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

Introduction: Flap-based breast reconstruction demands greater operative labor and offers superior patient reported outcomes compared to implants. However, implants continue 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 2009-2013, patients were identified who received tissue expander (i.e. implant) or free-flap breast reconstruction. The ratio of implants/flaps and physician payments was 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: 21,259 episodes of breast reconstruction occurred within 122 U.S. markets. The distribution of implant/flap ratio varied by market, ranging from 5th percentile at 1.63 to 95th percentile at 43.7 (median 6.19). Modeling the implant/flap ratio vs. implant payment showed a more elastic quadratic equation (f(x)=0.955x2 + 2.766x) compared to the function for flap/implant ratio vs. flap payment (f(x)=-0.061x2 + 0.734x). Probability modeling demonstrated that switching the reconstructive method from implants to flaps with 0.75 probability required a $1,610 payment increase, while switching from flaps to implants at the same certainty occurred at a loss of $960. Conclusion: There was a correlation between the ratio of flaps/implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a revenue value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort. Financial Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Funding: This research was funded in part though the NIH/NCI Cancer Center Support Grant P30 CA008748 Acknowledgement: none Corresponding Author: Evan Matros, MD, MMSc, MPH, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, MRI 1036, New York, N.Y. 10065, matrose@mskcc.org ©2018American Society of Plastic Surgeons

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