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Hospital Plastic Surgery Business Grows

 |  By jcantlupe@healthleadersmedia.com  
   May 04, 2012

This article appears in the April 2012 issue of HealthLeaders magazine.

In healthcare, the plastic surgery business is more than skin deep, but not wrinkle free.

Cosmetic plastic surgery is often tied to the variables of economic trends, but some hospital officials are seeing an uptick in certain procedures. Patients are opting for more facelifts and eyelid surgeries. And they are seeking more of the lower-cost procedures such as chemical peels, Botox, and "fillers" to get the shape and proportion of faces, noses, and breasts they want, even if it is temporary.

Plastic surgery for medical purposes continues to advance. Breast reconstruction surgery is increasing—by at least 8% in 2010, with many instances linked to cancer cases, according to the American Society of Plastic Surgeons. The 2011 American College of Surgeons reported that the number of women undergoing breast reconstruction procedures doubled between 1998 and 2007.

Overall, there were 13.8 million cosmetic procedures (surgical and minimally invasive) in 2011, up 5% since 2010, and 5.5 million reconstructive plastic surgeries in 2011, up 5% over 2010.

Hospitals that have offered a wide range of multidisciplinary programs related to cosmetic as well as medical procedures are seeing increased patient load.

"We have seen a significant increase in our breast reconstruction annually," says Rod J. Rohrich, MD, chair of the department of plastic surgery at the 424-bed University of Texas Southwestern Medical Center in Dallas, which reported an overall 10% increase in plastic surgery procedures over the past several years.

As for cosmetic procedures, they are "self-pay, and obviously that’s waxed and waned over the years," Rohrich says. "I still think patients want to look as good as they feel. If they don’t want to pay for major procedures, they’ll resort to more temporizing and cost-effective fillers like Botox, which will make them look good but not be as costly or as permanent as a facelift."

For its breast cancer patients especially, UT Southwestern’s Harold C. Simmons Comprehensive Cancer Center specializes in a multidisciplinary approach for its plastic surgery program that relies on partnerships with oncologists, radiation oncologists, and breast imagers in the same facility, Rohrich says. As part of its specialty care, the hospital targets patients with a family history of breast cancer or high-risk benign breast conditions, using a comprehensive risk counseling program developed at UT Southwestern.

To generate more ROI, UT Southwestern built what hospital officials described as a four-star hotel for patients, bringing them from around the world, whether it be for facial rejuvenation or body and breast contouring. The UT Southwestern campus includes a 21,000-square-foot outpatient surgical facility as well as Medallion Guest Suites, which are available for patients resting and recovering from treatment or surgery.

The suites have "contributed to our ability to attract patients from around the globe with the concept of comprehensive, private, and safe patient care in a protected environment that is not in a hospital setting," Rohrich says.

James E. Zins, MD, chairman of the department of plastic surgery at the 1,300-bed Cleveland Clinic, says hospitals that have developed service lines in plastic surgery have optimized care and outcomes by having both medical and cosmetic programs.

Zins recalls that several years ago, private practice plastic surgeons began sustaining financial reverses from a decline in cosmetic surgeries, which was "very frightening to the private practice cosmetic surgeon."

But systems such as Cleveland Clinic were able to weather recessionary storms in plastic surgery by maintaining cosmetic and medical options through reconstructive surgery, including dermatology and facial plastic surgery. "If the hospital was just doing cosmetic surgery, it would be in big trouble," Zins says. "Our department, for instance, is big and diverse enough that the downturn wasn’t a big hit on us. Now, as it is, noninvasive procedures like Botox and fillers are going up dramatically."

While the number of cosmetic surgeries has been uneven in recent years, often dependent on economic factors, medical procedures in plastic surgery continue to increase, says Andrew Winkler, MD, assistant professor and director of the Visage Center, a facial plastic surgery practice run by the 437-bed University of Colorado Hospital in Aurora. A plastic surgery service line draws patients who like the prospect of a program supported by the depth of medical care, adds Winkler. "For a hospital, it’s important to provide the full service to the community. We want to provide every kind of service. Plastic surgery is that service."

Some hospital systems aren’t eager to develop a plastic surgery service line, but instead keep the programs within specific service lines such as oncology, concentrating on reconstructive rather than cosmetic surgery. "It’s very competitive; you are competing with a lot of outpatient centers," says Marcia Manker, CEO of the 218-staffed-bed Orange Coast Memorial Medical Center in Fountain Valley, CA, referring to hospital-run plastic surgery centers. As opposed to reconstructive surgery, which is typically covered by health plans, cosmetic surgery is "a cash-based program very susceptible to economic forces and very price contrived," she says.

Success key No. 1: Increasing awareness, increasing ROI
For greater ROI and improved patient outcomes, hospitals rely on breast reconstruction surgery following oncological procedures. Hospital systems, however, are concerned that they aren’t doing enough to get the message across about the availability of reconstructive surgery following a lumpectomy, or partial removal of the breast. If they do get the message across, there would be greater ROI for the hospitals as well as increased satisfaction for the patients, says Terry Myckatyn, MD, director of breast and cosmetic plastic surgery at the Washington University School of Medicine in St. Louis.

Breast cancer is one of the leading causes of cancer-related deaths, with 80% of breast cancers treated for breast conservation therapy such as a lumpectomy. Congress guaranteed universal coverage for breast reconstruction after cancer surgery in 1998, but  nationally only 30%–40% of women who had mastectomies now receive breast reconstruction.

