Local surgeon Dr. Elisabeth Potter leads the fight to protect safe breast reconstruction surgeries under insurance.
By Samantha Greyson, Photos courtesy of Dr. Elisabeth Potter
Dr. Elisabeth Potter, an Austin-based breast reconstruction surgeon, specializes in DIEP flap surgery. This is a type of breast reconstruction surgery that allows for a patient to receive reconstruction surgery without damaging their abdominal muscle.
DIEP flap surgery is currently under threat. The Center for Medicare and Medicaid Services (CMS) took away the specific insurance code pertaining to DIEP surgeries in December 2020. Now Potter is leading the fight to reinstate the code and make DIEP accessible for all women.
“If your insurance covers your mastectomy, they have to cover your reconstruction,” Potter says. “That comes in two varieties: using an implant or using your own tissue. Implants have issues, and they’re safe to use, but there’s downsides. They only last 10 to 12 years, you have to replace them and they can have infections or capsular contracture or other issues.”
Surgeons are paid by submitting a code to an insurance company. Specific codes are attached to specific reimbursements.
“There was an old type of surgery that removed a woman’s muscle when you created the breast. Obviously that is very debilitating and leaves a patient with a new medical problem,” Potter says. “As surgeons, we got better at performing those surgeries in a way that didn’t take muscle at all. We were able to do the same type of breast reconstruction where we take skin and fat from your belly…and can take the blood vessels and leave the muscle completely intact and alive. When we developed that surgery, we got a new code. That new code had a reimbursement that was appropriate for a more advanced procedure.”
With the CMS’s decision to consolidate codes, access to safer breast reconstruction surgeries will diminish. This is exactly what Potter is fighting.
“In December 2020, we got a little announcement saying they had decided to collapse all of the codes together and equate all of the breast reconstruction using your own tissue into the old code,” Potter explains. “All of the reimbursements went to the lesser code. CMS announced they were going to get rid of the newer codes, the better codes, at the end of 2024. That gave permission to insurance companies to start getting rid of them beforehand. [Now] they have the ability to just stop paying that rate anytime.”
Because the codes for the safer breast reconstruction surgeries no longer exist, surgeons can’t get paid for them. Meaning access to the surgeries for patients using insurance will become more and more rare. The decision to consolidate the codes didn’t come from the government. Potter shares that the call came from an insurance company.
“Blue Cross Blue Shield was the insurance company that asked for this to happen,” she reveals. “Then the American Society of Plastic Surgeons and the American Medical Association agreed to it. That is really hard to accept. They called it ‘streamlining codes,’ but they didn’t factor in the patient impact. That’s a problem with that process.”
CMS didn’t talk to patients or doctors, like Potter, who specialize in these safe surgeries, when making their decision.
“Plastic surgery is a $26 billion business a year,” she says. “Less than 2% of that is breast reconstruction using natural tissue. The vast majority is cosmetic surgery. That includes implants, and implants are the other option from this natural tissue. There seems to be a protection of implant-based reconstruction at the expense of natural reconstruction.”
In addition to prioritizing implant surgery over natural tissue surgery, the “decrease in access will disproportionately impact people of color,” Potter says. Due to a lack of access, when breast cancer technology improved, outcomes became better for white women, but not for women of color.
“Seven out of 10 mastectomies happen in communities,” Potter says. “They happen outside of academic centers and outside of National Cancer Institutes. So the vast majority of mastectomies happen in places without power. These decisions impact community doctors and patients really hard because we don’t have a backup system. We’re just businesses. If we can’t pay our bills, we close our doors.”
When the 2020 decision released, Potter contacted people in power within the medical field to ask for help but received little response.
“I decided personally to fight this,” Potter says. “I talked to my husband, and we put our own finances at risk. We hired lobbyists in D.C. Last April, when United announced that they were going to stop paying us in 90 days, I talked to my colleagues around the country. They said, ‘Elisabeth, we’re going to have to close our practices.’ As doctors, we’re not used to fighting political fights. It’s actually really demoralizing. We spend so much of our emotional energy taking care of patients.”
Potter has since created the Community Breast Reconstruction Alliance (CBRA), a coalition to protect safe breast reconstruction. The process has been long, but Potter ensures they have made some progress. It is a bipartisan issue, and they have gotten the attention of congress people.
CMS could reinstate the code for DIEP flap surgeries, which would “stop the bleed” as Potter put it. But she insists a change to the Women’s Health and Cancer Rights Act of 1989 is extremely necessary. Not only to protect all reconstruction and ensure that women know their options; it must apply to women in all states.
“I find myself as a doctor in a society with conflicted values,” Potter says. “I’m trying to do my best to take care of patients with cancer, and I’m having to ask for my portion of the resources from folks who do cosmetic surgery. It’s very odd.”
Community members can support Potter’s mission to restore access to safer breast reconstruction surgery by joining CBRA, partnering with the community or by donating. Potter also strongly encourages people to spread the word on how the current practices will impact breast cancer patients.
“This is bringing issues of community health, racial disparity in women’s health and the economics of medicine to a head all at once,” Potter says. “I don’t know where this fight is going to end up. But I was raised to do the right thing. I think the universe led me here, and I’m here to do this work. If one person, one group can do it, we can. We are so determined.”