Abstract
Background With greater acceptance of postmastectomy breast reconstruction (PMBR) as a safe
and reliable treatment option, the role of plastic surgeons in breast cancer management
continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals
may increase charges. Excessive markups can negatively affect uninsured and underinsured
patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain
insights into recent trends in utilization and billing.
Methods We queried the 2013 to 2020 Medicare Provider Utilization and Payment Data with 14
Current Procedural Terminology (CPT) codes to collect service count numbers, hospital
charges, and reimbursements. We calculated utilization (service counts per million
female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement
ratios (CRRs). We calculated total and annual percentage changes for the included
CPT codes.
Results Among the 14 CPT codes, 12 CPT codes (85.7%) with nonzero service counts were included.
Utilization of mastectomy and breast reconstruction procedures decreased from 1,889
to 1,288 (−31.8%) procedures per million female Medicare beneficiaries from 2013 to
2020. While the utilization of immediate implant placements (CPT 19340) increased
by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%.
Reimbursements for the included CPT codes changed minimally over time (−2.9%) but
charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to
4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest
CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%).
Conclusions Our analysis of mastectomy and breast reconstruction procedures billed to Medicare
Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in
hospital charges and CRRs may limit uninsured and underinsured patients from accessing
necessary care for breast cancer management. Legislations that monitor hospital markups
for PMBR procedures may be considered by policymakers.
Keyword
breast reconstruction - mastectomy - billing - markup - breast cancer
