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Annals of surgical oncology
May, 2025;32 (5): 3695-3704.

Lower Commercial Rates for Breast Surgical Procedures are Associated with Socioeconomic Disadvantage: A Transparency in Coverage Analysis.

Danielle H Rochlin, Yang Wang, Uchechukwu O Amakiri, Jacob Levy, Lillian Boe, Clifford C Sheckter, Gerard Anderson, Babak J Mehrara, Jonas A Nelson, Evan Matros
Author Information
  1. Danielle H Rochlin: Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. rochlind@mskcc.org.
  2. Yang Wang: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
  3. Uchechukwu O Amakiri: Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
  4. Jacob Levy: Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
  5. Lillian Boe: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
  6. Clifford C Sheckter: Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA, USA.
  7. Gerard Anderson: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
  8. Babak J Mehrara: Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
  9. Jonas A Nelson: Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
  10. Evan Matros: Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
PMID: 39719512 DOI: 10.1245/s10434-024-16738-z

Abstract

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) implemented the Transparency in Coverage Rule in 2022, which requires payers to disclose commercial rates for the first time in the history of the US healthcare system. The purpose of this study was to characterize payer-disclosed commercial facility rates and examine the relationship with county-level social disadvantage for common breast surgical procedures.
MATERIALS AND METHODS: We performed a cross-sectional study of 2023 pricing data for 14 ablative and reconstructive breast procedures from Turquoise Health. Socioeconomic disadvantage was quantified using the Social Vulnerability Index (SVI). Within- and across-payer ratios quantified rate variation. Linear regression assessed the relationship between relative value unit (RVU)-adjusted median commercial rates and facility-level variables including SVI quartile.
RESULTS: There were 4,748,074 unique commercial rates disclosed by four payers from negotiations with 10,023 hospitals. Rates varied by a factor of 9.8-15.6 within and 10.0-18.1 across payers. RVU-adjusted commercial rate decreased in a stepwise fashion as SVI quartile increased and varied by payer (p < 0.001). Higher RVU-adjusted rates were associated with hospitals compared with ambulatory facilities (β = 138, 95% CI 138-139, p < 0.001). Lower rates were associated with areas of less healthcare infrastructure (β = - 37, 95% CI - 38 to - 37, p < 0.001).
CONCLUSIONS: Facility rates for breast surgical procedures varied significantly within and between payers and were higher for hospitals compared with ambulatory surgery centers. Facilities in areas of higher social vulnerability were associated with lower negotiated rates. The health equity implications of lower payment in areas of higher disadvantage, particularly in terms of access to care, deserve further investigation.

Keywords

Breast surgery Commercial facility rates Health equity Price variation Social vulnerability index Transparency in coverage

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Grants

  1. KL2 TR003143/NCATS NIH HHS
  2. KL2TR003143/CTSA
  3. P30 CA008748/NCI NIH HHS
  4. P30 CA008748/NCI NIH HHS

MeSH Term

Humans
Female
Cross-Sectional Studies
Breast Neoplasms
United States
Socioeconomic Factors
Insurance Coverage
Mammaplasty
Mastectomy
Healthcare Disparities
Socioeconomic Disparities in Health
Journal Article
Article has an altmetric score of 1

Word Cloud

Created with Highcharts 10.0.0ratescommercialpayersTransparencydisadvantagebreastproceduresSVIhospitalsvariedp<0001associatedareashigherCoveragehealthcarestudyfacilityrelationshipsocialsurgicalHealthSocioeconomicquantifiedSocialratevariationquartile10RateswithinRVU-adjustedcomparedambulatoryβ=95%CILower- 37surgeryvulnerabilitylowerequityCommercialBreastBACKGROUND:CentersMedicare&MedicaidServicesCMSimplementedRule2022requiresdisclosefirsttimehistoryUSsystempurposecharacterizepayer-disclosedexaminecounty-levelcommonMATERIALSANDMETHODS:performedcross-sectional2023pricingdata14ablativereconstructiveTurquoiseusingVulnerabilityIndexWithin-across-payerratiosLinearregressionassessedrelativevalueunitRVU-adjustedmedianfacility-levelvariablesincludingRESULTS:4748074uniquedisclosedfournegotiations023factor98-1560-181acrossdecreasedstepwisefashionincreasedpayerHigherfacilities138138-139lessinfrastructure- 38CONCLUSIONS:FacilitysignificantlycentersFacilitiesnegotiatedhealthimplicationspaymentparticularlytermsaccesscaredeserveinvestigationSurgicalProceduresAssociatedDisadvantage:AnalysisPriceindexcoverage

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