From the Plastic and Reconstructive Surgery Service, Department of Surgery, and Department of Finance, Memorial Sloan Kettering Cancer Center; Division of Plastic and Reconstructive Surgery, Stanford University Medical Center; and Section of Plastic Surgery, Department of Surgery, University of Michigan Health System.
Plast Reconstr Surg. 2020 Feb;145(2):333-339. doi: 10.1097/PRS.0000000000006453.
Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction.
The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality.
Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001).
Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
与假体技术相比，自体乳房重建的比例停滞不前。对显微自体乳房重建术医生薪酬不足是一个可能的解释。政府和商业支付者之间的薪酬差异创造了一个自然实验，以评估其对重建方法的影响。本研究评估了保险类型对接受显微自体乳房重建和植入物的可能性的影响。
从 2010 年至 2014 年，马萨诸塞州全支付者索赔数据库对接受即刻自体或植入乳房重建的女性进行了查询。单变量分析比较了不同重建方法的人口统计学和临床特征。逻辑回归探讨了保险类型和医生薪酬对乳房重建方式的相对影响。
在本研究的女性中，82.7%有商业保险，17.3%有政府保险。80%的女性接受了植入物，而 20%的女性接受了显微自体重建。与商业保险相比，拥有医疗补助的女性接受显微自体重建的可能性较小（16.4%比 20.3%；p=0.063）。商业保险、年龄较大和肥胖独立增加了接受显微重建的可能性（p<0.01）。比较中位医生支付金额，政府支付者为显微重建支付的费用比商业支付者低 78%和 63%（1831 美元比 8435 美元）和植入物（1249 美元比 3359 美元）。分层分析表明，随着医生支付金额的增加，接受显微重建的可能性也随之增加，与保险类型无关（p<0.001）。
与商业支付者相比，拥有政府保险的女性接受显微自体乳房重建的可能性较低。无论支付者如何，对显微重建的更多报销增加了接受显微重建的可能性。与假体技术相比，目前对显微自体乳房重建的报销可能与医生的工作量不成比例。
临床问题/证据水平：风险，II。
