From the Plastic and Reconstructive Surgery Service, Department of Surgery, and the Department of Finance, Memorial Sloan Kettering Cancer Center; the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center; and the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System.
Plast Reconstr Surg. 2021 Mar 1;147(3):505-513. doi: 10.1097/PRS.0000000000007679.
Commercial payments for implant-based breast reconstruction have increased within the past decade, whereas reimbursements have stagnated for microsurgical techniques. The physician payment-to-work relative value unit ratio allows for standardization when comparing procedures of differing complexity. This study aimed to characterize payment per work relative value unit for common breast and nonbreast microsurgical procedures.
The Massachusetts All-Payer Claims Database was queried from 2010 to 2014 for Current Procedural Terminology (CPT) codes related to microsurgical and breast reconstruction. International Classification of Diseases codes were further used to categorize procedures by anatomical region, including head and neck, breast, trunk, and extremities. Physician payments, both commercial and governmental, were aggregated by anatomical region and CPT code. Payment distributions were described with means and medians and compared using statistical tests.
Among 3435 commercial claims, distributions of physician payments per work relative value unit for microsurgical and common breast procedures differed only for breast free flaps billed through S codes (p < 0.001). Microsurgical breast procedures (CPT code 19364) had significantly greater median payments per work relative value unit compared to microsurgery of the head and neck, trunk, and upper extremities (p = 0.004). Payment per work relative value unit for common breast and nonbreast microsurgical procedures did not differ significantly among governmental claims (p = 0.103).
Adjustment of physician payments by work relative value units did not show significant variability across common breast procedures, except for S codes, suggesting that payments are mostly driven by differences in work relative value units and individual contractual negotiations. Lower payments per work relative value unit for other regions compared to breast suggests an opportunity for negotiation with commercial payers.
在过去十年中，基于植入物的乳房重建的商业支付有所增加，而显微外科技术的报销却停滞不前。医师支付与工作相对价值单位的比率允许在比较不同复杂程度的程序时进行标准化。本研究旨在描述常见乳房和非乳房显微外科手术的每工作相对价值单位的支付情况。
从 2010 年到 2014 年，从马萨诸塞州全支付者索赔数据库中查询了与显微外科和乳房重建相关的当前程序术语 (CPT) 代码。进一步使用国际疾病分类代码按解剖区域对程序进行分类，包括头颈部、乳房、躯干和四肢。按解剖区域和 CPT 代码对医师的商业和政府支付进行汇总。使用统计检验描述支付分布的平均值和中位数，并进行比较。
在 3435 份商业索赔中，显微外科和常见乳房手术的医师每工作相对价值单位支付的分布仅在通过 S 代码计费的乳房游离皮瓣方面有所不同（p < 0.001）。与头颈部、躯干和上肢的显微外科手术相比，乳房显微外科手术（CPT 代码 19364）的每工作相对价值单位的中位支付显著更高（p = 0.004）。在政府索赔中，常见乳房和非乳房显微外科手术的每工作相对价值单位的支付没有显著差异（p = 0.103）。
按工作相对价值单位调整医师支付并没有显示常见乳房手术之间有显著差异，除了 S 代码外，这表明支付主要由工作相对价值单位和个别合同谈判的差异驱动。与乳房相比，其他区域的每工作相对价值单位支付较低表明有机会与商业支付者进行谈判。
