productivity, basing decisions such as compensation and career advancement on this metric.⁹ Though there is a lack of consensus regarding coding for ILR, the wRVUs of CPT codes that are commonly used for these procedures include: 35206 (repair of upper extremity blood vessel, wRVU 13.84), 35236 (repair of upper extremity blood vessel with vein graft, wRVU 18.02), 35226 (repair of lower extremity blood vessel, wRVU 15.3), 38305 (incision procedure on lymph node, wRVU 6.68), 38308 (lymphangiotomy, wRVU 6.81), and 38999 (other procedures on the lymphatic system, wRVU 0). In comparison, insertion of a breast tissue expander (CPT 19357), a basic plastic surgery procedure that does not require microsurgical expertise, garners 14.84 wRVUs. Breast reconstruction with a free flap (CPT 19364) is assigned 42.58 wRVUs (Supplemental Table 1, Supplemental Digital Content 1, https://links.lww.com/SLA/E436 for complete list of wRVUs for free autologous tissue transfer procedures).

Though already low in absolute terms, we hypothesized that comparing the efficiency of breast cancer surgery involving ALND with and without ILR would illustrate the magnitude of ILR undervaluation. Using 2008 to 2020 data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), we compared the efficiency of surgery involving mastectomy or lumpectomy and ALND with and without ILR. Though RVUs encompass the time and effort provided within the full 90-day global period, efficiency was approximated by total wRVUs per case (wRVUs for primary and other procedures performed during a single anesthetic) divided by total operative time (ie, RVU rate), as established in previous methodology.¹⁰ The cohort consisted of 117,475 patients. A total of 213 patients underwent ILR, while the remaining 117,262 patients served as a control group. Median total wRVUs per operation was 23.6 [interquartile range (IQR): 18.2–42.9] for the control group and 38.5 (IQR: 27.4–65.3) for the ILR group (P<0.001, Wilcoxon rank sum test). Median operative time was 130 (IQR: 87–195) minutes for the control group and 231 (IQR: 163–319) minutes for the ILR group (P<0.001). Efficiency was 13.5 (IQR: 9.5–18.7) wRVUs per hour and 11.4 (IQR: 7.7–16.8) wRVUs per hour for the control and ILR groups, respectively (P<0.001; Fig. 1A). Overall, this calculation demonstrates that the current low level of wRVU allocation for ILR CPT codes inadequately compensates for the increase in operative time required for this procedure in the context of breast cancer surgery.

FIGURE 1: (A) Median total wRVU, operative time, and wRVU per hour with and without ILR for mastectomy or lumpectomy with ALND. (B) Median total wRVU, operative time, and wRVU per hour with and without ILR for isolated ALND. Bars represent interquartile range. ILR indicates immediate lymphatic reconstruction; wRVU, work relative value unit.

We similarly hypothesized that the addition of ILR to isolated ALND would render this procedure inefficient because of undervaluation of ILR. Using NSQIP data through analogous methodology, we calculated efficiency metrics for 7320 patients who underwent ALND without concurrent mastectomy or lumpectomy; of these, 163 patients underwent ILR. Median total wRVUs per operation was 13.9 (IQR: 13.9–13.9) for the control group and 18.8 (IQR: 13.9–24.3) for the ILR group (P<0.001). Median operative time was 92 (IQR: 61–134) minutes for the control group and 132 (IQR: 83–199) minutes for the ILR group (P<0.001). Efficiency was 9.8 (IQR: 6.8–14.3) wRVUs per hour and 8.0 (IQR: 5.2–13.5) wRVUs per hour for the control and ILR groups, respectively (P=0.001, Fig. 1B).

These data suggest that current wRVU allocation undervalues ILR, thus introducing inefficiency into breast cancer operations when coupled with ILR. Though avoidance of BCRL contributes to determinations of cost-effectiveness when third-party payers and society are the stakeholders, these long-term benefits do not factor into short-term assessments of physician productivity or hospital budgeting on an annual fiscal calendar. This is problematic not only because of the economic benefits demonstrated from third-party payer and societal perspectives, but also because ILR encompasses some of the most technically challenging microsurgery that demands a high level of “time, mental effort and judgment, technical skill and physical effort, and stress.” ILR requires additional mental effort and clinical judgment beyond a standard microsurgical anastomosis to select the appropriate lymphatic channel(s) and vein(s) to use for bypass and the method of anastomosis (intussusception vs. end-to-end anastomosis). Additional technical challenges—beyond the submillimeter size of the lymphatic channels—include use of smaller suture (10-0 or 11-0 nylon) and the difficulty of performing this anastomosis in the axilla. Lymphatic microsurgeons typically undergo additional specialty training beyond residency in order to master these technical feats. Particularly in the context of these considerations, the additional median 14.9 wRVUs for 101 added minutes of operative time for ILR in patients undergoing mastectomy or lumpectomy with ALND, and 4.9 wRVUs for 40 added minutes of operative time in patients undergoing isolated ALND, suggests that ILR is substantially undervalued. In comparison to the RVU rate for the 100 most common procedures in plastic surgery, as calculated by Blau et al,¹⁰ ILR would rank just above the 10 least efficient procedures (RVU rate 1.8–6.4).

The quantity of RVUs assigned to CPT codes used for ILR must be reevaluated in order to make this procedure economically and professionally sustainable. From a hospital’s standpoint, based on current RVU allocation, it is not financially favorable to offer ILR in conjunction with ALND, versus ALND alone. From an employed surgeon’s standpoint, performing ILR detracts from productivity metrics given the high opportunity cost and comparatively low wRVUs gained per hour of operative time. To the detriment of patient outcomes, hospitals and surgeons may therefore forgo ILR in favor of more efficient procedures. The downstream consequence of a grossly devalued and, in many cases, uncompensated RVU for ILR is that most patients will never have the option of this procedure, which could reduce their risk of incurable and progressive lymphedema. The disabling consequences of this disease, which progress even with total compliance with physiotherapy, also carry a heavy financial burden to the health care system—estimated to be $3160.52 annually per patient for surgery, decongestive therapy, and equipment alone—that outweighs the cost of a single ILR procedure (estimated $2957.32 per patient).⁷

RVU reallocation requires joint action from the American Medical Association (AMA) and Centers for Medicare & Medicaid Services. Ideally, the AMA should develop a CPT code specific to ILR given the current lack of coding consensus and consequent variation in wRVUs based on chosen code. The Centers for Medicare & Medicaid Services maintains the RVU schedule under the advisement of the AMA Specialty Society Relative Value Scale Update Committee (RUC). The RUC should prioritize reassessment of RVUs for ILR such that RVUs per hour for ILR are at least equal to that of ALND with or without mastectomy or lumpectomy, in order to avoid detracting from the efficiency of those operations. Such reassessment will ensure that RVU-based value is commensurate with demonstrated clinical value, avoid de-incentivizing ILR, and prevent artificial access barriers to patients with cancer.