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Reflections on Cost and Outcomes in Facial Plastic Surgery: Five Reasons to Measure Value
27 July 2010 (online)
Laura Pizzi, Pharm.D., M.P.H. Anthony P. Sclafani, M.D., F.A.C.S.
In this issue of Facial Plastic Surgery, we focus on the costs and outcome issues pertinent to facial plastic surgery. Though there exist few studies on the topic, we pursued this issue with the belief that the facial plastic surgery community will be called upon to furnish these data in the future. Regarding measurement of patient outcomes, there is a lack of data on patient satisfaction with treatment and the emotional and physical quality-of-life effects of aesthetic facial procedures. Are patients satisfied with their appearance? How does facial plastic surgery impact relationships? Does it impact employability or one's self-confidence in the workplace? How does the presence of clinical depression influence these outcomes? What are the functional outcomes of treatment, such as the impact of rhinoplasty on nasal respiration? What are the outcomes of home treatments, such as products for epilation or dermal rejuvenation, and how do these outcomes compare with those resulting from physician-delivered services? We address some of these issues through the articles herein.
One reason for the lack of data is that patients may fail to complete follow-up care, particularly for nonsurgical procedures (especially as patients are “well” and generally satisfied with results). The typical facial plastic surgeon is not trained in statistical analysis or outcomes study design. Even in the busiest practices, care is still provided in a very direct and personal way, and staff use is typically maximized, making labor-intensive data collection difficult for most practices. Undoubtedly, another reason is the lack of validated measurement tools. In this issue, we report on our experiences with a new tool to measure outcomes of dermal filler treatment: the Facial Injectables: Longevity, Late and Early Reactions and Satisfaction Questionnaire (FILLERS-Q). In addition, Klassen et al summarize progress toward developing a patient-reported outcomes instrument (FACE-Q) for facial aesthetic and reconstructive surgery.
With respect to cost measurement, certain types of economic analysis such as cost-effectiveness analysis might not be deemed relevant to cosmetic facial plastic surgery as insurers have limited influence on cosmetic procedures and consumers do not make health choices based on cost effectiveness; however, other types of economic analysis are relevant. These analyses include examinations of patient willingness to pay for cosmetic procedures, opportunity cost differences between procedures (i.e., revenue that will be lost by choosing to perform one procedure instead of another), and return on investment for expensive technologies.
For readers who are not yet convinced of the need to measure Facial Plastic Surgery (FPS) value, we offer five compelling reasons:
1. Procedures that are reimbursed by insurers, such as reconstructive procedures, are likely to be subject to future quality reporting initiatives. As reported in this issue by Berman and Friedman, there is a national movement toward value-based purchasing in health care where conscious decisions are made to improve quality and reduce costs. These authors have summarized initiatives requiring physicians to achieve quality for maximal reimbursement. Though these efforts have not focused specifically on facial plastic surgery, there are certain measures that broadly relate to surgical specialties, such as assessment of smoking status and provision of smoking cessation counseling, antibiotic prophylaxis, and venous thromboembolism prevention. Despite unresolved questions about value-based purchasing (i.e., what are the “right” measures and what level of differential reimbursement is appropriate), public and private payers are proceeding with these initiatives. In anticipation that these payers will eventually demand quality data for reimbursable facial plastic surgical procedures, development of appropriate outcome measures must begin now so that the facial plastic surgery community can play an active role in determining how their services will be evaluated. 2. There will be increased competition among facial plastic surgeons due to increasing popularity of the specialty of facial plastic surgery. Facial plastic surgery is an increasingly popular specialty, with a greater number of surgeons choosing it than anticipated in workforce projections,1 and there exists competition from other health care providers who perform cosmetic services. Though the volume of common facial plastic surgical procedures is also projected to increase,2 it is not clear whether this increase will be commensurate with physician supply—particularly in the wake of the current economic recession. Under increased competition, outcomes data can be used to differentiate “good” from “excellent” facial plastic surgeons. The use of outcomes data to answer even simple questions such as “What is you revision rate for primary rhinoplasty?” and “What is the chance of hematoma after face-lift?” will prove useful, as provision of these rates to patients will not only build confidence but also help the physician define areas for self-improvement.
