I have been caught off guard a few times recently when patients have asked about the costs of breast reconstruction, and they reveal to me what they are expecting to hear.
Breast reconstruction is an inherent part of treating breast cancer. As such, I (like many surgeons) feel that I have an ethical responsibility not to unreasonably profit from misfortune. This means that we typically work within the confines of the various insurers’ “gap” schemes to minimise out of pocket costs to our patients where possible. Unfortunately, it isn’t always possible.
The issue of surgical costs, surgeons’ fees, hospital charges, and what is covered by insurance remains a very difficult maze to navigate for patients.
So let’s be very clear: Breast Reconstruction is covered by both Medicare, and private health insurance. But that coverage is by no means complete, and there is almost always some out of pocket expense for patients.
I am often asked what the cost of breast reconstruction is. I am asked this question by patients who are under the impression that breast reconstruction is something only available at significant expense. These women will ask about the cost of breast reconstruction and they will give me some idea of what they expect their costs to be. They do this not in the form of complaint or dissatisfaction, but simply to confirm their expectations.
When my patients tell me that they are expecting to have out-of-pocket costs of $20 000, and when they say this without batting an eyelid, it really confirms that there is something wrong with the provision of breast reconstruction surgery in this country.
The question for me is: where the hell is this idea coming from? Who is telling these women that breast reconstruction should cost them TWENTY THOUSAND DOLLARS on top of what their insurance will cover?
Sadly, the source of such information seems to be varied. Which makes it harder to combat.
The various peer support networks and breast cancer forums providing information and assistance to patients in Australia do an incredible job. But I do fear that this is one way in which such ideas proliferate. It seems that if one woman is told that the cost of a breast reconstruction is X, then this information filters through the networks and this then becomes a standard expectation for members of that network. So then I guess we have to ask who is responsible for telling that first lady what a breast reconstruction will cost? Is it the breast surgeon who performs only implant reconstruction? Is it a plastic surgeon offering a free flap reconstruction? Is it a GP who heard from another colleague that this is what breast reconstruction costs?
I recently spoke with a large group of GPs at a local practice about the Breast Reconstruction services that I offer. I was startled to find that not only are most GPs not aware of what breast reconstruction entails, they also often don’t know who provides these services, and they are under the impression that this type of surgery isn’t covered by Medicare. Many of these GPs thought that the only way for a patient to access breast reconstruction was to be treated privately at massive personal expense.
So, allow me to offer my opinion on this issue.
Firstly, I am aware of General Breast Surgeons who perform mastectomies and also offer implant based breast reconstruction, who are charging their patients these very large sums of money. I am also aware of Plastic Surgery colleagues who, whilst perhaps offering DIEP flap reconstruction rather than just an implant, are also charging very high out of pocket costs.
These surgeons are neither wrong, nor are they breaking any “rules”. I do however think that this indicates a rather deep seated malaise within our healthcare system, and it is unfortunately doing nothing to combat the increasing public perception of surgeons and other specialists as reaping undue reward from the misfortune of their patients.
The AMA each year publishes a list of recommended fees. These fees (which cover every procedure with a medicare item number) are set to ensure that surgeons are adequately compensated. These fees take into account the costs of running a private practice, as well as the time and effort required in performing complex surgery (like DIEP flaps). As I indicate to all my patients in our fees policy:
“The fees charged by Campbell-Lloyd Reconstructive Surgery are proportional to the nature and complexity of Plastic Surgery, and may be dependent on the time required for your consultation or surgery. Fees charged take into account the effort, skill and resources required for the provision of service. “
It is reasonable to expect that, much as one would when seeing any other highly trained professional, there may be an appropriate cost involved. Nothing for nothing, right?
However, the AMA schedule (which I follow) is also set to ensure that patients are not being gouged by mercurial or greedy individuals who believe they have a right to profiteer from a patient with cancer.
Unfortunately, health insurers (who seem to be more and more intent on their own profit-making, selling junk policies and covering someone else’s gym membership, rather than appropriately covering the costs of necessary surgery) do not cover the entire cost of surgery. There is always a gap between what the insurer pays, and the AMA recommended fee or what a surgeon charges. And unfortunately, the insurers also penalise patients in those situations where the gap between the appropriate fee and what the insurer will cover is more than $500. In these cases, the insurer chooses to punish the patient by reducing what they cover to just 25% of the Medicare fee (which as you probably know, has now been frozen for 6 years by successive governments) for a procedure.
So what is the real cost of breast reconstruction? It varies (obviously) according to a number of issues. Like what kind of procedure you have, and whether any additional steps are required.
We have been working extraordinarily hard to minimise the costs for our patients. We are now able to offer ALL breast reconstruction procedures on the various “known gap” schemes offered by insurers. These schemes have various names including “access gap”, “access scheme”, “known gap” or “fixed gap”, but they amount the same thing. Our patients will never have an out of pocket costs of more than $500 for any reconstructive procedure. EVER. This is true for implant-based and DIEP flap breast reconstruction, as well as revisionary procedures.
I guess the real question is: Why is there a gap at all? Why doesn’t your insurance cover the real costs of surgery?
I don’t know. Perhaps you could ask your insurer the next time you have to lodge a claim. But that is a discussion for another day.