Association of Insurance Status with the Use of Immediate Breast Reconstruction in Women with Breast Cancer

Background: Our group sought to determine the influence of health insurance coverage on use of immediate breast reconstruction for working-Age women undergoing mastectomy for breast cancer. Methods: We used 2 complementary databases, the Texas Cancer Registry-linked Medicaid database and the MarketScan private insurance database, to identify working-Age women in Texas from 2000 to 2007 treated with mastectomy for incident breast cancer. Logistic regression tested the association between Medicaid versus private insurance and receipt of immediate breast reconstruction, adjusting for patient, treatment, and socio-demographic covariates. Reimbursement for reconstruction, adjusted for inflation and reported in 2014 dollars, was estimated from claims. Results: Median age was 49.7 years for the Medicaid cohort compared with 50.4 years for the MarketScan cohort (P = 0.02). From 2000 to 2007, use of reconstruction increased significantly for patients in the MarketScan cohort (38.1-53.9%; P_trend = 0.009) but not those in the Medicaid cohort (10.5-16.6%; P_trend = 0.24). In total, 15.7% of patients in the Medicaid cohort underwent immediate reconstruction (n = 213/1,360) compared with 50.7% (n = 1,405/2,772) of patients in the MarketScan cohort (adjusted relative risk, 3.09; 95% CI, 2.78-3.40). Reimbursement for reconstruction was $3,167 (95% CI, $2,512-$3,820) for patients in the Medicaid cohort compared with $15,432 (95% CI, $14,030-$16,834) for patients in the MarketScan cohort. Conclusions: Type of insurance coverage is an important factor associated with receipt of immediate breast reconstruction. We postulate that the marked difference in reimbursement for reconstruction between Medicaid and private insurance creates a relative disincentive for plastic surgeons and hospitals to offer breast reconstruction to patients with Medicaid.