When a patient facing mastectomy brings on a plastic surgeon solely to perform a flat closure after their SO (surgical oncologist) performs the mastectomy, this is called “co-surgery,” and reimbursement by insurance can be complicated. Often, it results in both surgeons receiving less than full payment for the procedure. Medicare, for example, splits 125% of the single procedure fee between the two co-surgeons, so each gets paid 65% of what they would have if they’d done the entire procedure themselves. Other insurance will pay 100% to the first surgeon performing the “primary procedure” (onc) and only 50% for the “secondary procedure” (plastics).
Since the plastic surgeon is already getting paid less for their time in the OR to make the patient flat, and they’re getting paid per procedure – NOT per hour – they seem to have every incentive to spend as little time as possible working on the patient, and potentially to do a hasty, incomplete job. And they know that they won’t be getting any further business from this patient who doesn’t want recon. Unless… unless they need another surgery to be truly flat.
Payment is not the only factor at play here. But it’s clear from the reimbursement perspective that plastic surgeons are highly disincentivized to provide a flat result in one surgery.
When my surgical oncologist recommended bringing a plastic surgeon onto the team to do a flat closure for me, I was completely unaware of these conflicts of interest. I have since anecdotally observed that women who used only one surgeon, the surgical oncologist, tend to have better and more completely flat results, than those of us who used a plastic surgeon. How sad is that? That we have worse outcomes with the specialist, than the generalist. Because of money? Is it that simple?
This is why we need buy-in from hospitals and surgeons. And we need solid data on this problem, bait and switch mastectomy surgery. How often does it happen? Under what circumstances? What are the risk factors or contributing factors? And how can we counteract them?
If we are committed to stopping this battery against patients, this is where we end up. We need to characterize the problem, before we can come up with a solution.