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.