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AUTOLOGOUS BREAST RECONSTRUCTION TECHNIQUES

AFTER MAMMARY RESECTIONTime 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

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* Fondation Registre du Cancer

Background

Patients claim about « Esthetic supplement »*

Plastic surgeons : « Fee for autologous breastreconstruction = insufficient »

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* 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

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Objectives

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Secondary objectives2. Description of Belgian practice3. Description of the medical context

1. Provide objective cost and time dataMain objective

How to value the surgical act?

Based on time-driven costing study

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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

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Step 1. List of activities

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Intervention Time

Prepareintervention

& anaesthesia

Marking(((Positioning

for Mastectomy)

(Ablative Surgery)

Positioningfor

reconstruction

Preparedonor flap

(Repositioningfor

Reconstruction)

Prepareacceptor

site

Microvascularanastomosis

Remodelbreast

Close donor site

(Lipofilling) (Lipo-Suction)

(Prosthesis) (Reduction) Wound dressing

Finish intervention

(NippleReconstruction)


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Intervention Time

Prepareintervention

& anaesthesia

Marking(Positioning

for Mastectomy)

(Ablative Surgery)

Positioningfor

reconstruction

Preparedonor flap

(Repositioningfor

Reconstruction)

Prepareacceptor

site


Remodelbreast

Close donor site



Finish intervention



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Intervention Time

Prepareintervention

& anaesthesia

Marking(Positioning

for Mastectomy)

(Ablative Surgery)

Positioningfor

reconstruction

Preparedonor flap

(Repositioningfor

Reconstruction)

Prepareacceptor

site


Remodelbreast

Close donor site


(Prosthesis) (Reduction) Wounddressing

Finish intervention



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Intervention Time

Prepareintervention

& anaesthesia

Marking(Positioning

for Mastectomy)

(Ablative Surgery)

Positioningfor

reconstruction

Preparedonor flap

(Repositioningfor

Reconstruction)

Prepareacceptor

site


Remodelbreast

Close donor site



Finish intervention



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Intervention Time

Prepareintervention

& anaesthesia

Marking(Positioning

for Mastectomy)

(Ablative Surgery)

Positioningfor

reconstruction

Preparedonor flap

(Repositioningfor

Reconstruction)

Prepareacceptor

site


Remodelbreast

Close donor site



Finish intervention


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

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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)

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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

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Scenario A Scenario B Scenario C

€133 €246 €163 €300 €228

€ 2 142

€ 2 584

€ 1945

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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, inclstart & stop activities) + Lipofilling + Liposuction + Nipple reconstruction + Tattoo + Scar correction + …

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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 variabilityNecessity to agree on a hourly remuneration

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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

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Bedankt, Merci, Thank you!

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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 Licencehttp://kce.fgov.be/content/about-copyrights-for-kce-reports.

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