To Rachana Pradhan and By Anna Werner CBS News and By Lee Ann Winnick, CBS News
The federal government is reconsidering a decision that would limit women’s reconstructive surgery options after protests by breast cancer patients, plastic surgeons and lawmakers.
This procedure offers potential advantages over implants and surgery that harvest muscle from the abdomen. But it also comes at a higher price. Patients undergoing uninsured surgery can cost upwards of $50,000. Plastic surgeons’ associations also argue that some surgeons in their network will stop offering surgeries if the government’s decision causes insurance companies to significantly reduce the cost of surgery.
DIEP flap controversy, Featured on CBS News in Januarypresents an esoteric and indirect way the federal government can influence the health care options available to even those with private insurance. In many cases, the answer comes down to billing codes (identifying specific medical services on the forms doctors submit for reimbursement) and competing petitions of groups that pledge their interests.
Medical coding is at the core of “how we do business in healthcare,” he said. Karen Joint Maddoxa physician at the Washington University School of Medicine in St. Louis, who studies health economics and policy.
CMS, the agency that oversees Medicare and Medicaid, maintains lists of codes representing thousands of medical services and products. Periodically evaluate whether to add code or modify or remove existing code. Last year, it decided to repeal a provision that allowed doctors to raise far more money for DIEP flap surgery than for simpler types of breast reconstruction.
In 2006, CMS established an ‘S’ code S2068 for breast reconstruction with a then relatively new procedure, the deep perforating vein flap (DIEP flap). S code temporarily fills a gap in parallel system billing code known as CPT code. The CPT Code is maintained by the American Medical Association, a medical association.
The law does not specify how much private insurance companies pay for medical services. These reimbursements are usually negotiated between the insurance company and the healthcare provider. However, physicians and hospitals can use targeted S-codes to differentiate DIEP flap surgery, which requires complex microsurgical techniques, from other forms of surgery that are shorter in duration and generally have lower reimbursement. of breast reconstruction can now be distinguished.
In 2022, CMS announced plans to retire the S code by the end of 2024, which some doctors claim will cut surgeons’ fees. (CMS, to be precise, has announced that it will retire a series of three S codes for similar operations, but some of the more acrimonious critics have focused on one of them, S2068.) The agency’s decision has already changed the landscape of reconstructive surgery and brought new creations. Anxiety in breast cancer patients.
Kate Getz, a single mother from Morton, Illinois, found out she had cancer in January when she was 30. While battling his diagnosis, he said he was overwhelmed by what would happen to his body in the long run. She said that one day she imagined herself getting married and she wondered, “How in the world can she wear a wedding dress with only one of her breasts left?” .
She thought a DIEP flap was the best option and was worried that if she got an implant instead, she would have to have repeat surgeries. Implants generally need to be replaced every 10 years. But Goetz said after spending more than a month getting answers on how DIEP flap surgery would be covered, Goetz’s insurance company Cigna offered a lower CPT code to cover his doctor. I was told to use it. As far as she could see, it would have been impossible for Goetz to have the surgery.
I didn’t even have the option to pay for it myself.
“I’m a single mother. You can handle it, right? But I’m not rich by any means,” she said.
Cost is not necessarily the only hurdle that patients seeking a DIEP flap must overcome. Goetz said his local plastic surgeon told him the operation would be difficult because of the complexity of the procedure. She ended up traveling from Illinois to Texas for her surgery.
The government’s plan to repeal the three S-Codes was promoted by the Blue Cross Blue Shield Association, a leading lobbying group for health insurance companies. The group told CMS in 2021 to repeal the code, arguing that it was no longer necessary because the American Medical Association updated the CPT code to explicitly include DIEP flap surgery and related procedures, according to the report. requested. CMS document.
The American Medical Association has long advised physicians that the CPT code is appropriate for DIEP flap surgery. But since the government’s decision, at least two major insurance companies have warned doctors that they will no longer reimburse them under rules that pay high premiums, sparking a backlash.
Physician and breast cancer patient advocacy groups (such as non-profit organizations) Susan G. Komenargues that many plastic surgeons will stop offering DIEP flaps to women with private insurance because they are not well compensated.
Rep. Debbie Wasserman Schultz (D-MN) with breast cancer, Sen. Amy Klobuchar (D-MN), and Sen. Marsha Blackburn (R-Ten).
CMS At the June 1st meeting Consider keeping the three S-Codes or delaying their expiration.
In a May 30 statement, Blue Cross Blue Shield Association spokeswoman Kelly Parsons reiterated the group’s position that “there is no longer a need to store S-codes.”
Joint Maddox, a doctor at the University of Washington, said in a profit-driven healthcare system there is a tug-of-war over reimbursement between providers and insurers, often at the expense of patients.
“We have this constant battle over who has more power at the bargaining table,” Joint Maddox said. “And that clinical part is often lost because clinical benefits, clinical priorities and patient centricity are often at the center of these conversations.”
Elizabeth Potter, a plastic surgeon who specializes in DIEP flap surgery, decided that Signa would have Goetz’s surgery at any cost.
In Potter’s hometown of Austin, Texas, insurance companies charge $9,323 if they bill doctors in their network for surgery with a CPT code, according to Fair Health, a nonprofit that provides information on medical costs. said he could pay $18,037. code. These amounts are not averages. Rather, Fair Health estimates that his 80% of payouts are below these amounts.
Ms Potter said Cigna’s reimbursement amount was “substantially reduced”.
A few weeks before his surgery in May, Goetz received big news. Cigna reversed course and covered her surgery under the S Code. “It felt like a real win,” she said.
However, she is still afraid of other patients.
“I still call on these companies to do the right thing by women,” Goetz said. “I still demand that the necessary procedures be provided for women to repay at rates that are available regardless of wealth.”
In a statement to this article, Cigna spokeswoman Justin Sessions said the insurer “ensures our customers have affordable coverage and access to the full range of breast reconstructive surgeries and the quality of these complex surgeries.” We are continuing to work on providing access to surgeons.”
Medical costs covered by health insurance companies are generally passed on to consumers in the form of premiums, deductibles, and other copayments.
All types of breast reconstruction have benefits, risks, and trade-offs. 2018 A paper published in JAMA Surgery found that women who underwent DIEP flap surgery were more likely to develop “re-operation complications” within two years than women who received prosthetic implants. However, DIEP flaps had a lower probability of infection than implants.
Implants involve additional surgery, pain, rupture, and even the risk of rare types of immune system cancer.
Other flap surgeries that harvest abdominal muscles can weaken a woman’s abdominal wall and increase her risk of developing a hernia.
Academic studies show that which women are eligible for DIEP flap breast reconstruction affects reimbursement, creating a two-tiered system of private health insurance and government programs such as Medicare and Medicaid. . Private insurance generally pays doctors more than government insurance, and Medicare doesn’t use her S code.
Lynn Damitz, a physician and executive vice president for health policy and advocacy at the American Association of Plastic Surgeons, said the group supports the continuation of the S Code, either temporarily or indefinitely. Lower reimbursement rates will discourage some doctors from doing DIEP flaps, she said.
the study published in february found that among patients who used their own tissue for breast reconstruction, those with private insurance were more likely to undergo DIEP flap reconstruction than those with public insurance. discovered.
For Potter, this shows what happens when private insurance payouts plummet. “If you’re a Medicare provider and you’re not getting paid to do a DIEP flap, you never tell a patient it’s an option. You don’t do it,” Potter said. Told. “If you have private insurance and your reimbursement rate suddenly drops from $15,000 to $3,500 for him, you won’t be able to have the surgery. I’m not saying that’s the right thing to do, but it is. That’s what happens.”
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