AUTOLOGOUS BREAST RECONSTRUCTION TECHNIQUES · PDF file 2017. 6. 19. · AUTOLOGOUS...

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Transcript of AUTOLOGOUS BREAST RECONSTRUCTION TECHNIQUES · PDF file 2017. 6. 19. · AUTOLOGOUS...

  • AUTOLOGOUS BREAST RECONSTRUCTION TECHNIQUES

    AFTER MAMMARY RESECTION Time measurements for a potential re-

    evaluation of the surgeon fee

    Sophie GerkensCA - RvB, 15/09/15

    SOPHIE GERKENS, STEFAAN VAN DE SANDE, ROOS LEROY, ANNE-SOPHIE MERTENS, JONATHAN SCHREIBER, DRIES VAN HALEWYCK, JAN BELLAERT, HANS VAN BRABANDT, NATHALIE SWARTENBROEKX, CAROLINE OBYN

  • Background

     Breast cancer: each year, >10 000* woman  Treatment includes a mammary resection for most  Breast reconstruction is reimbursed by NIHDI

     Implant  Autologous breast reconstruction

    2

    * Fondation Registre du Cancer

  • Background

     Patients claim about « Esthetic supplement »*

     Plastic surgeons : « Fee for autologous breast reconstruction = insufficient »

    3

    * Gemiddelde € 2620 - Vlaamse Liga tegen Kanker

    But….

  • Background

     September 2015 - Negotiations at RIZIV-INAMI:  Re-evaluation of the fee  Question of supplements  KCE was asked to determine what would be a fair

    remuneration?  Response = global revision of the nomenclature  Not possible in the timing of the negotiations

    4

  • Objectives

    5

    Secondary objectives 2. Description of Belgian practice 3. Description of the medical context

    1. Provide objective cost and time data Main objective

  • How to value the surgical act?

     Based on time-driven costing study

    6

  • 3 steps

    Step 1 • Which activities are performed during a

    reconstruction?

    Step 2 • Which resources are used?

    Step 3 • How to link these resources to activities?

    • Measured time x cost per hour

    7

  • Step 1. List of activities

    8

    Intervention Time

    Prepare intervention

    & anaesthesia

    Marking (((Positioning

    for Mastectomy)

    (Ablative Surgery)

    Positioning for

    reconstruction

    Prepare donor flap

    (Repositioning for

    Reconstruction)

    Prepare acceptor

    site

    Microvascular anastomosis

    Remodel breast

    Close donor site

    (Lipofilling) (Lipo- Suction)

    (Prosthesis) (Reduction) Wound dressing

    Finish intervention

    (Nipple Reconstruction)

  • Step 1. List of activities

    9

    Intervention Time

    Prepare intervention

    & anaesthesia

    Marking (Positioning

    for Mastectomy)

    (Ablative Surgery)

    Positioning for

    reconstruction

    Prepare donor flap

    (Repositioning for

    Reconstruction)

    Prepare acceptor

    site

    Microvascular anastomosis

    Remodel breast

    Close donor site

    (Lipofilling) (Lipo- Suction)

    (Prosthesis) (Reduction) Wound dressing

    Finish intervention

    (Nipple Reconstruction)

  • Step 1. List of activities

    10

    Intervention Time

    Prepare intervention

    & anaesthesia

    Marking (Positioning

    for Mastectomy)

    (Ablative Surgery)

    Positioning for

    reconstruction

    Prepare donor flap

    (Repositioning for

    Reconstruction)

    Prepare acceptor

    site

    Microvascular anastomosis

    Remodel breast

    Close donor site

    (Lipofilling) (Lipo- Suction)

    (Prosthesis) (Reduction) Wound dressing

    Finish intervention

    (Nipple Reconstruction)

  • Step 1. List of activities

    11

    Intervention Time

    Prepare intervention

    & anaesthesia

    Marking (Positioning

    for Mastectomy)

    (Ablative Surgery)

    Positioning for

    reconstruction

    Prepare donor flap

    (Repositioning for

    Reconstruction)

    Prepare acceptor

    site

    Microvascular anastomosis

    Remodel breast

    Close donor site

    (Lipofilling) (Lipo- Suction)

    (Prosthesis) (Reduction) Wound dressing

    Finish intervention

    (Nipple Reconstruction)

