Free-flap breast reconstruction: cost analysis in the Swiss healthcare system

Breast cancer is the most common type of malignancy among women. Mastectomy maintains an essential role in oncological therapy and led to the development of breast reconstruction procedures. The deep inferior epigastric perforator (DIEP) free flap became in the last decade a popular approach for breast reconstruction. Although this procedure is known to be more complex than other techniques, it offers one of the highest patient satisfaction rates. However, the cost-effectiveness of this technique has rarely been assessed; and the real cost coverage by health insurance has never been studied. This study estimated the real cost of immediate DIEP free flap breast reconstruction after unilateral mastectomy and evaluated the cost coverage by healthcare insurers according to the diagnosis-related group (DRG) reimbursement scheme in Switzerland. Medical files of 20 consecutive patients who underwent immediate DIEP free-flap breast reconstruction between 2012 and 2017 were reviewed retrospectively. Billing data according to DRG rates were compared with an estimation of the real cost generated by the procedure. The mean charge according to the DRG model for one-stage DIEP free-flap reconstruction was CHF 29,573 (CHF 19,256–64,741). The mean real estimated cost was CHF 33,416 (CHF 20,633–47,036). Seven different DRG codes were used between 2012 and 2017, each offering a different definition and compensation. The DRG pricing scheme evolves through annual revisions. Progressively, more specific codes were created and used, allowing a better cost coverage for the procedure. Since 2017, the use of the dedicated code J01B has resulted in adequate cost coverage of the procedure. Since it has been widely accepted that DIEP breast reconstruction has advantages such as high patient satisfaction, we encourage the inclusion of this procedure in the reconstructive arsenal of breast cancer centres in Switzerland.