The article in the July issue of Medical Forum on the difficulty faced by plastic surgeons accessing theatre lists in private hospitals, provided a good overview of a problem that has been developing for a few years.
By Dr Brigid Corrigan
However, comments made by HBF’s Executive General Manager Insurance and Health Services, Dr Heredia, require clarification.
In the article he is quoted as saying: “It also had to be recognised that because a lot of the procedures in question were cosmetic, when there were scarce resources and limited theatre time, hospitals had to make decisions on urgent vs cosmetic surgery.” He predicted some of the cosmetic work would “increasingly move into day surgery or doctor-run type facilities.”
The current access issues are not with cosmetic surgical procedures.
Private health insurance does not cover cosmetic surgery. Hospitals charge patients directly for their theatre and admission costs, usually based on length of theatre times that are profitable for the hospital.
The Medical Benefits Schedule, and therefore private health insurance, does cover surgical procedures for reconstructive or functional reasons.
For these procedures, the hospital accepts payment according to their contract with the health fund. As the article outlines, this varies but may be based on procedure banding or the DRG system.
The procedures which are currently of greatest concern are autologous breast reconstruction and belt lipectomy following massive weight loss. These procedures are often long and complex, with relatively long inpatient stays.
They utilise a large amount of theatre time which is not adequately compensated for by the amount paid by insurers, and hence leads private hospitals to see them as “loss makers” and actively avoid doing these cases.
This is leading to the current issue where patients holding private insurance, which theoretically covers these procedures, but in practice they have difficulty accessing them in the private sector.
The most common autologous breast reconstruction is a free DIEP flap. This is a complex microsurgical procedure which takes approximately six hours for a unilateral procedure, and often up to 10 hours for a bilateral procedure, when performed at the time of mastectomy.
These patients require high dependency care post-operatively.
Given the complexity of the surgery and aftercare these procedures can only be safely done in large private or public hospitals with appropriate resources. They are not suitable for the smaller day surgery or overnight facilities where many plastic surgery lists are done.
DIEP flaps provide an excellent choice for breast reconstruction for many women, particularly for those patients who for various reasons wish to avoid implant reconstruction or who require radiotherapy as part of their breast cancer treatment.
While they are resource intensive at the initial procedure, there is evidence that in addition to being a good clinical option, they are cost effective over the lifetime of the patient as there is a much lower rate of revisional surgery, often required for implant-based procedures.
Patients requiring belt lipectomy after massive weight loss are also affected by the current situation. These patients have often had bariatric surgery and present having lost 50-60kg or more of weight, resulting in dramatic amounts of excess skin.
Contrary to some perceptions these are not primarily cosmetic procedures. These patients have significant functional problems including dragging pain, difficulties with clothing and skin integrity issues as well as significant psychological distress.
Belt lipectomy is, again, a relatively long procedure, with significant risks and aftercare requirements and combined with the frequent co-morbidities found in this group, means it often needs to be done in a larger facility to ensure the safety of the patient.
The current situation has developed over time due to a complex, often opaque system that means some procedures and specialties are looked on much more favourably than others by private hospitals.
Fundamentally this results in a situation where patients who very legitimately require surgery for medical reasons, are not able to access the care they require.
Ultimately this is about equity of access for patients who have taken out private insurance, with the reasonable assumption that they have comprehensive cover for their health requirements.
The issue requires urgent attention.
ED: Brigid Corrigan is a plastic surgeon and council member of the Australian Society of Plastic Surgeons.
In reply, Dr Daniel Heredia writes: Feedback from plastic surgeons is that access issues are faced for both cosmetic and medically necessary procedures. However, I agree with Dr Corrigan that of greatest concern is the access issues currently faced by patients who require plastic surgery for reconstructive or functional reasons.