Is there a future for “reconstructive” abdominoplasty?

Obesity is epidemic in the United States. All you have to do is turn on your television set to see a celebrity who has resorted to bariatric surgery to lose weight. With so much focus on weight loss and appearance, body contouring is also much-discussed topic.

In traditional plastic surgery training, body contouring—specifically abdominoplasty—is indicated for moderate-sized patients who present with excess skin and fat, bulging lower abdomens, and diastasis. “Cosmetic” abdominoplasties, or self-pay procedures, are reserved for those whose insurance does not reimburse for the procedure: the asymptomatic patient or, commonly, the more slender patient.

With the resurgence and success of bariatric procedures (see the sidebar “Not Without Its Risks” on page 33), increasing numbers of people come to plastic surgery offices to request—or insist on—correction of their once obese abdomens, and expect insurance to cover it. These are motivated patients who have suffered through obesity, accepted the risks related to bariatric surgery, and now want to complete the job.

Legitimate Diagnoses

Insurance companies vary widely in their reasons for coverage. Historically, symptoms such as intertrigo and chafing were legitimate diagnoses for reimbursement. Cur­rently, in­surers in Michi­gan, where we practice, require either a pannus that hangs below the pubis or more than 100 pounds of weight loss from bariatric surgery.

In general, there are two types of patients visit a plastic surgeon for these procedures: those who have no previous knowledge of what it takes for their insurance companies to pay for their procedure—and those who not only know the answers to interview questions, but will do whatever it takes to qualify for coverage. These patients typically have been to group meetings, often weekend retreats organized for the obese, where a speaker promotes the concept of bariatric surgery and discussions are held to address options such as abdominoplasty that may be available to them after bypass surgery.

When these patients are informed by their surgeons that their insurance companies may not pay for their care, they may be quite surprised. “After all this time and effort,” they say, “I thought that this part would be automatic.” These patients re-quire a tremendous amount of surgery time and follow-up, and have a higher complication rate than other patients. Talented plastic surgeons race to find improved surgical solutions for the difficult correction of massive volumes of excess skin, and the maze of issues involving insurance coverage versus self-payors among postbariatric patients grows in parallel.

The current trend affects patients and surgeons alike. Historically, and under the current procedural terminology (CPT) global definition code 15831, a standard abdominoplasty includes elevation of the entire abdominal flap, repair of rectus diastasis, translocation of the umbilicus, and resection of the excess skin. Other procedures commonly performed that are not outlined specifically in this code may include liposuction of the flanks or abdominal flap, or a lower-body lift.

In contrast, a panniculectomy is typically recommended for patients whose risk factors preclude a standard abdominoplasty or who are too obese for this procedure to realistically make a difference. This similar, yet less involved, procedure—which has the identical 15831 code—involves a primary lower abdominal skin (wedge) resection with little or no undermining.

In a perfect world, all pa-tients would fall into one of these two categories, and how to ap-proach them would be very clear. How­ever, the majority of post-bariatric patients fall into a gray area. Most have lost weight throughout their trunk and are left with an overhanging pannus above and below the umbilicus. (See the “before” photos in Figures 1 and 2, pages 28 and 30.)

Treating these abdo­mens with only a traditional panniculectomy (Figure 1) would leave them with a residual supraumbilical pannus, an inferior result. For this reason, most plastic surgeons have historically performed a standard ab­dom­i­noplasty, despite the pure definition of the code and the recommended limited approach.

Worsening Climate

Today, many factors contribute to a worsening climate for performing abdomi­no­plasties. The ever-increasing number of patients who legitimately present following massive weight loss is overwhelming reconstructive surgeons’ schedules, and the ongoing financial pressure on insurance coverage has resulted in a change to the insurance system that affects patients and physicians alike.

