The Insurance Landscape for Implant- and Autologous-based Breast Reconstruction in the United States

Louisa C Boyd; Jason A Greenfield; Sravya S Ainapurapu; Rachel Skladman; Gary Skolnick; Durai Sundaramoorthi; Justin M Sacks

doi:10.1097/GOX.0000000000004818

The Insurance Landscape for Implant- and Autologous-based Breast Reconstruction in the United States

Plast Reconstr Surg Glob Open. 2023 Feb 17;11(2):e4818. doi: 10.1097/GOX.0000000000004818. eCollection 2023 Feb.

Authors

Louisa C Boyd¹, Jason A Greenfield², Sravya S Ainapurapu³, Rachel Skladman⁴, Gary Skolnick⁴, Durai Sundaramoorthi⁵, Justin M Sacks⁴

Affiliations

¹ Division of Plastic and Reconstructive Surgery, Saint Louis University School of Medicine, Saint Louis, Mo.
² Miller School of Medicine, University of Miami, Miami, Fla.
³ James McKelvey School of Engineering, Washington University in Saint Louis, Saint Louis, Mo.
⁴ Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Mo.
⁵ Olin School of Business, Washington University in Saint Louis, Saint Louis, Mo.

Abstract

Insurance coverage of postmastectomy breast reconstruction is mandated in America, regardless of reconstructive modality. Despite enhanced patient-reported outcomes, autologous reconstruction is utilized less than nonautologous reconstruction nationally. Lower reimbursement from Medicare and Medicaid may disincentivize autologous-based reconstruction. This study examines the impact of insurance and sociodemographic factors on breast reconstruction.

Methods: A retrospective analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database from 2014 to 2017 was performed. International Classification of Diseases Clinical Modification and Procedure Coding System codes were used to identify patients for inclusion. De-identified sociodemographic and insurance data were analyzed using χ ², least absolute shrinkage and selection operator regression analysis, and classification trees.

Results: In total, 31,468 patients were identified for analysis and stratified by reconstructive modality, sociodemographics, insurance, and hospital characteristics. Most patients underwent nonautologous reconstruction (63.2%). Deep inferior epigastric perforator flaps were the most common autologous modality (46.7%). Least absolute shrinkage and selection operator regression identified Black race, urban-teaching hospitals, nonsmoking status, and obesity to be associated with autologous reconstruction. Publicly-insured patients were less likely to undergo autologous reconstruction than privately-insured patients. Within autologous reconstruction, publicly-insured patients were 1.97 (P < 0.001) times as likely to obtain pedicled flaps than free flaps. Black patients were 33% (P < 0.001) less likely to obtain free flaps than White patients.

Conclusions: Breast reconstruction is influenced by insurance, hospital demographics, and sociodemographic factors. Action to mitigate this health disparity should be undertaken so that surgical decision-making is solely dependent upon medical and anatomic factors.