Cost Of Reconstructive Breast Surgery
September 27th, 2012
Cost of Reconstructive Breast Surgery in the Era of Oncoplastic surgery: Coding and Remuneration.
Treating breast cancer is a costly matter. It is said that it costs approximately a million pounds to save a woman’s life from breast cancer. Screening alone in the UK costs approximately £96 million a year. Modern chemotherapy with expensive drugs cost an arm and a leg. Interestingly, in comparison to all the costs incurred by non-surgical modalities, breast surgery costs peanuts. However, primary care trusts (PCTs) are balking at the costs of oncoplastic surgery. Why is there so much fuss about the cost of breast surgery and in particular reconstructive breast surgery? This unrest amongst trusts all over the country is due to the fact that they are losing vast amounts of money in treating the breast, and it is claimed that breast reconstructive surgery is the main villain. Perhaps this is because the breast reconstructive surgery cost is relatively new in the equation of costing and tariffs determined by PCTs. It does not take account of the fact that modern evolving breast surgical practice is considerably different from basic oncological breast surgery, which was predominantly based on just taking the breast cancer out without the benefit of aesthetic surgical issues. The fact is, yes breast reconstruction is expensive and will probably become more expensive as we train more and more oncoplastic breast surgeons to give women what they want and need.
The various trusts all over the country who are getting anxious due to the fact that breast surgical procedures are costing too much are are putting pressure on the oncoplastic breast community to find ways of cutting the costs of breast surgery in order to make this more profitable for the trusts, especially in the current financial environment.
So how is the costing calculated for various procedures and how does the trust get remunerated from PCTs for performing this service?
Clinical coders using the Operating Procedures Code Schedule (OPCS) determine the most suitable code for every procedure we perform. They also calculate the actual cost incurred by the trust in treating that event, which is calculated by adding the cost of various events, e.g. theatre cost, surgeon’s cost, anaesthetist’s cost, in-patient cost and junior doctors cost. Coders, whilst applying these codes to the procedure, also take in account other patient related factors whilst applying these codes, e.g. co-morbidities such as hypertension, IHD, DM, etc. These factors give an uplift to the OPCS code. The costs and codes are then handed over to the financial coders. Their job is to apply Health Resource Group (HRG) codes, which translate that event into actual money. PCT then pays trusts accordingly.
There are several problems at this stage of coding. Sometimes there is no appropriate code for that particular procedure and in these cases coders will find the best suitable OPCS code. Another issue, although not very common, is that coders will not apply an appropriate code to the procedure, which sometimes is beneficial and sometimes not so beneficial to the trust. More often than not, it leads to a loss of money to the trust.
Two of the most important factors which dictate the procedural cost are length of the actual surgical procedure and the length of in-patient stay. For example an EALD flap with mastectomy and axillary clearance, which takes almost two theatre sessions (one session is four hours) and stays as an in-patient for five days, can cost the trust approximately £10,000, whereas the maximum remuneration from PCT is £5697. It does not take a genius to realise that these procedures are not tariffed correctly. Even in the hands of the slickest surgeon, these reconstructive procedures will lead to a loss of money to the trust, in the current tariff structure.
An example of lack of proper coding and remuneration for a newly evolving procedure is that of therapeutic mammoplasty. Currently, despite having a code (under reduction mammoplasty), the tariff is same as a wide local excision and the trust is paid £2030. It is widely accepted that therapeutic mammoplasty needs more resources in terms of an experienced surgeon and more theatre time. In actuality, the average cost to the trust is approximately £4000, whereas the PCT will only pay £2030.00.
Every year an average of procedural costing is calculated and based on this, HRG costing is produced. Unfortunately, the data used for these calculations is a few years old. These HRG tariffs become rapidly out-dated, and as we are training more and more oncoplastic surgeons, there are increasing number of units across the country who are performing breast reconstructions and advance breast conservation (therapeutic mammoplasties).
One solution to this is to base HRG costing on the current average costing of reconstructive breast procedures across the country instead of out-dated and diluted costings of all breast surgery, which is diluted by basic oncological breast surgery.
In essence, some of the more complex procedures (therapeutic mammoplasties, glandular re-shaping, lower pole sling reconstruction, etc.) have not been correctly coded by OPCS and HRG, and breast reconstruction procedures are incorrectly tariffed, hence generating lower income for the respective trusts.
To rectify this we need to act and we need to act quickly. We need to involve commissioners in constructive dialogues to make them aware of the current costing issues of oncoplastic breast surgery. There are certain aspects of practice which can be streamlined in order to improve our income. A better and more regular communication between clinical coders and the clinicians will allow more accurate OPC coding. In-patient stay can be optimised by various measures, e.g. an early discharge with good community nursing support. This can have some positive effect on overall costing of reconstructive procedures. And lastly, knowing more about OPCS and HRG coding systems will give us continuous feedback about our own performance.