Reply; Reply: “The Influence of Physician Payments on the Method of Breast Reconstruction: a National Claims Analysis”

Dear Dr. Rohrich,

We appreciate the thoughtful commentary submitted by Mullens et al regarding our recent investigation of physician payments and method of breast reconstruction(1). Their appraisal probes into the nuances of physician remuneration and the complex relationship with surgical decision-making.

Mullens et al describe the limits of reconstructive surgeons relative to their training; those surgeons without microsurgical training likely do not offer autologous microvascular breast reconstruction. For this reason, we analyzed payments at the market level—as defined by the Blue Health Intelligence database(2). We purposefully did not want to confound the study with markets that did not perform microvascular breast reconstruction; thus, we excluded any market that performed less than five flaps per year. We cannot speak to the training of surgeons within the markets that performed flaps; however, we make the assumption that these cases were performed by reconstructive surgeons who have the ability to perform implant-based reconstruction as well.

Regarding the complexities of physician reimbursement, we were fortunate to use a single payer in our analysis (i.e. Blue Health Intelligence), which removes confounding from macro-reimbursement structures. For example, if one performed a similar analysis including mixed payer types—especially managed care payers—then it would be difficult to draw conclusions. In that setting, salaried physicians might not see the actual reimbursements, and therefore, there would be no financial incentive to perform a particular operation. It would be interesting to evaluate our findings with other payers. Additional studies looking at capitated systems could evaluate whether salaried surgeons without bonus structures perform autologous reconstruction at higher or lower frequency.

Even with a commercial payer, depending on the institution and contract, surgeons often receive a proportion of the collected payment. Assuming that the fraction of collections is the same for tissue expanders and flaps, this should not affect the conclusions within our study. Our study is limited, however, by the assumption that surgeons are reimbursed based on collections. If instead an institution reimburses based on Revenue Value Unit (RVU) schedules, the payments from insurers are moot. In that setting, RVU schedules are the sole determinate of individual surgeon payments.

Our study was performed at the population level, and all conclusions should be drawn within that context. We do not intend to overstate our findings or suggest applicability to every reconstructive breast surgeon in the US. Our ultimate goal was to encourage a national conversation regarding surgeon payment and breast reconstruction, such that surgeons can provide women with their desired method of reconstruction without financial persuasion.

Sincerely,

Clifford Sheckter, Evan Matros