Increased competition also provides a rationale to measure patients' willingness to pay for cosmetic procedures. Increased competition typically drives down prices; however, this does not necessarily translate to health care because of imperfections inherent to the market. Unlike other markets where the consumer makes purchasing decisions based on his or her knowledge and preferences, in the health care marketplace, consumers of facial plastic surgery services make purchasing decisions primarily based on preferences, relying on the physician's knowledge to inform their treatment decisions. Thus, the relationship between price and consumer demand for facial aesthetic services does not follow typical economics, and there is increased need to understand what patients are willing to pay for these services to inform prices.
3. Certain facial aesthetic technologies require significant capital expense. Excitement regarding new medical devices can cloud purchasing decisions, particularly in the absence of training or tools to assist in calculating return on investment. Priced at upwards of $75,000, skin lasers serve as an example of one such technology. In this issue, Jutkowitz and Carniol estimate the return on investment with ablative fractional lasers, and their analysis serves as a useful model for surgeons who are faced with determining whether to purchase an ablative laser and what procedure volume would be required to recoup the investment. The same holds true for other energy-based skin treatments (radiofrequency, intense pulsed light devices, etc.). 4. Health care itself is moving toward evidence-based practice and practice-based evidence. This movement is being borne out through a national agenda to fund comparative effectiveness research (CER). A 2009 Institute of Medicine committee commissioned by the U.S. Congress defined CER as: “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical condition, or to improve the delivery of care.” The purpose of CER is “to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels.”3 The U.S. Congress authorized a $1.1 billion down payment for CER through the American Recovery and Reinvestment Act (ARRA),4 and later, through health reform (HR 3590; The Patient Protection and Affordable Care Act, signed into law on March 23, 2010),5 authorized a national nonprofit Patient-Centered Outcomes Research Institute. This institute will be governed by a 17-member board of stakeholders (physicians, other providers, private health care payers, patients, government agency and state representatives, and drug, device, and diagnostic company representatives, quality improvement research) and will evaluate the comparative effectiveness of medical treatments and services through an annual operating budget of $1 per enrollee in Medicare Part A or Part B in 2013 then $2 per enrollee in the period 2014–2019. Funds will be obtained from the Medicare Part A and Part B Trust Fund.6
The amount of CER data available for most areas of medicine is low and is particularly low for facial plastic surgery treatments. A 2007 literature review of outcomes studies in plastic surgery yielded 1850 publications from 1988 to 2004, of which only about one-fourth included facial procedures. This review also included assignment of an outcomes impact (scale from 1 to 4 where 1 = low and 4 = high) and concluded that 90% were level 1, 0.2% level 2, 0% level 3, and 10% level 4, suggesting that, overall, the evidence is not strong. As a result, clinical decisions currently rely more heavily on physician knowledge, physician preference, and patient preference than on evidence. There are no head-to-head data comparing the efficacy and safety of dermal fillers, nor are there cost-effectiveness studies comparing these products. Likewise, there are no data comparing cost and outcomes of choosing repeated filler treatments with those for choosing plastic surgery. In this issue, Biskupiak and colleagues present an economic analysis comparing large-volume facial soft tissue filler treatments versus rhytidectomy. To our knowledge, this is the first analysis of its kind. Though comparative effectiveness studies like this one are not yet being demanded by facial plastic surgery purchasers (who, right now, are primarily the consumers), the national efforts described will stimulate demand for these data moving ahead.
5. It is the right thing to do from a patient perspective and from a business perspective. Need we say more?
We hope that you will be as intrigued by this topic as we are and that we will inspire you to engage in cost and quality initiatives as these efforts evolve.