Economic Burden of Out-of-Pocket Spending for Plastic Surgery Procedures: Value From the Patient’s Perspective

Abstract

PURPOSE: Health insurance reimbursement structure has evolved with patients becoming increasingly responsible for their healthcare costs through rising out-of-pocket (OOP) expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients.1,2 Given the possible negative effects of OOP expenses on the patient, we aim to investigate temporal trends in OOP expenses for plastic and reconstructive surgical procedures and determine drivers for increased cost sharing. METHODS: The study cohort comprised of patients undergoing the most common outpatient reconstructive plastic surgeries (skin cancer excision with closure, breast reconstruction, breast reduction, hand surgery, facial fracture repair, and scar revision/complex closure),3 using Truven MarketScan databases from 2009 to 2017. Sociodemographic characteristics, insurance type, and outpatient surgery location data were collected. Total cost of the surgery paid to the insurer and OOP expenses, including deductible, copayment, and coinsurance, were examined over time. OOP expenses were investigated using multivariable generalized linear modeling with log link and gamma distribution. All costs were inflation adjusted to 2017 dollars. RESULTS: We evaluated 3,181,125 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. The adjusted mean total cost in 2009 was $1,055 and in 2017 was $1,338 (increase in 27%), and the adjusted mean OOP expenses in 2009 were $121 and in 2017 were $184 (increase in 52%). Patients undergoing hand surgical procedures had the largest increase in total cost ($1,776 in 2009 to $2,545 in 2017, increase of 43%, P < 0.001) and OOP expenses ($197 in 2009 to $331 in 2017, increase of 68%, P < 0.001). Procedures performed in ambulatory surgical centers accounted for the largest increase in cost sharing between 2009 and 2017 (increase of 74%), but total costs only increased 24%. Facility fees were $385 on average in 2009 compared to $704 in 2017 (P < 0.001), and mean professional fees were $538 in 2009 compared to $635 in 2017 (P < 0.001). In the adjusted regression, managed care, Medicare-managed care, and Medicare-fee-for-service had approximately 42%–64% of the OOP expenses compared to fee-for-service insurance (P < 0.001). CONCLUSION: For outpatient plastic surgery procedures, OOP expenses are increasing at a faster rate than total costs. Wide variability in cost sharing was seen across the different plastic surgery procedures, surgical location, and insurance type. For outpatient plastic surgical care that is largely elective, these temporal trends in OOP expenses must be explored and should be incorporated in the decision-making process for surgery. Given the increased scrutiny placed on rising healthcare costs, policy makers should consider the impact of cost sharing and the financial burden placed on the patient when discussing value-based reimbursement reform. REFERENCES: 1. Adrion ER, Ryan AM, Seltzer AC, et al. Out-of-pocket spending for hospitalizations among nonelderly adults. JAMA Intern Med. 2016;176:1325–1332. 2. Ubel PA, Abernethy AP, Zafar SY. Full disclosure--out-of-pocket costs as side effects. N Engl J Med. 2013;369:1484–1486. 3. American Society of Plastic Surgeons. Plastic Surgery Statistics Report. 2017. Available at https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf. Accessed February 21, 2019.