inDepth | February 2014 Plastic Surgery Practice

Bracing for the Perfect Storm

Does the new health care law, the ICD-10 conversion, and the adoption of EMRs threaten the practice of plastic surgery?

By Denise Mann

Slowly, and certainly not surely, the new healthcare law, also known as the Affordable Care Act and/or Obamacare, is taking effect.

The rollout has been fraught with hiccups, many of which are to be expected with such a huge undertaking. As a result, significant questions remain about exactly how the changing health care landscape will affect physicians—including plastic surgeons.

Robert X. Murphy, Jr, MD, assistant chief medical officer of the Lehigh Valley Health Network in Allentown, Pennsylvania, and the president of the American Society of Plastic Surgeons (ASPS), had a candid conversation with Plastic Surgery Practice about the Affordable Care Act’s breadth, reach, and its possible unintended downstream consequences.

PSP: Should plastic surgeons be concerned about Obamacare?

RXM: Yes. 80% of ASPS members have a mixed cosmetic and reconstructive practice, so 80% of us will have to deal with it in some way. We are not on the front lines yet. The Affordable Care Act is impacting primary care doctors and other generalists right now. In light of all the rollout glitches, it may take some time for the law to become fully operational and for the majority of plastic surgeons to be affected, but it will have an impact on the practice of plastic surgery.

PSP: What type of impact?

RXM: I believe the two biggest ways that it will affect us will involve patient access. More middle-class individuals may be paying higher deductibles, and that could lessen the amount of disposable income for elective, cosmetic procedures. In addition to a shrinking patient population, more providers may be tempted to enter the cosmetic market to thicken their revenue streams. We may see more non-board-certified plastic and facial surgeons entering this space, which could have deleterious effects on patient safety.

PSP: That sounds like the perfect storm.

RXM: It is. And at the same time that the Affordable Care Act is being rolled out, the ICD-10 conversion is also taking place. This is a game changer as far as how we submit diagnoses, correlate billing, and submit claims. We have to deal with the Affordable Care Act and the ICD-10, and this may overwhelm a lot of practices.

PSP: That sounds daunting. Any advice to impart?

RXM: Pay attention to what is on the horizon and start to adjust yourself in a proactive, but not a reactive, way. Know the conversion timelines, and consider coding courses. Start to educate yourself and office staff. Your billing clerk needs to know the ropes in advance, or he or she will be hit with a tsunami that will impact their ability to bill correctly.

PSP: How do you see health care law affecting patients overall?

RXM: The goal of the Affordable Care Act is to control cost while providing high-quality care. The pro is the premise that no one will go uninsured, including individuals with pre-existing conditions. The con, as we have seen, is that the promise that we could maintain our existing plans is not always the case. People are seeing their plans reformatted with very high deductibles, which can be a deterrent to seeking care. The other negative is that the mechanisms that were initially in place to fund the act are being reconsidered, so the financial basis for the operational aspect of this law is in question.

PSP: The law of unintended consequences?

RXM: Yes. The benefit is open enrollment and getting all people covered, but the downside is that it may not be global inclusion, global access, and global benefit that we were hoping for.

PSP: You wear at least two hats: administrator and practicing plastic surgeon. How do you feel about the health care law from each vantage point?

RXM: As an administrator, in the global sense, I am very cautiously optimistic that ultimately, we will develop a system that delivers good-quality care to the population that we are asked to serve. As a practicing surgeon, I am more pessimistic due to the threats of the cosmetic market being inundated by folks who are not qualified or board-certified, the ICD-10 coding changes and the evolution from paper charts to electronic medical records, the financial solvency of the new paradigm, and the recognition and inclusion of plastic surgeons as important providers within the healthcare system. We are in for a very stormy near-term course.

PSP: EMRs may be a whole other can of worms.

RXM: The transition to electronic medical records will have a significant impact on productivity. In addition, EMRs alter the doctor-patient relationship as patients may not be happy because you are punching and tapping on a keyboard instead of looking at them.

PSP: Will we see more plastic surgeons retire as a result of these changes?

RXM: Some of the surgeons who have provided for themselves well and are at the end of their career will exit or exit the insurance world. Under this circumstance, it would be more attractive to go into a purely cosmetic practice as long as the market can support it. In many countries with national health care, a two-tiered system has emerged, and that may happen here as well. The single-payor system has worked for basic care for the population it is asked to serve, but those who have extensive resources often seek medical care outside of the nationalized system.

PSP: A provision set to take effect in January 2015 calls for paying physicians based on value, not 

volume. How will that play out?

RXM: Metrics are already a very important part of how physicians and hospitals are judged and reimbursed in many parts of the country. The insurance providers are basing reimbursement upon patient satisfaction with their care as well as more objective outcome measures, such as readmission to the hospital within 30 days, surgical-site infections, and other metrics. The ability to translate some of these quality measures into a “value equation” is imminent. It may soon be that surgeons are rewarded for knowing when not to operate as well as when to intervene and take a patient to surgery.

Denise Mann is the editor of Plastic Surgery Practice. She can be reached at

Original citation for this article: Mann, D. Bracing for the perfect storm: does the new health care law, the ICD-10 conversion, and the adoption of EMRs threaten the practice of plastic surgery?, Plastic Surgery Practice. 2014; February: 28-29