The Pied Piper of Hamelin

“And a matter of money to put in your poke;

“But as for the guilders, what we spoke

“Of them, as you very well know, was in joke.

“Beside, our losses have made us thrifty.

“A thousand guilders! Come, take fifty!”

—Robert Browning¹

Sometimes, old fashioned tales achieve modern day relevance. What makes a bedtime story real is context—events or circumstances that juxtapose and trigger an ancient memory—a déjà vu of sorts. A review of upcoming changes to reimbursement strategy, the Pay-for-Performance initiative, did just that. A contextual view of the Pay-for-Performance policy (analyzed by Jones et al.² and Polk³) revealed how lopsided the entire reimbursement scenario could potentially get. Elegantly crafted, covertly one-sided, Pay-for-Performance seemed like a Trojan proxy aimed more at denying payments than rewarding performance. Perhaps Pay-for-Performance actually meant perform-for-peanuts or, better still, peanuts-for-pay. Perhaps that, or the inherent unfairness or, as reconstructive surgeons, lack of leverage, or all three triggered an instant recall of an old time favorite: The Pied Piper of Hamelin.¹

Much like the piper, plastic surgeons are often considered (by payers and nonsurgical peers alike) mavericks who perform reconstructive surgery more for their own satisfaction and joy than to actually make a living. The common perception is that our cash-rich cosmetic practice pays for much more than our indulgence in low-paying reconstructive work. Just as the piper was, reconstructive plastic surgeons are offered as pay not what is due but what is convenient. Again, like the piper, having already rendered our services when they were most required, by being available, effective, and prompt, the need of the hour is past and payment is past due. Much as the piper did, every time we give up our most effective bargaining chip—leverage—we lose more than what is done. We lose the simple right to fairness. As we have often experienced, there are innumerable reasons for not paying the piper, all golden, all stellar, and all valid: rising health care costs, and Medicaid losses; a hemorrhaging war; mounting national debt; an increasing underserved population; the pressing need for frugality; tightening market pressure, and so on. Others' realities always eclipse our realities.

Marching orders are hard to find and harder to give. Of course, the solution the piper sought in the poem is not tenable in our context and cannot even remotely be considered. Three potential solutions are in play. The first, a somewhat uneasy reaction (and an unfortunate fallout of bottomed-out reimbursements) is to “shrink away” or drop out. This path is already being taken by many. Craniofacial surgeons in Ohio have all but minimized performing orthognathic surgery⁴; the available list of providers for Medicare-paid breast reconstruction has diminished; and plastic surgeons available on trauma call are scarce. Stay away, drop out of the poorer insurance plans, and let the rats win. Although it is easier to understand the underpinnings of this view, to rationalize it is far more difficult. Contradicting our sense of responsibility to the patient, withholding care is unconscionable and, even in the hearts of proponents of this approach, does not sit well.

The second solution has been to direct all poorer patient segments to the university hospitals. An old strategy, this one burdens teaching hospitals with higher costs of caring for the indigents alone. Without any room left for paying patients, university practices in teaching hospitals become a “dumping ground,” making some of their practices financially unsustainable, foreshadowing attrition of staff and faculty. Indirectly, these foreclosures affect the vital element that keeps a field alive—residency training.

The third and perhaps the most promising solution is political action. A strongly proactive approach, making local representatives our strongest allies at least allows our voice to be heard. Petitioning governance is the most effective way to gain a seat at the bargaining table. Using patient advocacy groups, especially the disenfranchised segments, we could deliver a stern warning to insurance payers against unfair practices of denial and profit. Of course, there is a price to pay: the unsavory aspects of health care lobbying; partisan politics; and the Sisyphean challenge of going head-to-head with insurance companies, hospitals, and pharmaceutical companies who collectively spend upward of three and a half times as much on health care lobbying as physician groups do.⁵

Solutions will have to find their seekers. As I drive out of the hospital late one evening—having performed yet another Medicare (almost free) free flap reconstruction of a mandibular defect—I bask in the clarity of a professionally satisfying day's work (albeit one without pay). Suddenly, the last verse of the poem dawns on me. The solution was right there, marching orders, simple and clear. Convey a powerful, self-evident message to insurance payers against arbitrary and rapacious behavior. One that reads thus:

“So, Willy, let me and you be wipers

“Of scores out with all men - especially pipers!

“And, whether they pipe us free from rats or from mice,

“If we've promised them aught, let us keep our promise!”

—Robert Browning¹