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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
2
* Fondation Registre du Cancer
Background
Patients claim about « Esthetic supplement »*
Plastic surgeons : « Fee for autologous breastreconstruction = 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 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
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
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)
Step 1. List of activities
9
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)
Step 1. List of activities
10
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)
Step 1. List of activities
11
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)
Step 1. List of activities
12
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)
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, inclstart & 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 variabilityNecessity 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 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