Mastectomy Services: The Hidden Gem Among DMEPOS

Published in Member Communities on July 11, 2022

The mastectomy market continues to grow; however, there is still a huge need for additional providers of post-mastectomy supplies. Once thought of as a loss leader, mastectomy can be a profit center in your business.

Demand for Post-Mastectomy Products Is High

Breast cancer became the most common cancer globally as of 2021, accounting for 12% of all new annual cancer cases worldwide, according to the World Health Organization.

In 2022, an estimated 287,850 new cases of invasive breast cancer are expected to be diagnosed in women in the U.S., along with 51,400 new cases of non-invasive (in situ) breast cancer. About 1 in 8 U.S. women (about 13%) will develop invasive breast cancer over the course of her lifetime. Incidences continue to rise by about 1% a year, while the death rate goes down 1% per year since 2013. As of January 2022, there are more than 4 million breast cancer survivors in the United States, many of whom may be candidates for delayed reconstruction or revisions of prior reconstruction.

In 2019, more than 40% of women in the U.S. who underwent a mastectomy had reconstruction. Many plastic surgeons have noticed a rise in patient-driven requests for bilateral mastectomy with immediate breast reconstruction. However, one in three women undergoing breast reconstruction have complications. One in five women require more surgery and in 5% of cases, reconstruction fails.

Women who experience breast cancer are living longer, are not always undergoing breast reconstruction surgery, or are in need of a revision surgery. There is a large patient population  in need of breast prosthetics and other post-mastectomy supplies. With sinking mortality and more survivors, there is more demand.

However, prosthetics and post-mastectomy supplies aren’t always talked about with their doctor or breast surgeon. Many women are still unaware of their eligibility for prosthetics. After women receive their diagnosis, they likely turn to Google and the internet to research all of their options, creating savvier consumers of post-mastectomy products and more opportunity for suppliers to get into the business. As demand for these products has increased, manufacturers like American Breast Care have created more fashionable and modern bras and garments.

But What about Profitability?

In years past, many post-mastectomy providers got out of the business due to falling reimbursement rates. However, Medicare and private insurance reimbursements have actually increased over the last 9 years at a rate of 15%.

Mastectomy Billing Codes

L8000 Mastectomy Bra
L8001 Breast Prosthesis Bra & Form
L8015 External Breast Prosthesis Garment
L8030 Breast Prosthesis Without Adhesive
L8035 Custom Breast Prosthesis

Demand has also increased for more functional, dynamic, and fashionable post-op garments as well as compression to manage breast cancer-related lymphedema. Surgeons are looking to DMEs and mastectomy boutiques to dispense these types of products, which are ideal for use after a mastectomy, breast reduction, or reconstruction. Post-op garments typically include pouches to hold drains and a front zipper. Compression helps reduce bruising and swelling, prevents blood clots, reduces recovery time, and speeds the healing process.

Reimbursement for Mastectomy over the last 9 years
Reimbursement over last 9 years

Custom Breast Prosthesis

In 1999, the L8035 code was developed for custom breast prosthetics. Custom breast prosthetics are a non-surgical breast reconstruction option that many women do not realize is an option. The custom breast prosthetic is the most significant innovation in the external breast prosthesis business in over 30 years.

With surgeries becoming more individualized and complex, the demand for customized prosthetics is higher than ever before. Custom breast prosthetics can be used in several different capacities, not just for women who have undergone a mastectomy. After breast surgery of any kind, including reconstruction, there may be symmetrical issues where a custom overlay could help. Reconstruction and lumpectomies are not always successful and may require a full prosthesis or overlay for breast symmetry to be achieved. A custom breast prosthetic may also be the answer in some stages during the reconstructive process. For example, someone may need a shell or nipple if expanders are implanted in preparation to reconstruction.

While Medicare still has not caught onto reimbursing for the L8035, other insurers may provide coverage. Check your fee schedules to determine your exact reimbursement rates. Essentially Women has been pursuing Medicare coverage for custom breast prosthetics through the Let Her Decide campaign and the Breast Cancer Patient Equity Act for many years. Visit the Essentially Women website for up-to-date information on this legislation. Also, do not always expect that an item must be covered by insurance for your patients to pay for the item. Many women simply do not understand that this type of a product exists and is an option to them.

