Assessment of the current Medicare reimbursement system for breast cancer operations.
BACKGROUND
Medicare determines procedural reimbursement by means of formulas considering physician work, practice, and liability expenses. Since no mechanism exists to consider outcomes in calculating reimbursements, we hypothesized that Medicare reimbursements do not correlate with outcomes for different breast cancer operations.


METHODS
We prospectively studied 240 patients with T1, 2N0M0 breast cancer in three surgical treatment arms: segmental mastectomy with axillary node dissection (SM&ALND ; n = 42); SM with sentinel node dissection (SM&SLND ; n = 96); and mastectomy without reconstruction (MRM; n = 102). Outcome parameters of complications, hospital stay, analgesic usage, and days to return to work were correlated with procedure reimbursements.


RESULTS
Median follow-up was 26 months. SM&SLND patients rarely required hospital stays (14%) in comparison with either SM&ALND (96%) or MRM patients (99%) (P < 0.001). SM&ALND and MRM patients required 9 and 10 median days of narcotics, respectively, versus 1 day in the SLND group (P < 0.001). SM&SLND patients returned to work at a median of 3 days, in comparison with 19 for SM&ALND and 26 for MRM patients (P < 0.001). Complications were more common in the MRM group (67% numbness/10% pain) and the SM&ALND group (56%/9%) than in the SM&SLND group (0%/1%). Reimbursements were inversely correlated with outcomes. MRM was reimbursed the highest, at an average of 1,075.03 dollars, with SM&ALND at 882.72 dollars. SM&SLND was reimbursed at 642.00 dollars.


CONCLUSIONS
Medicare reimbursements for breast cancer operations do not correlate with outcomes. Less-invasive procedures are paid for at lower rates despite better outcomes and fewer complications. The data from this study raise the question of the impact of reimbursement on breast procedure selection.
Lucci
Anthony
A
Michael E. DeBakey Department of Surgery and the Breast Care Center at Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA. alucci@mdanderson.org
Shoher
Angela
A
Sherman
Marc O
MO
Azzizadeh
Ali
A
D000368:Aged; D001943:Breast Neoplasms / Q000601:surgery*; D005245:Fee Schedules; D005260:Female; D006801:Humans; D007349:Insurance, Health, Reimbursement; D008408:Mastectomy / Q000191:economics*; D015412:Mastectomy, Segmental / Q000191:economics*; D006278:Medicare / Q000191:economics*; D010347:Patient Care Planning; D011183:Postoperative Complications; D011446:Prospective Studies; D016896:Treatment Outcome; D014481:United States