#PRSJournalClub Wrap-Up: Prospective Analysis of Payment per Hour in Head and Neck Reconstruction: Fiscally Feasible or Futile? (March 2016)

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by Jordan Frey, MD

The March Edition of the PRS Journal Club- led by Resident Ambassadors Sammy Sinno (@sammysinnoMD), Amanda Silva (@AmandaKSilvaMD), and Raj Sawh-Martinez (@docrfsm)-  was a very provocative and interesting discussion!

 

  • The Resident Ambassador’s picks and paired classics for the March issue are offered FREE– did we mention they’re FREE to read– on PRSJournal.com. We hope you had many discussions and debates about these amazing articles.
  • The podcasts from are available on our website, via iTunes, and on Youtube and have been listened to hundreds of times.
  • Our third live Twitter #PRSJournalClub discussion, featuring Q&A with the authors was very informative, exciting, and interactive.

Many of our #PRSJournalClub members couldn’t pass up this golden opportunity to have this Q&A with the authors.

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If you missed the live chat, aren’t on Twitter, or just need to re-read and have easy access to some of the best interactions between the authors, residents, patients, surgeons and other interested parties, we’ve put together the following re-cap.

The article:

Prospective Analysis of Payment per Hour in Head and Neck Reconstruction: Fiscally Feasible or Futile?

The authors:

Benjamin Smith – @benjaminS2003
Ashley Chandler
Anthony Braswell
Denis Knobel
Brian Andrews
Katie Weichman
Nicholas Bastidas
Victor Moon
Armen Kasabian
Neil Tanna- @drneiltanna

Discussion points:

The article got some very interesting responses from across the world. One of the most interesting ideas was a graphic solution to the Reconstructive Paradigm from Camilla Jay Stewart from the United Kingdom:

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The Best Tweeted Q&A:

1. Question: Do you think payments should be higher for head and neck recon or less for smaller elective cases?

From: Sammy Sinno
Answer: Neil Tanna – ‪Plastic surgery‬‪ should advocate fair payment for all procedures, whether its longer or shorter cases‬‬

2. Question: Would having accredited micro centers of excellence like for bariatrics be a consideration?

From: Shuja Shafqat
Answer: Neil Tanna – Plastic surgery centers of excellence are the trend. High volume should help control expense‬
Answer: David Song – That may be where we are headed with reimbursement models based on quality and outcomes

Follow-Up Question: Shuja Shafqat – Would that limit the job market by limiting centers or increase it by inc volume/efficiency?
Follow-Up Question: Amanda Silva – And what about patient access to care?
Answer: Fawn Hogan – Definitely limits access – we can already see this with DIEP breast recon

3. Question: What are most important criteria for determining centers of excellence for head/neck micro?

From: Nicholas Berlin
Answer: Neil Tanna – Plastic surgery quality metrics are being determined- complications, cost, patient satisfaction

4. Question: How can we advocate for better reimbursements for H&N like there is for breast reconstruction?

From: Stephen Lu
Answer: Neil Tanna – At local level we should speak with our hospital administration

5. Question. Have you learned anything from negotiations w/ your hospital that you’d rec?

From: Amanda Silva
Answer: Neil Tanna – In any negotiation know your data – volume, or time, complications, readmission

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6. Question: In the move towards bundled care, who decides reimbursement division? PRS+ENT+Onc+Rads=?

From: Sabrina Pavri
Answer: Neil Tanna – Hospital administration most likely determines the distribution in a bundled payment system.

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7. Question: Do you think a single payer healthcare system alleviate or worsen the reimbursement disparity?

From: Amanda Silva
Answer: Neil Tanna – If ‪plastic surgery‬ doesn’t advocate its value, the specialty will see a drop in reimbursement with single payer
Answer: David Song – Yes and No. Single payor will accelerate a tiered medical system much like the NHS

Follow-Up Question: Sammy Sinno – Would a single payer healthcare system help or worsen these reimbursements?
Answer: Benjamin Smith – SP alone likely no guarantee of correcting, but hope thoughtful design would better match reimbursement to value

8. Question: How best to show value to insurance providers in this & other cases? Better PROMs?

From: Jordan Frey
Answer: Neil Tanna – Hope everyone tracks their outcomes. This is most important insurance co. assessment. Demonstrate + outcomes like patient satisfaction, readmission, complications, & cost.

Follow-Up Question: Shuja Shafqat – What things should we track when we get into practice to present to admin and insurance?
Answer: Neil Tanna – ‪Data‬‪ is everything. We can’t just rely on complication rates. Show insurance how good we really are!‬‬

‪”#Data‬‪ is everything. We can’t just rely on complication rates. Show insurance how good we really are!‬‬”

9. Question: How can we prove the worth of microsurgery from a cost benefit perspective?

From: Sabrina Pavri
Answer: Neil Tanna – Everyone should track his/her outcomes. It will prove utility in itself.

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10. Question: With this information, will surgeons start performing less complex reconstructions?

