We are pleased to see the article by Sheckter et al.,1 regarding physician payments and their potential influence on breast reconstruction, added to the literature. The authors should be commended for their application of rigorous study design, bootstrapping models, financial modeling, and geographic mapping to breast reconstruction in order to better understand practice patterns. However, the conclusions made in this study are not fully substantiated due to consideration of limitations, which may mislead readers of this article.
The authors discuss the “preference sensitive” nature of breast reconstruction, meaning that the modality of reconstruction utilized is decided based on physician and patient preferences. However, evidence suggests that patient preferences in breast reconstruction are highly influenced by physician preferences.2
Microsurgery-based breast reconstruction typically requires additional training and experience in order to achieve acceptable outcomes. Many plastic surgeons who lack training in reconstructive microsurgery do not include microsurgery-based breast reconstruction as part of their practice’s armamentarium. Moreover, microsurgery is a resource-intensive endeavor, which we should not assume can be supported by all institutions. In addition, the conclusions drawn by the authors surrounding the probability of reconstructive method based on per-procedure payment changes is potentially misleading. While extensive statistical methods were performed by the authors, the nature of their data (population-based) should prevent them from making claims surrounding the impact of payment structures on a per-surgeon basis. The unknown impact of significant payment increase on hospital infrastructure is a potential confounder to their claim that payment increase is required to switch from implant-based to flap-based reconstruction. Payer reimbursement rates are known to drive hospital infrastructural change, which has led to an increase in support for subspecialty surgical procedures over time.3
While reimbursement rates may serve as part of the driving force behind shifts in reconstructive method, the three aforementioned points are undoubtedly also part of the preference-sensitive paradigm. To appreciate the key takeaways of this thoughtful study, we believe it is important for other readers to also understand the factors outlined in this letter, which could limit conclusions drawn by the authors.
Dr. Serletti is a stockholder in Johnson & Johnson, Pfizer, and Merck. The senior author (J.M.S.) has received payment in the last 18 months for consultation to Axogen. The remaining authors have no financial conflicts to disclose.
Cody L. Mullens, B.S.West Virginia University School of MedicineMorgantown, W.Va.Perelman School of MedicineUniversity of PennsylvaniaPhiladelphia, Pa.
J. Andres Hernandez, B.S.Perelman School of MedicineUniversity of PennsylvaniaPhiladelphia, Pa.
Joseph M. Serletti, M.D.Division of Plastic SurgeryDepartment of SurgeryPerelman School of MedicineUniversity of PennsylvaniaPhiladelphia, Pa.
1. Sheckter CC, Panchal HJ, Razdan SN, et al. The influence of physician payments on the method of breast reconstruction: A national claims analysis. Plast Reconstr Surg. 2018;142:434e–442e.
2. Hasak JM, Myckatyn TM, Grabinski VF, Philpott SE, Parikh RP, Politi MC. Stakeholders’ perspectives on postmastectomy breast reconstruction: Recognizing ways to improve shared decision making. Plast Reconstr Surg Glob Open 2017;5:e1569.
3. Field RI. Mother of Invention: How the Government Created “Free-Market” Health Care. 2013.Oxford, United Kingdom: Oxford University Press.