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Discussion: Impact of Insurance Payer on Type of Breast Reconstruction Performed.

9e I this article, Chouairi et al. retrospectively examined 1640 breast reconstructions performed by 16 academic and community surgeons at Yale, collecting procedure type, comorbidity, and insurance status.1 Patients with Medicare and Medicaid were older and had a greater incidence of obesity, hypertension, active smoking, and American Society of Anesthesiologists classification greater than 3. On univariate analysis, the authors demonstrated that patients with commercial insurance were more likely to undergo autologous breast reconstruction compared to patients with Medicare or Medicaid. Among patients undergoing autologous breast reconstruction, patients with higher income and commercial insurance were more likely than their counterparts to undergo deep inferior epigastric artery perforator flap surgery than musclesparing transverse rectus abdominis muscle flap surgery. On multivariate analysis, controlling for age, comorbidities, surgical history, and cancer characteristics, these disparities persisted. Interestingly, among private surgeons operating at Yale, commercial insurance was also predictive of receipt of a deep inferior epigastric artery perforator flap by 10-fold, which the authors posit is a result of S-code availability. Specific marketing patterns of these private surgeons may also incentivize their behavior and skew the overall data set. The authors do a laudable job of critically examining practice patterns and identifying insurance status disparities within a single institution. The results are timely and warrant a greater discussion. Despite a multitude of evidence suggesting superior long-term satisfaction and improved quality of life, many studies have found that autologous breast reconstruction rates have remained stagnant, whereas prosthesis-based reconstructions have become the most common form of reconstruction since 2002.2–5 This trend correlates with changes in professional fees, which have declined for autologous breast reconstruction but remained steady for prosthesis-based reconstruction, translating into a 300 to 1000 percent difference per operating room hour.6,7 Albornoz et al. similarly found that Medicare patients were 1.45 times more likely to undergo prosthesis-based reconstruction.5 When examining facility fees, prosthesis-based reconstruction was found to generate a decrease in total income, which one can predict to be further exacerbated by increased use of acellular dermal matrix in prepectoral reconstruction, routine use of indocyanine green scans, and overall implant costs.6 A helpful framework of thought when considering disparities in receipt of surgical care and outcomes is to consider patient, provider, and systemic factors exacerbating disparities along the breast reconstruction pathway.8 From initial consultation to delivery of breast reconstruction, the complex interplay of these factors significantly influences the initial decision-making to the delivery of reconstruction.9,10 Historically, insurance has been considered a patient and systemic factor. Patients may suffer delays in care as a result of their insurance (or lack thereof) and the limitations of safety net hospitals with a high Medicaid burden.11–14 However, emerging evidence and one of the conclusions of this study now posits that type of patient insurance can be a provider factor. Controlling for patient characteristics and capabilities of a single center, the differences in provider practice pattern based on insurance generate measurable differences in reconstructive choice. Similar findings have been found in the orthopedic literature, where in a single center, disparate repair rates of meniscal tears were identified among patients with differing insurances.15