Change in reimbursement and costs in German oncological head and neck surgery over the last decade: ablative tongue cancer surgery and reconstruction with split-thickness skin graft vs. microvascular radial forearm flap

Clin Oral Investig. 2018 May;22(4):1741-1750. doi: 10.1007/s00784-017-2269-x. Epub 2017 Nov 9.


Objectives: Defects after ablative tongue cancer surgery can be reconstructed by split-thickness skin grafts or free microvascular flaps. The different surgical options may influence costs, reimbursement, and therefore possible profits. Our goal was to analyze the development of these parameters for different procedures in head and neck reconstruction in Germany over the last decade.

Materials and methods: After tumor resection and neck dissection of tongue cancer, three different scenarios were chosen to calculate costs, reimbursement, length of stay (LoS), and profits. Two options considered were reconstruction by split-thickness skin graft with (option Ia) and without (option Ib) tracheotomy. In addition, we analyzed microvascular reconstruction with radial forearm flap (option II). Furthermore, unsatisfactory results after options Ia and Ib may make secondary tongue plastic with split-thickness skin grafting necessary (option I+). The calculations were performed considering the German Diagnosis Related Group (DRG) system and compared to the specific DRG cost data of 250 German reference hospitals.

Results: The overall average length of stay (aLoS) declined from 16.7 to 12.8 days with a reduction in every option. Until 2011, all options showed similar accumulated DRG reimbursement. From 2012 onwards, earnings almost doubled for option II due to changes in the DRG allocation. As was expected, the highest costs were observed in option II. Profits (reimbursement minus costs) were also highest for option II (mean 2052 €, maximum 3630 Euros in 2015) followed by options Ia (765 €) and Ib/I+ (681 €). Average profits over time would be 17 to 19% higher if adjusted for inflation.

Conclusions: We showed the development of the DRG allocation of two commonly used methods of reconstruction after ablative tongue cancer surgery and the associated LoS, reimbursement, costs, and profits. As expected, the highest values were found for microvascular reconstruction. Microvascular reconstruction may also be the primary choice of treatment from a medical point of view. However, prolonged operation times, intensive care, and hospital stay in connection with complex microvascular operations can easily turn profits into losses as opposed to the results of simple, reliable, and fast split-thickness skin grafting. The inflation rate influences profits in reimbursement systems where costs are based on a previous period of time.

Clinical relevance: Surgeons find themselves daily in an area of conflict between economic interests and medical decision-making. Due to its multidimensional aspects, the choice of the reconstructive technique should be primarily based on the best medical care for the patient. But there should also be awareness of the economic risk of all three surgical procedures.

Keywords: Costs; Diagnosis Related Groups; Head and neck reconstruction; Radial forearm flap; Reimbursement; Split-thickness skin graft.

MeSH terms

  • Adult
  • Aged
  • Female
  • Forearm / blood supply*
  • Germany
  • Glossectomy / methods
  • Humans
  • Length of Stay / statistics & numerical data
  • Male
  • Middle Aged
  • Neck Dissection
  • Plastic Surgery Procedures / economics*
  • Plastic Surgery Procedures / methods*
  • Reimbursement Mechanisms
  • Skin Transplantation / economics*
  • Skin Transplantation / methods*
  • Surgical Flaps / blood supply*
  • Tongue Neoplasms / surgery*
  • Tracheotomy
  • Treatment Outcome