Procedural Trends in Medicare Reimbursement and Utilization for Breast Reconstruction

Abstract

PurposeDevelopment of appropriate reimbursement models for breast reconstruction in the United States requires an understanding of relevant economic trends. The purpose of this study is to evaluate longitudinal patterns in Medicare reimbursement for frequently performed breast reconstruction procedures between 2000 and 2019.MethodsReimbursement data for 15 commonly performed breast reconstruction procedures were analyzed using the Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool for each Current Procedural Terminology code. By utilizing changes to the US consumer price index, monetary data were adjusted for inflation to 2019 US dollars. Inflation-adjusted trends were used to calculate average annual and total percentage changes in reimbursement over time.ResultsFrom 2000 to 2019, average adjusted reimbursement for all procedures fell by 13.32%. All procedures demonstrated a negative adjusted reimbursement rate other than immediate insertion of breast prosthesis, which increased by 55.37%. The largest mean decrease was observed in breast reconstruction with other technique (−28.63%), followed by single pedicle transverse rectus abdominis myocutaneous flap (−26.02%), single pedicle transverse rectus abdominis myocutaneous flap with microvascular anastomosis (−23.33%), latissimus dorsi flap (−19.65%), and free flap reconstruction (−19.36%).ConclusionsThere has been a steady yet substantial decline in Medicare reimbursement for the majority of breast reconstruction procedures over the last 20 years. Given increasing medical costs and the financial uncertainty of the US health care system, an understanding of Medicare reimbursement trends is vital for policymakers, administrators, and physicians to develop agreeable reimbursement models that facilitate growth and economic vitality of breast reconstruction in the United States.

Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020

“…We initially hypothesized that decreasing Medicare reimbursement rates may be a potential driving force for changes in hospital charges, as studies in various surgical specialties have demonstrated a decline in Medicare reimbursement rates. 7 8 9 13 25 26 However, we found that reimbursements minimally changed over the study period, while hospital charges continued to rise rapidly at a rate faster than the overall Medicare Part B (+29.5% for mastectomy and breast reconstruction CPT codes vs. +11.6% for all CPT codes). One potential contributing factor to excess charges may include the significance of mastectomies and PMBRs in the surgeon's practice.…”

Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020

“…We initially hypothesized that decreasing Medicare reimbursement rates may be a potential driving force for changes in hospital charges, as studies in various surgical specialties have demonstrated a decline in Medicare reimbursement rates. [7][8][9]13,25,26 However, we found that reimbursements minimally changed over the study period, while hospital charges continued to rise rapidly at a rate faster than the overall Medicare Part B (+29.5% for mastectomy and breast reconstruction CPT codes vs. +11.6% for all CPT codes). One potential contributing factor to excess charges may include the significance of mastectomies and PMBRs in the surgeon's practice.…”

Discussion: Comparing Trends in Medicare Reimbursement and Inflation within Plastic Surgery Subspecialties

“…The authors observed a specialty-wide undervaluation from 2010 to 2020, in line with prior studies on Medicare reimbursement for plastic and reconstructive surgery. [2][3][4] Undervaluation affected microsurgery (−19.2%) and craniofacial surgery (−17.6%) the most, whereas hand surgery (-9.1%) and breast surgery (-6.9%) were the least impacted. The authors' findings serve as a call to action for the Centers for Medicare & Medicaid Services (CMS) to improve its reimbursement methodologies.…”

“…The authors observed a specialty-wide undervaluation from 2010 to 2020, in line with prior studies on Medicare reimbursement for plastic and reconstructive surgery. 2–4…”