A breast cancer survivor says she is scrambling to get a life-changing surgery before insurance makes it inaccessible — and she's not alone
- A popular type of breast reconstruction surgery might soon be hard for cancer patients to access.
- The procedure, called DIEP flap, involves harvesting fat from a patient's abdomen to make a breast.
Diane Hager is ready for her breast cancer journey to be over. The 52-year-old was diagnosed almost five years ago, and while she's currently free of active disease, her chest is still misshapen from multiple attempts at breast reconstruction.
"I have a boob muscle under my armpit and a sunken chest in the front," Hager told Insider. "On the non-cancer side, I have a very small implant that is in place, but it doesn't look natural or normal at all."
She was diagnosed with breast cancer in April 2018 and quickly found out that it had spread to her liver. She immediately started an "intense" course of chemotherapy and radiation, got a mastectomy in March 2019, and then began the rocky process of breast reconstruction.
After a failed attempt to place implants, Hager said her surgeon recommended a muscle flap reconstruction, which involves taking muscle and fat from her back and moving it to her chest to create a breast.
But that surgery also failed. For the two and a half years since her reconstruction surgery, the muscle has crept back around her side, causing a constant tugging pain.
A newer type of breast reconstruction surgery, known as a Deep Inferior Epigastric Artery Perforator or DIEP flap, has the potential to restore Hager's symmetry and peace of mind. However, only a select few plastic surgeons offer the procedure — and Hager isn't sure yet if her insurance will cover it.
"I feel like this is like the last leg of what I have control over," she said. "And I don't even have control over that at this point, because insurance companies will take that away."
The surgery will be even harder for patients to access soon, due to a change in insurance reimbursement that could lead to doctors getting paid less for the procedure. One doctor told Insider that the surgery could be relegated to university hospitals as it becomes less profitable, potentially leaving whole communities without access to the full range of reconstruction options.
DIEP flap surgery is the best option for some breast cancer patients
DIEP flap is a newer and more complex surgery with better long-term patient outcomes compared to other breast reconstruction options, according to Elisabeth Potter, an Austin-based plastic surgeon who specializes in DIEP flap reconstruction.
The procedure requires a skilled surgeon to harvest fat and skin from a patient's midsection while preserving the abdominal muscles, which reduces the risk of complications such as muscle weakness and hernia, according to UCSF Health.
The surgery is widely considered an improvement over older techniques like the TRAM flap, which moves a swath of abdominal muscle up to the chest, or the lat-flap reconstruction that Hager got at the end of 2020.
It's also a better option for breast cancer patients who have to undergo radiation treatment compared to silicone breast implants, Potter told Insider.
"Implants become contracted if the skin over them has been or will be radiated," she explained. "That can be very painful and deforming — the failure rate, meaning the need to remove the reconstruction, is over 20%."
Hager initially tried to get silicone implants after her 2019 mastectomy, but her subsequent radiation treatments led to complications, including a gaping chest wound.
Now, she feels like the DIEP flap procedure is her only option left.
Soon, fewer doctors might be willing to perform the DIEP flap surgery
Patient advocates told Insider that, due to a change in health insurance regulations, breast cancer survivors will soon have a harder time accessing DIEP flap surgeries.
The DIEP flap surgery used to have its own billing code for insurance companies, meaning that surgeons who trained to perform the complex procedure were paid a separate and often more lucrative rate. But in 2021, the Centers for Medicare and Medicaid Services decided to lump the surgery in with all other non-implant breast reconstruction surgeries — despite the fact that the DIEP procedure requires a more specialized surgeon and is more labor intensive than other procedures.
"A DIEP flap is a very hard surgery for a surgeon to perform, and there's a lot of risks that the surgeon is taking on there," Potter told Insider, but it comes with a much easier recovery for the patient.
Essentially, what it means is that doctors who are willing to perform this procedure are getting a giant pay cut. Potter, and breast cancer patient advocates, worry that means there will be less surgeons willing to perform the surgery.
"Of course I'm going to do it," Potter said, "but I'm going to take a 70% pay cut."
It's not just people who are covered by Medicare and Medicaid who will be affected. Private insurance companies, taking their cue from the government, are also implementing the same billing code for the procedure.
That change will be effective for all private insurance companies by the end of 2024, according to the Department of Health and Human Services. Some insurers — namely Cigna — are ending the separate DIEP reimbursement codes as soon as this month.
In an email to Insider, a Cigna Healthcare spokesperson said the change should not have a significant impact for the majority of in-network surgeons or patients.
"For Cigna customers using in-network surgeons, the procedure will continue to be covered and this coding change should not result in any additional out-of-pocket costs," the spokesperson said.
Some patients are left in surgical purgatory
A DIEP flap procedure could help Hager solve the dysmorphia and discomfort she's felt since her mastectomy and failed reconstructions. But she's not sure if her insurance policy will change its billing practices before she can qualify for the surgery.
"I keep thinking, 'Am I going to be left feeling like this for the rest of my life?'" she said.
Potter said she worries that not all surgeons who are trained to do DIEP flaps will choose to continue performing the complicated surgery for lower reimbursement rates. She said some providers have already stopped accepting insurance for the procedure, making it financially inaccessible to those who need it most.
Additionally, any change in access to non-implant reconstruction options is bound to disproportionately affect women of color, who are more often diagnosed with aggressive or recurring breast cancers that will require radiation, Potter said. With less financial incentive to perform DIEP flap surgeries, some doctors may push implants or older flap reconstructions.
"If you don't pay for innovation, it goes away," she said.
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