Impact of Insurance Payer and Socioeconomic Status on Type of Autologous Breast Reconstruction
Jacob Dinis, B.S1, Alexandra Junn, A.B1, Fouad Chouairi, B.S1, Michael Mercier, B.A1, Tomer Avraham, M.D1, Evan Matros, M.D, MMSc, MPH2, Michael Alperovich, M.D, M.Sc1
1Department of Surgery, Yale University School of Medicine, New Haven, CT, USA, 2Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center New York, NY, USA
Purpose: Autologous breast reconstruction has evolved from more morbid procedures that sacrificed the patient’s abdominal muscle (the TRAM or transverse rectus abdominus muscle flap) to more elegant autologous reconstructions termed “perforator” flaps that spare fascia and muscle to harvest only the adipose tissue. Commercial insurers have recognized the higher technical demand for perforator flaps relative to other autologous reconstructions by creating separate procedural codes with significantly higher professional fees. This study examined whether a perforator flap procedure code unavailable with Federally issued Medicare or Medicaid disproportionally incentivizes perforator flaps among the commercially insured and, subsequently, patients from a higher socioeconomic status.
Methods: Autologous reconstructions performed between 2008 and 2014 were reviewed from the National Inpatient Sample (NIS) using the ICD-9-CM procedure codes 85.72, 85.73, 85.74, 85.75, 85.76. Extracted variables included age, race, comorbidities, hospital type, hospital region, insurance payer type, and median household income quartile. Autologous breast reconstruction was subdivided into microvascular perforator flaps (85.74, 85.75, 85.76), microvascular TRAM flaps (85.73), and pedicled TRAM flaps (85.72). Demographics, comorbidities and access to care were compared between cohorts by chi-squared and ANOVA tests. A logistic regression comparing microvascular reconstructions only was created to predict the effects of insurance, geography, income quartile, and race on the likelihood of perforator flap reconstruction while controlling for age and comorbidities.
Results: After querying and weighting NIS data, 33,246 microvascular perforator flap breast reconstructions, 16,804 microvascular TRAM flap reconstructions, and 16,918 pedicled TRAM flap reconstructions were compared.The majority of patients undergoing autologous reconstruction were white (64.1%) with a mean age of 51.1 years. Patients receiving microvascular perforator flaps had fewer total comorbidities than patients receiving microvascular TRAM (p<0.001) or pedicled TRAM (p=0.003) flaps. Perforator flaps were significantly more likely among the commercially insured (perforator flap: 85.8% vs. microvascular TRAM: 75.9% vs. pedicled TRAM: 75.0%, p<0.001). Patients of higher income quartiles were significantly more likely to receive perforator flap autologous reconstruction (p<0.001).When comparing microvascular reconstruction, logistic regression revealed an odds ratio of 1.72 (p<0.001) for perforator flaps among the commercially insured as compared to patients with Medicare or Medicaid. As compared to the lowest income quartile, the second quartile had an odds ratio of 1.11 (p=0.003) for perforator flap reconstruction, the third 1.07 (p=0.029), and the fourth 1.36 (p<0.001).
Conclusion: Reimbursement incentives disproportionally favor perforator flap autologous reconstruction among the commercially insured. Differences across insurance status exaggerate already existing disparities in breast reconstruction across socioeconomic status.
Back to 2021 Abstracts