Gender-affirming Plastic Surgery
Exploring the intersection of health policy and plastic surgery
I’ve been spending the last two weeks on a surgery selective with our plastic surgery service which has given me the opportunity to scrub into cases ranging from breast reconstruction to fat grafting to complicated skin flap reconstructions. Outside of the OR, we also get to see underinsured/Medicaid patients as part of a resident-run clinic.
Perhaps one of the most consumer-oriented specialties out there, plastic surgery may have some of the most aligned “direct-to-consumer” incentives between patients and providers because of its elective and mostly out-of-pocket procedures. However, steep costs of plastic surgery procedures can exacerbate healthcare disparities if they aren’t covered under insurance. This being said, there has been interesting policy innovation in the last few decades and more value-based purchasing in other surgical specialties may provide new opportunities to incentivize plastic surgery innovation.
In conversations consulting with one of our patients in preparation for surgery, one of the memorable comments reminded me how high-deductible health plans are still a predominating driving force behind healthcare consumer decisions, “I’d prefer to do the surgery before my deductible resets in January”.
One of the highlights of my rotation was meeting Dr. Jess Ting, a Julliard-trained musician turned plastic surgeon who started the nation’s first fellowship in gender-affirming surgery. As someone who also changed careers into medicine, it’s inspiring to see how his love and continued musical pursuits flows into the creative work he does as a surgeon.
All these conversations and experiences the last two weeks inspired me to take a deeper look into systems-level forces driving consumer and surgeon incentives.
An estimated 0.6% of the U.S. population identifies as transgender or gender-nonconforming. Transgender patients not only face many unique health risks, including an increased risk of suicide (an especially saddening 41% have attempted suicide in their lifetimes), mental health issues, and HIV but are also more likely to be uninsured. Even if they are insured, transgender patients often find insurance coverage for gender-affirming lacking and moreover are often discriminated against even by healthcare providers.
During my primary care rotation at the Samuel Friedman Health Center I had the opportunity to work with a number of LGBTQ patients who were in different stages of their transgender transition journey. Knowing how transgender care spans complex co-morbidities with many mental health illnesses, I was glad to see how psychiatrists as part of Mt Sinai’s newly launched Transgender Psychiatry Fellowship are tackling LGBTQ care more holistically. Now on plastic surgery, it’s great to see engaged surgeons are in supporting the transition of transgender patients through procedures like phalloplasty, facial feminization surgery, etc…
Dr. Jess Ting’s work in designing a new vaginoplasty technique now called the Peritoneum Vaginoplasty, uses one's own peritoneum lining to create a new vagina with similar properties to a cis-vagina - one that self-lubricates and has more elasticity and vaginal depth than a traditional vaginoplasty (e.g., penile inversion).
Coverage of these ground-breaking surgical procedures by commercial payers seems variable based on inconsistent qualifying measures. CMS covers “medically necessary” transition-related surgery but defers to Medicare Advantage or local Medicare contractors to determine what surgeries in particular qualify. New York is one of 9 states that require coverage for gender-affirming surgery secondary to gender dysphoria, which has led to an uptick in commercial payers (e.g., Aetna) covering surgical procedures for transgender patients.
I spent an hour or so trying to untangle the incredibly complex policy landscape of transgender treatment, but am excited to see entire companies like Folx Health and Included Health (now acquired) working in this space to help transgender patients navigate an this especially convoluted corner of healthcare coverage.
WHCRA and Racial Disparities in Plastic Surgery
Another example of how system-wide forces have shaped access to plastic surgery procedures is the Women’s Health and Cancer Rights Act (WHCRA) passed in 1998.
