Keep a copy of this article. What you’re about to read is a forecast of the future. Hold on to these comments so as to “keep score” of what unfolds in the next decade for plastic surgery (and healthcare in general)!
With so many changes in the way healthcare is paid for (volume reimbursement giving way to value-driven reimbursement), this will lead to changes in the way healthcare is delivered. You see, it’s a domino effect that starts with the Federal government. So let’s look at how the first domino was nudged. And before I get started, let me be clear that this is not a rant on ObamaCare…because if it wasn’t ObamaCare, it would be GOPCare or RomneyCare, etc. With the rising costs of healthcare, much of it due to increased regulations, technology, hospitals, doctors, lawyers, insurance companies, etc, one political party or another was going to intervene. And just because I point out different aspects of this domino effect doesn’t necessarily mean that all of these changes are evil but each change led to another change so they’re pointed out for clarity.
It all started with costs. In an effort to reduce costs, the Federal government (Medicare & Medicaid [part Federal/part state funding]) started by reducing reimbursements to hospitals and doctors. And when the Federal government leads, the private insurance companies often follow suit. Even cutting payments to so many hospitals and doctors, those cuts didn’t save enough money. The next step in reducing costs was to connect reimbursement to quality rather than to the number of procedures performed. It’s certainly a noble idea but carrying it out is an entirely different proposition. One way to accomplish this is value-driven reimbursement. For example, instead of paying for the number of procedures a hospital/doctor performs, they would pay the hospital and doctor better or worse based on their outcomes. How do they track outcomes? It requires a great deal of paperwork and time – time that is spent away from the patient. It’s a Catch-22. Spend more time with the patient and fail to complete your required quality assessing paperwork and not get reimbursed or spend more time on paperwork, away from the patient.
In an effort to improve quality and value, (and reduce costs), the next domino in line was electronic medical records (EMR). Again, a noble idea but will it be the end all, be all? EMR’s provide more sharing of patient records between doctors and hospitals so it’s easier for everyone to be on the same page for a particular patient’s care. EMR’s are wonderful in that respect – sharing relevant information for potentially safer and less redundant care. But does it save money? A recent New York Times article discusses a 2013 RAND Corporation review of a previous 2005 RAND Corporation study. The RAND Corporation, a research firm, did a study in 2005 stating that the adoption of EMR’s would save $81 billion annually. And then a follow up study 8 years later in 2013 says those figures were overstated. The rosy figures presented back in 2005 shouldn’t be surprising – the study performed by RAND at the behest (read – was paid for) of General Electric and Cerner Corporation…both companies that develop electronic medical records! As an aside, RAND Corporation’s Mission statement on their website is “To help improve policy and decisionmaking through research and analysis” and their Core Values are “Quality and objectivity.” Pretty laughable. But if you’re a stockholder for the Cerner Corporation, your revenue tripled since that 2005 study. So good for you.
Time to complete more paperwork, submit evidence of better quality and switching to electronic medical records, all to be reimbursed adequately for services provided, costs time and money on the part of an individual doctor. Enter the next domino. With these rising costs to the doctor and lower reimbursement from Federal/State and private insurance companies, an individual doctor can’t afford a team of employees to fight insurance companies for adequate reimbursement, pay for and support an EMR system or complete quality assurance paperwork. But hospitals are hedging their bets that they can afford to hire enough staff to do these tasks for the doctors that the hospitals hire. And this is why you see a huge shift in the last few years of more and more doctors becoming employees of hospitals. The bottom line is doctors who take insurance can’t afford to be on their own anymore. So, how will this trend affect your plastic surgeon, a doctor that relies on insurance reimbursement but also out-of-pocket payments for cosmetic procedures?
If you need a reconstructive procedure, such as breast reconstruction after a mastectomy, currently you go to any plastic surgeon that offers those procedures and takes your insurance plan. But this will change. For the reasons I stated above, it is getting more and more expensive for the doctor to take your insurance – all of the support staff to handle those claims and the regulations that you must be in compliance with to accept insurance. What will happen in the future is this. As it becomes too difficult for solo practicing/small group plastic surgeons to take insurance, plastic surgeons will shift to an all-cosmetic practice (since cosmetic surgery isn’t covered by insurance), or a hospital-based, insurance-accepting practice. The only plastic surgeons that will provide any reconstructive services will be those that are hired by hospitals/academic centers fresh out of training or veteran plastic surgeons that are employees of a hospital or academic center. Because only they will be able to provide the support staff to handle insurance claims and regulatory requirements. The individual or small-group plastic surgery practice accepting insurance that had a nice office in a quiet setting in a subdued area of town will be a thing of the past. If you need an insurance-based reconstructive procedure that your friendly, neighborhood plastic surgeon used to provide, you’ll need to look for a parking spot in the parking garage of the nearby hospital or academic center. But if you want a cosmetic procedure, you can still depend on your board certified plastic surgeon to provide those services in that serene private office setting. And if you really want a reconstructive, insurance-reimbursable procedure performed by that private-practice plastic surgeon that doesn’t take insurance (or you have a really high deductible health plan), the scenario wherein you just pay out of pocket for non-cosmetic procedures, like a mole removal, may become more common.
Another interesting domino effect is plastic surgeons hired out of training will work as an employee for a few years and once they have their “sea legs,” they’ll go out in the community as a cosmetic-only surgeon. This will create a setting for short term employment of plastic surgeons by hospitals, where the hospital is a revolving door of surgeons coming in for 2-3 years, “serving their time” by providing the reconstructive (trauma) needs of the hospital and then heading out for a more lucrative independent private practice. Not saying there’s anything wrong with this but it is an interesting paradigm shift after training – employed, hospital-based reconstructive practice followed by an independent cosmetic/self-pay private practice. The days of most plastic surgeons going straight into private practice and serving everyone’s needs, reconstructive or cosmetic, may be a thing of the past.
Be mindful that with the advent of regulatory health care, more and more doctors are seeking out cosmetic patients to perform cash-only procedures (and avoid insurance entanglements). Many of these doctors are not trained in cosmetic procedures the same way a plastic surgeon is trained in an accredited residency program. So buyer beware. Look for the term plastic surgeon on their door. If they only say they’re a cosmetic surgeon, then they’re hiding something.