  • Step 1. List of activities

    12

    Intervention Time

    Prepare intervention

    & anaesthesia

    Marking (Positioning

    for Mastectomy)

    (Ablative Surgery)

    Positioning for

    reconstruction

    Prepare donor flap

    (Repositioning for

    Reconstruction)

    Prepare acceptor

    site

    Microvascular anastomosis

    Remodel breast

    Close donor site

    (Lipofilling) (Lipo- Suction)

    (Prosthesis) (Reduction) Wound dressing

    Finish intervention

    (Nipple Reconstruction)

  • Step 2: Which resources?  Only resources that are covered by the physician fee

    13

    OR building and equipments

    OR nurses and other staff

    Materials

    Overhead

    Hospital budget

    Deductions en direct payments

    Surgeon act

    Surgeon fee

    Valued using the gross remuneration

  • Step 3: How to link these resources to activities?  Cumulative time of the activities

    (10 teams – 3 months) X

     Cost per hour (gross remuneration)

    14

  • Cost per hour : 3 scenarios  Scenario A: Gross remuneration of plastic surgeon  Scenario B: Average remuneration of all medical specialists  Scenario C: Fee for a breast reconstruction with prosthesis

     Scenario A & B: => KCE manual for cost studies (per half day, not per hour) => Number of RIZIV-INAMI hours per half day?  Average : 3h21  Minimum: 1h49

     15

    Scenario A Scenario B Scenario C

    €133 €246 €163 €300 €228

  • € 2 142

    € 2 584

    € 1945

    16

    Scenario A (Plastic surgeon)

    Scenario C (Fee for a prosthesis /

    average intervention time)

    Scenario B (All medical specialists)

    € 1 125 €1 341

    € 1 816

    € 2 344

    € 1 998

    RIZIV-INAMI fee 2015: €1 527

    +70%

    DIEP unilateral

    Average (3h21 per half day)

    Upper Bound

    (1h49 per half day)

    With start & stop

    activities

  • Most generous scenario for a DIEP

     2584 € (based on the max. cost-hour, incl start & stop activities)  + Lipofilling  + Liposuction  + Nipple reconstruction  + Tattoo  + Scar correction  + …

    17

  • But … important variation in results and a lot of limitations  Cost per hour

     Scenario A based on the current RIZIV-INAMI remuneration of plastic surgeons (they consider as insufficient, at least for autologous breast reconstructions)

    Vicious circle: Unsurprisingly, scenario A does not result in (much) higher costs compared to current reimbursement levels

    Other scenario (also with limitations)  Number of billable hours per half day

     Parameter with a critical impact BUT  Lack of data & important variability Necessity to agree on a hourly remuneration

    18

  • Recommendations  Current analysis can only be used for a temporary fee revision  A more global revision across medical specialists

    • Agreement on a fair and reasonable base hourly income for a physician • Adjusted for other factors, e.g.

     level of required expertise and experience  risks (including litigation risk) and stress  required intellectual effort  …

     Requires a simultaneous analysis across all medical specialists • to ensure coherency, and • to allow estimating and controlling the impact on aggregate expenditures

    ≠ consecutive analyses for 1 activity within 1 specialty

    19

  • Bedankt, Merci, Thank you!

    20

    Key message:

    Time to begin the vast challenge of a global revision of the nomenclature?

  • Colophon  Author(s): Sophie Gerkens, Stefaan Van De Sande, Roos Leroy,

    Anne-sophie Mertens, Jonathan Schreiber, Dries Van Halewyck, Jan Bellaert, Hans Van Brabandt, Nathalie Swartenbroekx, Caroline Obyn

     Publication date: 25 September 2015  Domain: Health Technology Assessment (HTA)  MeSH: Costs and Cost Analysis; Hospital Costs; Operative Time;

    Reimbursement Mechanisms; Surgical Flaps; Mammaplasty  NLM Classification: W74  Language: English  Format: Adobe® PDF™ (A4)  Legal depot: D/2015/10.273/88  Copyright: KCE reports are published under a “by/nc/nd”

    Creative Commons Licence http://kce.fgov.be/content/about-copyrights-for-kce-reports.

    This document is available on the website of the Belgian Health Care Knowledge Centre.21