The passage of WHCRA made incredible steps forward in equitizing the coverage of breast reconstruction procedures post-mastectomy regardless if it is prophylaxis or therapeutic for breast cancer. Under the 1998 law:
“Coverage must be provided for:
All stages of reconstruction of the breast on which the mastectomy has been performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema”
The passage of this law has led to a 4.2x fold increase in breast reconstruction amongst Medicaid patients and 2.9x increase in Medicare patients. However, healthcare disparities still persist despite this policy advances. In this 2017 American Journal of Surgery study, “The disparity was even starker when insurance status entered into the equation. White women with private insurance who live in areas with the highest plastic surgeon density had reconstruction 84 percent of the time. The number drops to 65 percent among Hispanics, 60 percent among African-Americans, and 58 percent for APINA.
Even in the public insurance group, where rates were lower across the board, researchers still found the disparity. The rate for white women was 34 percent, compared to 28 percent for Hispanics, 24 percent for African-Americans, and 24 percent for APINA.”
Regardless of insurance, it seems that patient outreach and more proactive plastic surgery referrals by physicians who are trusted by these communities can help bridge some of these disparities.
Value-based purchasing for plastic surgeons
Though value-based payments (e.g., Pay for Performance) are starting to drive incentives where reimbursement is more tied to metric-driven outcomes, best practices, and patient satisfaction, the majority of plastic surgeons who operate in private practices will likely be left out of most VBC models.
In addition to Pay for Performance, it’s an interesting thought exercise to consider how certain procedures can be bundled as an episode to better benchmark quality and cost. Consider if the transgender care experience was tied across multiple specialties (e.g., endocrinologist to manage hormone therapy, plastic surgery for gender-affirming surgery, psychiatrist to manage mental wellness, etc…). Coordination of multiple providers across a bundled episode would incentivize all parties to align in shared resources (e.g., care coordination, social work, etc…) that ultimately lead to higher quality and conserved costs for the same patient population.
HCAHPS scores were introduced in the last decade tying hospital-wide patient satisfaction to CMS bonuses. Though private practices likely don’t have enough volume to aggregate or assess patient satisfaction scores in a way that would roll up to a consolidated payer, companies like Real/Self help aggregate tens of thousands of patient reviews of plastic surgeons to empower consumers with more data. If we were to integrate these metrics into a standardized set of plastic surgery standards, we could create more transparency around quality and cost variables for patients seeking elective plastic surgery.
Idea: Proposal for Pay For Performance and plastic-surgery specific HCAHPS scores
Commercial payers could offer pay-for-performance (P4P) incentive structures for private or hospital-based plastic surgeons that take commercial insurance. These P4P incentives could be based on the integration of more patient satisfaction scores (integrated from verified websites like Real/Self) and clinical quality metrics around some of the most common plastic surgery cases (e.g., breast reconstruction, abdominoplasties “tummy tucks”, etc…) to create more accountability and incentive alignment for surgeons that obtain great results with low rates of complications.
The challenge of this value-based structure would be aggregating enough plastic surgeons into this care model and effective integration of consumer reviews. However, long-term a model like this could increase patient purchasing power and create a type of financially-incentivized patient-provider alignment that could help other specialties integrate patient satisfaction into more value-based payments.
Big thanks to surgery residents I worked with: Jocelyn, Nate, Carissa, Pierce, Jamie, Kathy and my classmates Caroline, Christine, Jeff for making working together something to look forward to each day. Special shout-out to our chief resident Paymon whose leadership style I look forward to emulating one day as a senior/chief resident. Special acknowledgement of my classmate Michael’s support as well who looked at early drafts of this and encouraged me to look deeper into transgender surgery policy.
Had a great time scrubbing into cases with Dr. Taub, Dr. Sbitany, Dr. Yao, Dr. Torina, and had an especially energizing conversation with Dr. Christina Weltz which ranged from the surgical pathology labelling, unique patient identifiers, and the ongoing Theranos trial. I mentioned Dr. Ting’s inspiring work earlier already - but wanted to encourage folks to look into Mt Sinai’s Center for Transgender Medicine and Surgery and the documentary Born to Be featuring his journey and work!