Jenny T. Chen

The Economics of Skin Cancer: An Analysis of Medicare Payment Data.

Purpose: The incidence and cost of nonmelanoma skin cancers are skyrocketing. Five million cases cost

The Affordable Care Act: a primer for plastic surgeons.

8.1 billion in 2011. The average cost of treatment per patient increased from

Plastic Surgeons’ Perceptions of the Affordable Care Act: Results of a National Survey

1000 in 2006 to

Abstract 96: the venous anastomotic flow-coupler for free flap monitoring: a prospective analysis of 85 microsurgical breast reconstruction cases.

1600 in 2011. We present a study of the economics and costs of skin cancer management in Medicare patients. Methods: We studied data released by the Centers for Medicare and Medicaid Services in 2014. Treatment modalities for the management of skin cancer were reviewed, and costs of treatment were quantified for a sample of 880,000 providers. Results: Review of Medicare payment records related to the management of skin cancer yielded data from over 880,000 health care providers who received

Postoperative Management of Lower Extremity Free Tissue Transfer: A Systematic Review

77 billion in Medicare payments in 2012. From 1992 to 2009, the rate of Mohs micrographic surgery (MMS) has increased by 700%, and these procedures typically have Medicare payments 120% to 370% more than surgical excision, even when including pathology fees. From 1992 to 2009, MMS increased by 700%, whereas surgical excisions increased by only 20%. In 2009, 1800 providers billed Medicare for MMS; in 2012, that number increased to 3209. On average, 1 in 4 cases of skin cancer is treated with MMS. Conclusion: Mohs excision is more expensive than surgical excision in an office setting. Procedures requiring the operating room are much more expensive than office procedures. In an era of high deductible health plans, patients’ financial burden is much less with simple excisions of skin cancers done in a clinic when compared with Mohs surgery or operative interventions.

Abstract: The Economic Impact of Skin Cancer

Summary: The Patient Protection and Affordable Care Act, sometimes referred to as Obamacare, was signed into law on March 23, 2010. It represents the most extensive overhaul of the country’s health care system since the passage of Medicare and Medicaid in 1965. The Affordable Care Act has two goals. The first goal is to reduce the uninsured population in the United States. Key elements to covering the uninsured include the following: (1) expanding Medicaid coverage for low-income individuals and (2) establishing health insurance marketplaces for moderate-income individuals with subsidies and tax cuts in an effort to make health insurance more affordable. The second goal of the Affordable Care Act is to address concerns about quality and the overall cost of U.S. health care. It is imperative that plastic surgeons thoroughly understand the impact that the Affordable Care Act will undoubtedly have on the country, on our patients, and on our clinical practices. Plastic surgery will see many changes in the future. This will include an overall increase in the number of insured patients, a push toward joining accountable care organizations, and a shift in payment systems to bundled reimbursement for episodes of care. In this article, the authors describe how these changes are likely to occur and what plastic surgeons must do to be part of the change.

A Twelve-Year Consecutive Case Experience in Thoracic Reconstruction.

Background: The Affordable Care Act (ACA) aims to expand coverage to the uninsured, improve quality, and contain costs. The goal of this study was to ascertain how plastic surgeons perceive the ACA. Methods: An electronic questionnaire was e-mailed to members of the American Society of Plastic Surgeons between May and June 2014. The survey was anonymous and voluntary and included questions to assess understanding and opinions of the ACA. Results: The survey was sent to 3070 members of the American Society of Plastic Surgeons, and the response rate was 17%. Sixty-eight percent agree or strongly agree that they understand the basic concepts of the ACA. The majority of respondents disagree (38% strongly disagree, 31% disagree) with the notion that the ACA will positively affect their practice, and 51% agree with the statement, “I do not support the ACA, and I believe it did too much.” Two thirds (66%) believe that the ACA deserves a grade of D or F. When answers were analyzed across demographics, 42% of respondents with “Academic” practice background identify with the statement, “I support the ACA but I think it needs more work,” compared to 15% of those who selected “Solo Practice” (p <0.001). Conclusions: The ACA will affect all specialties, including plastic surgery. The results of this survey suggest that many plastic surgeons believe that they have a baseline understanding of current health-care reform. The majority of surveyed surgeons do not support the Act. It is imperative that plastic surgeons possess the knowledge of the ACA; its changes, both current and impending, will likely affect patient mix, coverage of procedures, and reimbursement.

Challenging Traditional Thinking: Early Free Tissue Transfer for Active Hemifacial Atrophy in Children

PurPose: The venous anastomotic flow-coupler has recently been developed for clinical use, contributing to a multitude of flap monitoring devices and techniques. To date, only one published small retrospective series (19 patients) reported this device to be both reliable and accurate for use in head and neck reconstruction; however, no data exists in the setting of abdominal based free flaps for breast reconstruction. The authors present a prospective analysis of the venous anastomotic flow coupler in 85 microsurgical breast reconstruction cases.

Changes in Cutaneous Gene Expression after Microvascular Free Tissue Transfer in Parry-Romberg Syndrome

Background Free tissue transfer for lower extremity reconstruction is a safe and reliable option for a wide range of challenging wounds; however, no consensus exists regarding postoperative management. Methods A systematic review of postoperative management of lower extremity free tissue transfer was conducted using Medline, Cochrane Database, and Web of Science. Multicenter surveys, randomized controlled trials, cohort studies, and case series were reviewed. Results Fifteen articles investigating current protocols, flap physiology, and aggressive dangle protocols were reviewed. The following evidence‐based conclusions were made: (1) Free tissue transfer to the lower extremity is unique due to altered hemodynamics and dependency during orthostasis. Free flap circulation is dependent on locally mediated responses and deprived of compensatory muscular and neurovascular mechanisms that prevent venous congestion in the normal extremity. (2) Compressive wrapping reduces venous congestion and edema and may induce ischemic conditioning, which can increase blood flow. (3) Dangle protocols vary widely in timing of initiation, frequency, and monitoring. Small volume studies examining aggressive mobilization protocols initiating early dependency have led to earlier ambulation and discharge, with no change in flap survival as compared with conservative protocols. (4) Weight bearing may begin after the completion of dangle protocol if no orthopedic injury is present. Conclusions Early initiation of a dangle protocol does not appear to negatively impact flap survival based on this systematic review. Compressive wrapping may be a useful adjunct. Many surgeons agree that clinical monitoring is sufficient; there is no consensus on the utility of adjunct monitoring techniques. Weight bearing may begin after completion of dangle protocol with close flap monitoring, if not prevented by orthopedic restrictions. By providing additional outflow vasculature to reduce venous congestion, flow‐through anastomoses may eliminate the need for a dangle protocol. Further research, including large randomized controlled trials is still needed to establish high‐level evidence‐based conclusions.

Medicare for the Plastic and Reconstructive Surgeon

RESULTS: Fifty-five participants (31 patients and 24 parents) completed all questionnaires, 98.2% preferred active involvement in therapeutic decision-making. The SDM-Q-9 scores, assessed by patients and physicians, were acceptable (mean 68 out of 100). However, the independently assessed OPTION-5 scores were significantly lower (mean 31 out of 100). In the consultations, physicians rarely asked for patient preferences regarding involvement. In addition, the patient’s freedom of choice and pros and cons of treatment options were inadequately explained. The degree of patient involvement from the patient’s perspective (CollaboRATE) was significantly correlated with patient satisfaction (ρ 0.35, p<0.01).