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The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis

Sheckter, Clifford C., M.D.; Panchal, Hina J., M.D., M.P.H.; Razdan, Shantanu N., M.D., M.P.H.; Rubin, David, B.S.; Yi, Day, M.S.; Disa, Joseph J., M.D.; Mehrara, Babak, M.D.; Matros, Evan, M.D., M.M.Sc., M.P.H.

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 434e-442e
doi: 10.1097/PRS.0000000000004727
Breast: Original Articles
Outcomes: Cost

Background: Flap-based breast reconstruction demands greater operative labor and offers superior patient-reported outcomes compared with implants. However, use of implants continues to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments.

Methods: Using the Blue Health Intelligence database from 2009 to 2013, patients were identified who underwent tissue expander (i.e., implant) or free-flap breast reconstruction. The implant-to-flap ratio and physician payments were assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method.

Results: A total of 21,259 episodes of breast reconstruction occurred in 122 U.S. markets. The distribution of implant-to-flap ratio varied by market, ranging from the fifth percentile at 1.63 to the ninety-fifth percentile at 43.7 (median, 6.19). Modeling the implant-to-flap ratio versus implant payment showed a more elastic quadratic equation compared with the function for flap-to-implant ratio versus flap payment. Probability modeling demonstrated that switching the reconstructive method from implants to flaps with a 0.75 probability required a $1610 payment increase, whereas switching from flaps to implants at the same certainty occurred at a loss of $960.

Conclusions: There was a correlation between the ratio of flaps to implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a relative value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort.

Evidence-Based Outcomes Article.

Stanford, Calif.; and New York, N.Y.

From the Division of Plastic and Reconstructive Surgery and the Clinical Excellence Research Center, Stanford University; and the Plastic and Reconstructive Surgery Service and Managed Care, Planning and Analysis Group, Memorial Sloan Kettering Cancer Center.

Received for publication October 28, 2017; accepted March 8, 2018.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

Evan Matros, M.D., M.M.Sc., M.P.H., Memorial Sloan Kettering Cancer Center, 1275 York Avenue, MRI 1036, New York, N.Y. 10065,

Copyright © 2018 by the American Society of Plastic Surgeons