Business Impact

If you’re looking for a new revenue source, the post-mastectomy industry is a growing market with the advancement of custom breast prosthetics. With American Breast Care, custom breast prosthetics do not require you to carry an inventory and there are no upfront costs or minimums to join.

Let’s look at the numbers and how custom prosthetics can change your business.

The wholesale cost of a custom breast prosthetic is around $1,500. The retail price is around $3,200, leaving a supplier with an estimated profit of $1,700.

Off-the-Shelf Prosthetics

ABC Custom Prosthetics

Cost

$150

$1,500

Reimbursement

$300

$3,200

Profit

$150

$1,700

If your business sold three custom prosthetics per month, on average, your business would have $5,100 additional profit. Selling just one custom prosthetic generates as much revenue as 12 off-the-shelf fittings. Annually, this could mean an additional $61,200 annual profit on custom prosthetics alone, not including any additional post-mastectomy products breast cancer survivors may need.

Do I Need a Mastectomy Fitter on Staff?

In years past, many suppliers stopped providing post-mastectomy supplies if their mastectomy fitter left. A certified mastectomy fitter may not be required to be on staff to provide these items. Check with your facility accreditation for individual certification requirements and your state licensing requirements. Even if your state does require a license to provide breast prostheses and/or accessories, training is not expensive or time-consuming. Training days can be as low as 8 hours and cost as little as $100.

If you are wanting to get into the post-mastectomy industry or develop your program further, Essentially Women and American Breast Care are here to help you. Contact Essentially Women at [email protected] or 800-988-4484 for additional information.

Upcoming Webinar

Are you looking for more information on profitability in mastectomy? Join Essentially Woman and American Breast Care for an upcoming webinar on this topic. 

Mastectomy Services: The Hidden Gem Among DMEPOS
Thursday, Aug 11 at 1 p.m. CDT

Learn More and Register

From Our Experts

Important Updates on the Medicare Orthotics and Prosthetic Patient-Centered Care Act thumbnail Important Updates on the Medicare Orthotics and Prosthetic Patient-Centered Care Act Eve Lee, Executive Director of AOPA, recently released an important update about the O&P Patient-Centered Care Act. HME Woman of the Year Finalists Announced thumbnail HME Woman of the Year Finalists Announced The finalists for the 2022 HME Woman of the Year have been selected. The winner will be announced during a special virtual ceremony on Dec. 15, 2022. Put a Ring on it: Rules of Employee Engagement thumbnail Put a Ring on it: Rules of Employee Engagement If you are a leader, it is likely that you have become aware of the term “quiet quitting,” but leaders have been dealing with the root cause for as long as there have been teams to lead. The real problem is disengagement. As a leader, how do you help employees re-engage? Put a Ring on it: Rules of Employee Engagement thumbnail Put a Ring on it: Rules of Employee Engagement If you are a leader, it is likely that you have become aware of the term “quiet quitting,” but leaders have been dealing with the root cause for as long as there have been teams to lead. The real problem is disengagement. As a leader, how do you help employees re-engage? Put a Ring on it: Rules of Employee Engagement thumbnail Put a Ring on it: Rules of Employee Engagement If you are a leader, it is likely that you have become aware of the term “quiet quitting,” but leaders have been dealing with the root cause for as long as there have been teams to lead. The real problem is disengagement. As a leader, how do you help employees re-engage? FMA Hits ‘Good Cross Section' of Industry thumbnail FMA Hits ‘Good Cross Section' of Industry U.S. Rehab's Functional Mobility Assessment tool now has 13,000 data points showing the benefits of providing appropriate mobility equipment and involving assistive technology professionals (ATPs). Important Supplier Enrollment Updates - Changes to Contract! thumbnail Important Supplier Enrollment Updates - Changes to Contract! In this episode, we discuss how the Mississippi River is playing a role in the changes to the DMEPOS provider enrollment and what, if anything, you need to be doing. John Carter CRT, RCP Named VP of Sleep and Respiratory Compliance Services for VGM & Associates thumbnail John Carter CRT, RCP Named VP of Sleep and Respiratory Compliance Services for VGM & Associates John Carter has joined VGM & Associates as the Vice President of Sleep and Respiratory Compliance Services.