Reimbursement inequality for breast cancer follow-up surgeries: experts

People with breast cancer are discriminated against because follow-up operations after an initial reconstruction are not reimbursed, according to legal experts who spoke with NOS. They believe that outgoing Health Minister Ernst Kuipers should revisit this issue.

Dutch health insurers standarly reimburse reconstructive surgery after cancer, except in the case of breast cancer. Doctors must first apply for approval for follow-up surgery after an initial reconstruction of amputated breasts, and these applications are often rejected.

Health insurers met on Monday for the third time with the Dutch Society for Plastic Surgery (NVPC), following reports about disparities in reimbursement between cancer patients.

Breast cancer is the most common cancer among women, with one in seven being diagnosed. Last year, 15,500 women in the Netherlands received this diagnosis, and another 2,400 women were in a possible precancerous stage and under treatment. About a third of breast cancer patients undergo the amputation of one or both breasts. There are also women with a genetic predisposition who choose preventive breast amputation.

While these operations are standardly reimbursed, follow-up procedures for issues like pain, malposition of the prosthesis, or noticeable irregularities in breast contour are not automatically covered.

Plastic surgeons must apply in advance to health insurers for these additional surgeries, often including photos of the breasts. The insurers then use specific criteria to determine whether the follow-up operation will be reimbursed, focusing on the location and size of contour deviations, such as dents in the breast.

Reconstructions after other types of cancer and their follow-up surgeries are reimbursed without the need for pre-approval, and this discrepancy is viewed as discriminatory by legal experts.

According to Martin Buijsen, Professor of Health Law at Erasmus University Rotterdam, the issue is financial. With breast cancer leading to the most reconstruction surgeries, there is a push for more standardized regulations. "Rules have been drawn up here that are not justified,” he said. Buijsen criticized the arbitrary nature of these rules and the lack of justification for denying reimbursement based on the characteristics of a contour deviation.

Theo Hooghiemstra, a data protection and health law expert, argued that there are no legal or ethical grounds for treating breast reconstruction post-cancer differently from other reconstructions. He also takes issue with health insurers' requests for breast photos for evaluations, highlighting the potential data protection violations.

"How is it possible that you rely on medical judgment in all other cases of subsequent reconstruction, but not in breast reconstructions for women? That is discrimination, not only against women but also in general,” he said.

Corrette Ploem, professor of health law at the University of Amsterdam, argued that the decision for follow-up surgery should rest with the plastic surgeon, not the insurer. "If there is a justification, it should be made clear. I can't think of one,” she said.