AFPEa doctor with an implant for breast reconstruction (photo from 2022)
NOS Nieuws•vandaag, 16:33
Stikkelorum at sea
Domestic Editor
Stikkelorum at sea
Domestic Editor
There is discrimination because only in the case of breast cancer, follow-up operations after an initial reconstruction are not reimbursed as standard. This is what legal experts told NOS. They believe that outgoing Minister Kuipers should look at it again.
According to Martin Buijsen, professor of health law and head of the health law department at Erasmus University Rotterdam, patients with breast cancer are treated unequally compared to other cancer patients. “That can be justified, if there are good reasons for it that are explained. Now that this is not the case, I believe that there is discrimination,” he says. “I think these women should be helped.”
Today, health insurers are consulting for the third time with the Dutch Association of Plastic Surgeons (NVPC), following previous reporting by the NOS about the difference in reimbursement between cancer patients. Health insurers in the Netherlands and the Ministry of Health, Welfare and Sport do not want to respond because of the ongoing discussions.
To cover with clothing
Breast cancer is the most common cancer in the Netherlands. One in seven women experiences it. About a third of breast cancer patients undergo amputation of one or both breasts. In addition, there are women with a genetic predisposition who choose to preventively amputate their breasts. Every year, approximately 5,000 to 5,500 women opt for breast reconstruction with silicone implants or body tissue. After years of wrangling, these operations have been reimbursed as standard for some time now.
But this does not apply to follow-up operations due to, for example, pain complaints, rotating prostheses or a noticeable contour deviation or dent. The plastic surgeon must submit an application to the health insurer in advance, usually with photos of the breasts. The insurer uses detailed criteria to determine whether an operation will be reimbursed.
This makes it possible to distinguish where in the chest area there is a dent. If it can be covered with clothing (‘functional area’), it must have a diameter of at least 5 centimeters and a depth of 2 centimeters. Within the décolleté (‘functional area’), a diameter and depth of 2 centimeters is sufficient.
VAV Insurers have strict criteria when follow-up breast reconstruction is reimbursed
Such criteria have not been formulated for any other type of cancer. There it is the plastic surgeon himself who assesses whether a follow-up operation is necessary.
According to Professor Buijsen, this is a money issue. Breast cancer is the most common form of cancer and requires the most reconstruction surgeries. “Given the numbers, it was found necessary to standardize this further,” says Buijsen. “We call that implicit rationing of care; somewhere, choices are made in a non-transparent way. We don’t know why they are made that way, but they are made.”
It is anyone’s guess why follow-up surgery is less likely to be reimbursed if, for example, a dent is on the outside of the breast instead of in the décolleté, and why that dent must have certain dimensions, says Buijsen. “Rules have been drawn up here that are not justified. Women are fishing behind the net when dents are not deep enough and are in the wrong area.”
No justification
According to Theo Hooghiemstra, data protection and health law expert, there are no compelling legal or ethical grounds to treat reconstructions after breast cancer differently. He quotes the first article of the Constitution, which prohibits discrimination and requires equal treatment.
“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.”
From a data protection perspective, Hooghiemstra believes it is incorrect for health insurers to request photos of the breasts for assessment. “Who are they that they can do it with a photo, while doctors say that you cannot always see from a photo whether an operation is needed.” In addition, it is ethically unjustifiable to burden people so disproportionately, says Hooghiemstra. “They have to have those photos taken and cannot check who has seen the photos.”
Don’t cut it up
Corrette Ploem, professor of health law at the University of Amsterdam, emphasizes that a reconstruction process must be seen as a single whole. “It is very strange to cut pieces off and not reimburse it as one treatment.”
The responsibility for whether follow-up surgery is necessary should lie with the plastic surgeon and not with the insurer, she says. “Why should that assessment be moved to the health insurers? There are no plastic surgeons who know the most about it.”
Ploem sees no reason for the exceptional situation in breast reconstructions. “If there is a justification, it should be made clear. I can’t think of one.”
Heleen is one of the women who were not reimbursed for a follow-up operation. She is in pain every day, she said this summer. She has now heard from her insurer that her operation will be reimbursed after all.
Heleen continues to have pain after breast reconstruction, but follow-up surgery is not reimbursed
2023-11-06 15:33:05
#Lawyers #reimbursing #breast #reconstruction #standard #discrimination
