Plastic Surgery Research Council
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Impact of Physician Payment Variation on Breast Reconstruction Method: A National Claims Database Analysis
Shantanu N. Razdan, MD MSPH, Hina J. Panchal, MD MPH, Day Yi, MS, Claudia R. Albornoz, MD MPH, Joseph J. Disa, MD, Peter G. Cordeiro, MD, Babak Mehrara, MD, Evan Matros, MD MMSc. MPH.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Abstract
Purpose: Despite associations with greater quality of life, autologous transfer represents a declining proportion of US breast reconstructions. Poor physician reimbursement relative to prosthetic reconstructions may be a barrier contributing to this trend. The study aims to evaluate the impact of relative physician payments for common methods of immediate breast reconstruction (IBR). Methods: Following IRB approval, the Blue Health Intelligence (BlueCross/BlueShield) national claims database was analyzed from 2009 through 2013. Procedural volume and payments for plastic surgeon professional services were calculated for two common IBR methods: tissue expander (TE) and free flap (FF). Results: Of 25,209 patients who had IBR, 84.4% received tissue expanders (TE) and 15.6% underwent free flaps(FF). Five-year growth-rate in TE: FF was 4.3%. Average physician payment increased 18% for TE versus 14% for FF. Payment variation, expressed as the standard deviation relative to mean, was significantly greater for FF (116%) than TE(59%) [Figure 1]. Markets that experienced a $1,000 gain in TE payment, increased the TE:FF on average 103% (p<.05). The same gains in FF payment increased the FF:TE by 74% (p<.05)[Figure 2]. Conclusion: Physician payments are increasing at a greater rate for TE than FF. Markets are significantly more responsive to payment changes in TE than FF, suggesting larger scale changes in payment would be needed to influence flap growth. An alternative interpretation is that barriers beyond reimbursement may influence the number of FF performed. Larger payment variation for FF supports greater room for reimbursement negotiation.
Figure 1: Density plot illustrating greater payment variation for free flap (FF) compared to tissue expanders (TE)
Figure 2. Bubble chart illustrating the relationship between an increase in metropolitan statistical area physician payment (X-axis) versus ratio of reconstructive methods (Y-axis)


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