From: Selenid Gonzalez
Answer: Neil Tanna – If hospitals and physicians don’t align, the latter will have to look for higher reimbursing cases

Follow-Up Question: Raj Sawh-Martinez – Hospital income is also being cut; won’t this hurt alignment?
Answer: Neil Tanna – As cuts happen (profit = revenue – expense), we have to find ways to be more efficient (decrease expense). The take home here is that h&n reconstruction is viable when supported by the institution

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Response: Pallab Chatterjee – Agree! It’s not merely surgery. Such depleted patients show high incidence of post op complications.
Response: Stephen Lu – Agreed. ENT needs to hear this as well and recognize the significance of PRS

Follow-Up Question: Amanda Silva – Do you think there’s a trend towards less perforator free flaps & instead taking more muscle to quicken case?
Answer: Pallab Chatterjee – Indeed, the harvest of fibula is faster with the cuff of FHL/soleus taken along

Follow-up Question: Pallab Chatterjee – When even carpal tunnel release is more paying, isn’t it staring at the obvious
Response: M. Shuja Shafqat – I think the comparison to CTR in the article is unfair. Its an outpt relatively standard operation vs H&N recon.
Response: Pallab Chatterjee – Don’t think goal was to compare the returns of equal relative value surgeries, say like neurosurgical ones.
Answer: Neil Tanna – CTR Comparison was to demonstrate inequitable plastic surgery collections for H&N reconstruction.

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11. Question: Does medical modeling affect margin/reimbursement in these case?

From: Jordan Frey
Answer: Neil Tanna – Medical modeling does affect the hospital net revenue, as expenses go up but reimbursement stays same

Follow-Up Question: Jordan Frey – Thanks! Do you think it at least helps by decreasing OR time?
Answer: Neil Tanna – Medical modeling does affect the hospital net revenue, as expenses go up but reimbursement stays same
Answer: David Song – Decrease in OR time doesn’t = dramatic $$ savings but = safety and better outcomes

12. Question: Dr. David Song mentioned high vol centers to perform recon @ low cost. Does this increase poss of micro CAQ?‬

From: M. Shuja Shafqat
Answer: Neil Tanna – High volume more likely equates to high quality. CAQ in microsurgery is controversial

Follow-Up Question: M. Shuja Shafqat – Do you think this will then discourage microsurgery performed by non-fellowship trained surgeons?
Answer: Neil Tanna – hospitals/patients recognize high volume providers with good outcomes (fellowship is a plus). The volume outcome relationship has been shown in plastic surgery.

13. Question: How can plastic surgeons combat this worrisome trend of misaligned reimbursements?

From: Raj Sawh-Martinez
Answer: Benjamin Smith – Surgeons must be active players in negotiation of new health care economics. Self-advocate for where we add value. Health care economics changing quickly. Surgeons must be active players in process. Self-advocate and negotiate where we add value

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14. Point: Microsurgery is a passion. Despite declining reimbursements, those who love it will continue to do it!

From: Neil Tanna
Question: Raj Sawh-Martinez – So true! ‪Money isn’t everything‬ but won’t trends like these can make critical procedures scarce?
Answer: Neil Tanna – We may see more difficult plastic surgery procedures limited to certain centers
Answer: Neil Tanna – The answer isn’t to just negotiate with insurances but work with facilities. Bundle payment is the future

Follow-Up Question: Raj Sawh-Martinez – Great point, wondering if specialty centers will be the future bc of this?
Answer: Fawn Hogan – Seems like the way to do it. Unfortunate for those who truly love micro but can’t get reimbursed.

Follow-Up Point: Shuja Shafqat – Things like social media can help us become better advocates by increasing awareness & education
Follow-Up Point: Shuja Shafqat – Did mention how certain centers might have lower costs due to better expertise and efficiency
Answer: David Song – In the future high volume = low cost = high quality

“#Microsurgery is a passion. Despite declining reimbursements, those who love it will continue to do it!”

15. Question: True, but will the decreased costs lead to parity of reimbursement

From: Raj Sawh-Martinez
Answer: Fawn Hogan – Insurance will either pay adequately or micro will become an out of pocket procedure-IMHO
Answer: Neil Tanna – If successful at lowering hospital cost, plastic surgery has to make sure they are rewarded
Answer: Kenneth Lee – Efficient micro is the future. Develop OR teams and systems to improve quality

Follow-Up Point: Doreen Dupont – Good to hear you say that. Surgery should be a passion for results

16. Question: Any advice for practicing microsurgery in a large metropolitan area with large competition?

From: M. Shuja Shafqat
Answer: Neil Tanna – Just like anything else, do a lot and do it well
Answer: Minas Chrysopoulo – Remember pts can’t appreciate micro skills. Appreciate what they c in mirror most.

 

With fantastic feedback, engaged questions from people within and outside the field of plastic surgery, the March 2016 #PRSJournalClub was educational, exciting, provocative, and interesting.

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We look forward to you joining us on PRSJournal.com and on Twitter for the next #PRSJournalClub on “Impact of Prior Tissue Expander/Implant on Postmastectomy Free Flap Breast Reconstruction”: April 17 and 18.

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