Another negative trend is what many insurers are doing to limit reimbursement for reconstructive cases, including:

• rationing of care, that is, not approving procedures that have typically been covered previously;

• growing numbers of hoops for surgeons and their office staffs to jump through to obtain coverage for patients;

• increasing copayments from patients al­ready burdened by rising premiums; and

• reducing reimbursements to levels where overhead is not even met and the surgeon is, in a sense, paying the patient to perform the procedure.

Some physicians may consider the discussion of financial concerns petty, but providing medical services is a business—and losing money is a poor business plan. When you consider the socioeconomic level of the average obese patient, you will discover that there is a strong inverse correlation between obesity and socioeconomic status, which is contrary to the traditional notion that obesity occurs mainly in the socioecon-omic elite.1 

According to the American Society of Plastic Surgeons (ASPS), the national-average fee paid to surgeons for an aesthetic abdominoplasty—including skin reduction and muscle plication—is $4,505; for a lower-body lift, it is $6,425.2 These figures do not include the additional costs of performing a circumferential abdominoplasty, if required, or of anesthesia or facility use, including the operating room. For patients in lower socioeconomic groups, an aesthetic abdominoplasty is an extraordinary financial burden and is often not an option.

A Parellel to Breast Reduction

You must also consider the reimbursements by insurance companies compared with the time and effort put forth by both the plastic surgeon and the office staff. This issue parallels that of medically necessary breast reduction, for which patients in western Michigan are often expected to pay a copayment in addition to monthly insurance premiums, and reimbursements are at an all-time low.

Reimbursements for abdominoplasty by Blue Cross/Blue Shield of Michigan and Medicare are only 23% and 19%, respectively, of the actual charges. If the average office overhead is about 50%, we are practicing at a deficit of 30%. No private practice can remain solvent with purely reconstructive insurance patients as its sole source of income. As surgeons, we are truly becoming fearful of reconstructive surgery!

The estimated time spent for an uncomplicated reconstructive abdominoplasty patient is:

Consultation time 1 hour

Surgery time 3 hours

Insurance application, estimation, review 1 hour

Postoperative office visits (5 in global period) 1 hour

Total 6 hours

In a typical case, if reimbursement for code 15831 is $800 and office overhead is 50%, the physician is reimbursed at a rate of $67 per hour to care for this patient—assuming that there are no complications that increase the time spent on the patient. Whereas it is clear that surgical risks increase with obesity, there is a less well-defined relationship be­tween postoperative complications and the volume excised at the time of surgery. In any case, previously superobese patients (with a body-mass index greater than 39) are prone to a higher risk of complications, need more intensive postoperative care—and therefore generate an even lower reimbursement rate.

If the average standard abdominoplasty patient is seen five times within the global period after surgery and twice thereafter, how many surgeons will continue to provide this service under these conditions? On the other hand, a panniculectomy on patients who need a full abdominoplasty, but are unwilling or unable to pay for it, gives a far inferior result.

Informal Poll

We took an informal poll of surgeons who have practiced for less than 10 years, in both private practice and in academia, and turned up a mixture of approaches to this issue. In metropolitan areas, where overhead is higher and competition is fiercer than elsewhere, surgeons tend to refuse to perform abdominoplasty or accept these patients only on a fully aesthetic fee basis. Some surgeons agree to a partially aesthetic procedure, performing the panniculectomy and charging the patient for the aesthetic elements.

Most surgeons feel compelled to care for postbariatric patients, but refuse to perform an inferior procedure for patients who clearly need treatment of supraumbilical skin folds. Many surgeons in both smaller cities and metropolitan areas find it extremely difficult to ask patients to pay the difference and continue to perform a standard abdominoplasty, despite the dismal reimbursement.

This cannot continue, particularly in areas such as the Midwest, where states compete annually for the title of “fattest state in the union.” Many patients go untreated because a surgeon can afford to treat only a limited number of them. In a modest-sized city of approximately 500,000 residents and a regional draw of more than 1million, a plastic surgeon is inundated with requests. General surgeons in such a community would perform more than 3,000 bariatric procedures annually.

