The Impact of the Medicare Sustainable Growth Rate Formula on Reconstructive Plastic Surgery

Sir: This year, as Congress contemplates a 21.2 percent reduction in Medicare physician fees, the American Society of Plastic Surgeons and other major medical organizations have criticized the cutbacks, arguing that such a reduction is a short-sighted and short-term fix to a fundamentally flawed model.1 It is important that plastic surgeons, particularly those in reconstructive surgery, demand a permanent, sustainable solution from their congressmen and congresswomen. Congress' recent health care bill has provoked considerable debate over its attempt to allow the sustainable growth rate to cut physician reimbursements under Medicare.2 Enacted in 1997, the sustainable growth rate sets a target rate for physician compensation based on the relationship between Medicare part B expenditures and the gross domestic product. If expenditures exceed target rates, the sustainable growth rate calls for a reduction in the following year's physician reimbursements to recoup the loss. Since 2003, Congress has declined to enforce the sustainable growth rate reimbursement cutbacks, resulting in a growing deficit. Reconstructive plastic surgeons and their patients may suffer the most from these reimbursement cuts. The sustainable growth rate adjustments would reduce their fees despite generally long operative and hospital courses, changing the economic landscape of reconstructive surgery. The financial incentives, or disincentives, created by the sustainable growth rate may directly impact surgical management decisions. For example, under the influence of sustainable growth rate–mediated cutbacks, a surgeon may elect to perform prosthetic breast reconstruction over autologous free-flap reconstruction based on its better reimbursement-to–operative time ratio. The sustainable growth rate has clear ramifications beyond simple reimbursement, with repercussions that will be felt in the areas of patient care and surgical decision making. Economic factors already disfavor reconstructive surgery, especially when compared with the profitability of out-of-pocket elective procedures. Reconstructive surgery generally yields lower fees and greater administrative overhead, often requiring the surgeon to spend an exorbitant amount of time negotiating reimbursements with insurance companies. Because of the nature of plastic surgery, unique or specialized techniques are poorly differentiated in the reimbursement structure, making claims more difficult to file as well. Despite involving often more time-consuming and labor-intensive procedures, reconstructive practices are not compensated financially as well as elective, outpatient aesthetic procedures. The sustainable growth rate would only stress this imbalance, making reconstructive surgery a more unfavorable field to pursue for financially indebted medical students, residents, and fellows.3 These incentives may explain, at least in part, why fewer plastic surgery residents are actively seeking out careers in reconstructive surgery. Already, the American Society of Plastic Surgeons anticipates a shortage in the plastic surgery workforce over the next 10 to 15 years.4 Many academic centers have observed that fewer plastic surgery residents are pursuing microsurgery and reconstructive fellowships, let alone full-time careers, highlighting the expected shortage of reconstructive surgeons in the future. Congress should consider the effects of the incentives it creates, particularly when there has been no greater need for the reconstructive surgeon than now. With the growing elder population and advances in cancer treatment, patients are undergoing more aggressive resections than ever before. Furthermore, advances in medical care have made patients with formerly nonsurvivable traumatic injuries candidates for complex reconstruction. There is a growing need for reconstructive surgeons at the same time that these economic incentives discourage surgeons from performing these procedures. Policymakers should not create incentives that direct physicians to choose, for example, negative-pressure therapy to treat a complex wound that would be better managed with a flap. Instead, policymakers should create incentives to provide patients with optimal care, not merely cost-based care. Rather than seek short-term fixes and struggle with annual health care budget shortages, Congress needs to reform the entire cost structure. It is our duty as plastic surgeons to ensure that our patients with complex deformities are treated appropriately regardless of the complexity of care or surgical requirements. It is important for American plastic surgeons to follow the national health care reform process, as it will significantly mold the scope of our field and future practice environment. Anup Patel, M.D., M.B.A. James E. Clune, M.D. Antonio Forte, M.D. Christopher C. Chang, M.D. Section of Plastic and Reconstructive Surgery Yale University School of Medicine New Haven, Conn.