Impact of Regional Surgeon Competition on Use, Cost, and Outcomes of Breast Reconstruction in the United States.

Abstract

Breast reconstruction following mastectomy is underused in the United States. Evidence suggests that more competitive hospital markets offer increased access to procedural care across specialties. This study aimed to determine the impact of regional plastic surgeon competition on use, outcomes, and cost of breast reconstruction following mastectomy for breast cancer. The authors conducted a retrospective cross-sectional analysis using MarketScan claims data from 2009 to 2020. The Herfindahl-Hirschman Index, a measure of market concentration, was calculated using the sum of squares of the proportion of breast reconstruction cases performed by each surgeon in a metropolitan statistical area. Multivariable logistic regression was used to identify differences in rates, outcomes, and costs of reconstruction by the Herfindahl-Hirschman Index. Odds of receiving breast reconstruction within 2 years of mastectomy were higher for those in moderately competitive (OR, 1.51 [95% CI, 1.37 to 1.66]; P < 0.001) or competitive (OR, 1.71 [95% CI, 1.58 to 1.86]; P < 0.001) regions compared with noncompetitive regions. Patient out-of-pocket costs decreased when comparing moderately competitive regions with noncompetitive regions (-$67.38 [95% CI, -$88.65 to -$46.11]; P = 0.007), and decreased further when comparing competitive with noncompetitive regions (-$113.06 [95% CI, -$137.00 to -$89.12]; P = 0.02). No linear association between total, surgeon, or facility cost and market competition strata was identified. Greater competition among surgeons is associated with improved access to reconstructive surgery, but no difference in cost. Application of this evidence may include system-level strategies to bolster care coordination, while targeting drivers of cost, such as hospitals and hospital systems, through policy.