At Barnes-Jewish Hospital in St. Louis, where Myckatyn sees patients, about "70% of our patients who undergo mastectomy will have a reconstruction surgery, which is well above the national average," he says. The hospital attributes the tally to the hospital’s relationship with primary care physicians, as well as education programs.

"What dictates a patient having the surgery is referrals from a physician," Myckatyn says. "You can be in a referral pattern that detects more mammograms and detects more breast cancer. We are the downstream effect, basically, from that pattern."

Ultimately, "this is a complex procedure that requires more buy-in on the patient’s part," he adds.

State governments are taking steps to improve education about breast reconstruction. In New York, for instance, a law requires doctors and hospitals to discuss options for breast reconstruction with their patients before performing cancer surgery, to explain insurance coverage information, and to refer them to another hospital, if necessary, for reconstructive surgery, Myckatyn says.

Only now has the hospital begun to evaluate patient satisfaction scores related to plastic surgery and breast reconstruction.

"This is an area that has not been well studied largely because there is a lack of validated instruments to measure post-surgical satisfaction," Myckatyn says.

Success key No. 2: Growing interest among elderly
Increasing numbers of geriatric patients are becoming the focus of primary care physicians. And now plastic surgeons.

Indeed, health systems are seeing people with healthier lifestyles who seek to maintain a youthful appearance, says Zins, chairman of the department of plastic surgery at Cleveland Clinic.

About 40% of the population over the age of 65—which amounts to more than 12 million Americans—is likely to undergo plastic surgery, and their numbers may increase. Zins says he carried out a plastic surgery study that shows physical condition rather than chronological age impacts circumstances of people over 65 years old. Older Americans are seeking plastic surgery, in part, to appear younger for personal or professional reasons.

"Patients 65 and older represent an increase in percentage of patients seeking cosmetic surgery and represent a source of increase in patient volume," Zins says.

In 2010, there were 54,885 surgical procedures among patients aged 65 and older. That included facelifts, cosmetic eyelid operations, liposuction, breast reductions, forehead lifts, breast lifts, and breast augmentations. Those numbers represented a 352% increase over 1997 levels, according to the American Society for Aesthetic Plastic Surgery.

Zins says that age lone isn’t a risk factor for plastic surgery.

Zins found that patients who undergo a facelift after age 65 are at no higher risk of complications compared to younger adults, depending on proper screenings. In a review of facelifts of more than 200 people over a three-year period, Zins found no statistical difference in complications between the older and younger patients. One group had an average age of 70; the other was 57.6.

It is important that elderly patients are thoroughly screened, he says. In the study, the patients were screened for problems such as lung and heart disease, diabetes, and high blood pressure, as well as use of medications such as anticoagulants, he says.

Success key No.3: Reorganization and cohesive communication
Several years ago, Cleveland Clinic found inefficiencies in the manner in which it organized and generated plastic surgery procedures.

Throughout the campus, plastic surgeons were spread out. Cosmetic surgery was done by plastic surgeons and other subspecialists, and they were competing and duplicating services. The process lacked communication and coordination, says Zins.

"You could get different prices. You could get duplication of services, personnel, equipment, and operating rooms," Zins says. "We got together and looked at all the advances from a multidisciplinary approach. Rather than compete, we organized and began working together to connect the patient with the best person to do the procedure."

The hospital staff has become "verticalized," as each plastic surgeon has an area of clinical focus within the Cleveland Clinic departments of dermatology and plastic surgery, he says. The department of plastic surgery, which includes 17 plastic surgeons, focuses on areas including facial cosmetic surgery, cosmetic and reconstructive breast surgery, and body contouring. Plastic surgery centers have been situated in suburban outpatient facilities to create greater access for patients. "What we have done has become a tremendous opportunity for the patient," Zins says. "We want to provide convenience for the patient, and avoid any possible delay to their busy schedule." 

The Cleveland Clinic also has taken steps to plan for a video conferencing program that would allow patients from anywhere in the country to evaluate possible plastic surgery procedures, he adds.

Success key No.4: Rhinoplasty
Cosmetic procedures in plastic surgery often shift and depend on changing economic conditions, with overall procedures increasing since 2008, primarily due to noninvasive and less costly options such as Botox treatments.

"For some reason, human beings are more tolerant of aging changes in times of down economy," says Winkler. However, he adds, "Rhinoplasty hasn’t been hit as hard as other cosmetic surgery procedures."

Of the costly functional procedures, rhinoplasty "seems to be the only surgical procedure that’s recession proof because parts of the procedure are paid by insurance companies," Winkler says. In the plastic surgery world, rhinoplasty means income for health systems because of its unique appeal, he says.

"It straddles the line between cosmetic and functional. People may need surgery to breathe through their nose, but would like cosmetic changes done as well. Many people have functional problems that need to be fixed and figure it’s a good time to have cosmetic concerns addressed."

Clinically, rhinoplasty is directed toward improving nasal breathing disorders and nasal skin cancer reconstruction. Cosmetically, the procedure is designed to reshape a patient’s nose.

Winkler explains that "although people are still spending money on cosmetic procedures, they are spending it on the clinic-based, temporary and less-expensive ones. I would estimate that about 20% of the surgeries that I do are cosmetic in whole or part—meaning the patient is paying out of pocket."

In the past, Winkler says, "those in my position would do a great deal more cosmetic work. I know from personal communication with colleagues who have been in this business for 10 to 20 years who are doing roughly half as much flat-fee cosmetic work as they were five years ago, before the housing crash."


This article appears in the April 2012 issue of HealthLeaders magazine.

Reprint HLR0412-7

 

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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