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PRSonally Speaking
Thursday, October 31, 2013
The journey of a thousand miles starts with a single step
by Jon Ver Halen, MD
 
I read with great interest the article by Nicolas Balague, et al, in the October journal of Plastic and Reconstructive Surgery, “Plastic surgery improves long-term weight control after bariatric surgery”.  It is not the first time that researchers have identified that body contouring surgery after massive weight loss results in improved patient outcomes, in this case a sustained and increased reduction in weight.  Indeed, the researchers have previously demonstrated that body contouring procedures improved patient-reported outcomes in self-esteem, social life, work ability, physical activity, and sexual activity.  It is also well established that a reduction in percentage of body fat reduces insulin resistance and consequent diabetes mellitus, hormonal imbalance, hypertension, sleep apnea, and numerous other comorbidities.  In addition, the article was featured in the Wall Street Journal, “Not Just Vanity: Tummy Tucks that Heal.” And in 2012, ASPS statistics show that over 106,000 abdominoplasties were performed.
 
Given the known health benefits of this procedure, why is it so difficult to get insurers to pay for it? In 2011, the RVU total for a panniculectomy (CPT code 15830) was 17.11, and for the fleur-de-lis add-on code (15847) was “a round number” (i.e., 0).  Medicare reimbursement for a panniculectomy in my state is just under $600, when an insurer decides to approve it at all.  A 2008 study reported a surgical charge of $3,086 for panniculectomy, with a range of reimbursements from zero to the full amount, with the mean reimbursement of $615 and the median being $899.  Contrast this to breast reconstruction.  Prior to the Women’s Health and Cancer Rights Act of 1998, breast reconstruction was apparently much more difficult to obtain approval for than at the present time.  At the current time, carve-out rates for DIEP flap breast reconstruction are simply jaw-dropping, sometimes in excess of ten times the Medicare rates.  This is in the setting of conflicting results regarding the efficacy of the procedure to minimize abdominal wall morbidity.
 
I do not write this to suggest that DIEP surgery is not superior to TRAM or MS-TRAM breast reconstruction with regard to residual abdominal wall strength. I in fact believe the opposite, specialize in DIEP surgery, and suggest it to nearly all patients who want abdominal-based autologous breast reconstruction.  But I raise the point to give an example of what, to me, appears to be an essentially senseless and capricious system of medical reimbursement. I can make XXX dollars for performing a 5 hour DIEP procedure, versus a tenth of that for a 10 hour long mandible reconstruction case for cancer or osteoradionecrosis.  Not to mention something like lymphedema.  As a microsurgeon, I am intrigued by the results of lymphaticovenous bypass and vascularized lymph node transfer, and interested in offering the procedure to my patients.  Certainly patients want the procedure, given the paucity of effective treatment modalities.  But I am frustrated by my own (and others’) inability to get insurers to pay for these procedures.
  
What does this all mean? To me, it is a call to rigorously and quantitatively analyze everything we do.  If we can’t measure it, it might as well not be real.  Along these lines, I applaud the authors of the cited article, and others performing similar studies to measure patient outcomes (e.g., VTEPS, MROC, BREAST-Q, FACE-Q).  Given their example, and the necessity of this work in providing for our future, we should all strive to do the same.
 
About the Blog

Plastic and Reconstructive Surgery

PRSonally Speaking is the official blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit our blog for exclusive previews of and discussions on hot topics in plastic surgery as well as insider-tips on open access content. PRSonally Speaking is now powered by frequent contributions from the American Society of Plastic Surgeons’ Young Plastic Surgeons Forum (YPS); these practicing plastic surgeons provide the personal side of the plastic surgery story, from daily challenges to unique insights. PRSonally Speaking is home to lively, civil debate on hot topics and great discussions pertaining to our field. So, bookmark us, subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your Journal; have fun, be respectful, get engaged and interact with the PRS community.

The views and recommendations of guest contributors do not necessarily indicate official endorsements or opinions of the Journal, PRS, or the ASPS. All views are those of the authors and the authors alone.

Contributors

Anureet K. Bajaj, MD is a practicing plastic surgeon in Oklahoma City. She completed residency and fellowship in 2004, had a brief stint in academia at the University of Cincinnati, and then chose to join her father (Paramjit Bajaj MD, also a practicing plastic surgeon) in private practice in OKC, where she focuses on breast reconstruction and general cosmetic surgeries.

Devra B. Becker, MD, FACS, is an Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at University Hospitals/Case Western Reserve University School of Medicine in Cleveland, Ohio. She completed Plastic Surgery residency at Washington University School of Medicine in St. Louis, and completed fellowships with Daniel Marchac and with Bahman Guyuron. She currently has a primarily reconstructive practice.

Henry C. Hsia, MD, FACS is at Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey and also holds an appointment at Princeton University.  When he’s not working hard trying to be a good father and husband, he runs a practice focused on reconstructive surgery and wound care as well as a research lab focused on wound biology and regenerative medicine.

Stephanie K. Rowen, MD is a senior physician at The Permanente Medical Group in San Jose, California.  She joined TPMG upon finishing residency and a hand surgery fellowship in 2005.  She has a primarily reconstructive practice, about 50% hand surgery.  Outside of work she enjoys participating in triathlons and spending time with her family.

Jon Ver Halen, MD is currently Chief of plastic surgery, Baptist Cancer Center; Research member, Vanderbilt- Ingram Cancer Center; Adjunct clinical faculty, St. Jude Children's Research Hospital. He also acts as Program Director for the plastic surgery microvascular surgery fellowship. His practice focuses on oncologic reconstruction.

Tech Talk Bloggers

Adrian Murphy is a plastic surgery trainee in London, England. He studied medicine in Dublin, Ireland and has trained in Ireland, Boston, MA and the United Kingdom. He is a self-confessed geek and gadget aficionado.

Ash Patel, MD is Assistant Professor of Plastic Surgery and Associate Program Director at Albany Medical College, in Albany NY. His practice is primarily reconstructive.

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