It is unlikely that reimbursements for code-15831 surgeries will increase. Ignor-ing the problem and limiting the number of patients seen will only force the procedure into the hands of less-experienced surgeons, or the surgery will not be performed under insurance. Options available to plastic surgeons for caring for the growing number of postbariatric patients are few. 

In 1997, during the prebariatric-revival period, Raymond Janevicius, MD, the ASPS representative on the American Medical Association’s CPT advisory committee, recommended that medical pa­tients be treated with panniculectomy and did not comment on the treatment of the upper skin folds.3 Recent communication with him suggests that changes to the CPT codes are being addressed with new codes that better define the procedures performed—but this is typically a 5-year process. Will these changes create a separate postbariatric-patient code that in­cludes treating the upper skin folds and an acknowledgment of the increased level of difficulty and amount of time committed to these patients’ care? Will the insurance companies recognize the difference and reimburse appropriately, or will they consider all reconstructive abdominoplasties “cosmetic”?

Unacceptable Conditions

So who should pay? It is unrealistic to ask every postbariatric patient to pay out of pocket for an abdominoplasty, as much as it is unacceptable to ask plastic surgeons to continue to accept the current poor level of reimbursement. If there is to be a code to cover postbariatric panniculectomy, it should specifically allow the surgeon to charge the patient for care of the upper abdomen and any other procedures currently considered in the global procedure. Patients would have to be made aware before surgery that a standard abdominoplasty is a “luxury” procedure, removed from the ranks of reconstructive surgery.

What is the most likely outcome? Perhaps a grassroots uprising of patients complaining about the dismal choices available to them would convince their insurance companies to reconsider reimbursements to surgeons. But this is not likely. We believe that ultimately it would be up to the corporate world to “force” the insurance companies to cover these procedures for their employees. Unfortunately, corporations will not choose their insurance carrier based on their coverage of plastic-surgery procedures.

In addition, insurers are sidestepping the issue by inaccurately stating that they are “covering” the procedure, but are actually reimbursing physicians at only a fraction of the total cost.With such low reimbursement rates, surgeons can no longer provide these services under insurance, potentially placing patient and surgeon in antagonistic positions.

In conclusion, without major changes or reform, the climate for abdominoplasty along with reconstructive surgery remains dismal. We will continue to face:

• growing restrictions on coverage, with rationing of care, and therefore an increasing discrepancy between those who can and those who cannot afford treatment;

• increasing dissatisfaction of patients and plastic surgeons with the suboptimal results from panniculectomy-only surgeries; and

• growing frustration on the part of patients, who have increasing expectations because of their greater investment in the procedure: increased premiums and copayments, and now “à la carte” portions of the abdominoplasty.

These expectations, considered on a large-scale basis, may sway the public’s perception of plastic surgery and become a public-relations or litigation nightmare. During this time of change, it will be even more important for plastic surgeons to be up front with patients concerning what insurance companies will and will not cover, and to discuss reasonable fees and outcomes for each procedure we perform. Most importantly, we need to remain focused on the patient and continue to act as his or her primary advocate. PSP

Bradley P. Bengtson, MD, FACS, is a board-certified plastic surgeon in private practice at Plastic Surgery Associates in Grand Rapids, Mich. He is an assistant clinical professor at Michigan State University, Grand Rapids. He can be reached at (616) 451-4500 or [email protected]

Marguerite E. Aitken, MD, is the newest member of Plastic Surgery Associates and a clinical instructor at Michigan State.

References

1. Stunkard AJ, Sorensen TI. Obesity and socioeconomic status—A complex relation. N Engl J Med. 1993;329:1036–1037.

2. American Society of Plastic Surgeons. 2004 average surgeon/physician fees. Available at: http: //[removed]www.plasticsurgery.org/public[/removed]_education/loader.cfm?url= /commonspot/security/getfile.cfm&PageID=16163. Accessed November 1, 2005.

3. Janevicius R. What’s global in abdominoplasty? Plast Surg News. 1997;9b(7):17.