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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
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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
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Background
Patients claim about « Esthetic supplement »*
Plastic surgeons : « Fee for autologous breastreconstruction = insufficient »
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* Gemiddelde € 2620 - Vlaamse Liga tegen Kanker
But….
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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
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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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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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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) Wounddressing
Finish intervention
(NippleReconstruction)
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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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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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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
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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
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€ 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
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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?
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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