Creating Value in Plastic Surgery

Abstract

Value is defined as the worth, utility, or importance something holds. It can be derived from a variety of goods and services and is relative to a given industry or population. This article will discuss elements of plastic surgery that hold value as to how it pertains to the key players in a medical transaction. It will also discuss strategies for identifying and generating value. Roles of the different members in a plastic surgery transaction were analyzed, specifically the patient, the surgeon, and the facility. Different factors that generated value for all parties were identified throughout the literature. Factors identified that created value included the following: the surgeon's knowledge, experience, and decision-making ability; and technical skill/speed, restoration of life, restoration of form and function, restoration of psychological deficit, instant surgical results, convenience of access, outcomes, cost accounting, research, compassion, and bedside manner. Plastic surgeons can gear their practice to provide the system and their patients with services that hold value. We present several factors that can generate value for the patient, surgeon, and hospital system.

Value is defined as the worth, utility, or importance something holds. It can be derived from a variety of goods and services and is relative to a given industry or population. This article will discuss elements of plastic surgery that hold value as to how it pertains to the key players in a medical transaction. It will also discuss strategies for identifying and generating value. Value is generated by creating services or providing goods that stakeholders will pay for, or are value-additive from a core service like “correcting a surgical problem” to postoperative calls to inquire how patients are doing.

The Patient

Of the most diverse in any medical field, patients of plastic surgery range from newborn children with congenital functional defects to celebrities seeking cosmetic enhancements to elderly cancer patients requiring reconstruction post tumor resection. Neither sex, age, race, nor socioeconomic status limits the patient population which may require plastic surgery. The value of treatment for each of these populations is determined by the beneficiaries from the services, be it the patient, patient's family, society, or future patients that will be treated by the surgeon. Thus, value can be better anticipated depending on what subset or specialty of plastic surgery is targeted.

The Surgeon

Plastic surgeons come from a variety of training backgrounds—general surgery, otorhinolaryngology, and ophthalmology—and can specialize in various fields—microvascular, craniofacial, general plastic surgery, burn, pediatric, hand, and oculoplastics. The surgeon can choose to operate their practice in different settings: private or academic, solo or group.

The Facility

Depending on the physician practice, the setting can be a large hospital, clinic, ambulatory surgical center, or private office.

Factors the Generate Value

Knowledge, Experience, and Decision Making

Perhaps the most important value that the surgeon provides the patient is their ability to diagnose the problem the patient faces, and to integrate their knowledge of plastic surgery with experience to cast a path that will bring the patient the optimal result. At times, the clinical scenario forces the surgeon's hand down one path; yet, there are many instances in plastic surgery where the patient and surgeon have a plethora of surgical approaches to choose from. It is in this instance where education, experience, and decision making play a critical role. Extending this mindset to our nonplastic surgery colleagues can further improve outcomes for our patients. For example, a mastectomy patient who qualifies for a nipple-sparing mastectomy should be offered by a capable breast surgeon. Salvage of the nipple has been shown to leave patients with an improved psychosocial state and sexual well-being when compared with their skin-sparing only counterparts. ¹ In today's health care environment, patient autonomy in decision-making can compel the surgeon to provide a less than optimal result by selecting a less than optimal surgical procedure. Proper patient education and establishing a trustworthy relationship with patient can help guide the decision-making process, are critical to the end result, and should not be discounted.

Technical Skill/Speed

Once the patient and the surgeon determine the best plan for achieving the patient's goals, the operative skill possessed by the surgeon and the flow of their facility adds value to all parties involved. The patient is exposed to less anesthesia and less tissue trauma with a physiologic and financial benefit. It is important to note that even the world's most skilled surgeon cannot provide proper value to the patient if the incorrect operation is chosen. Through correct decision-making and outstanding technique, the surgeon can optimize the number of patients seen in one day, which also can bring more volume to the facility. Efficiency in patient treatment will allow outstanding care with no sacrifice in outcome or safety risk.

Restoration of Life

Patients who suffer functional deficit can affect many levels of society and the economy. An infant with a cleft palate cannot speak or feed properly. One with a retrusion of the mandible may have airway compromise. A cancer patient who undergoes mandibular resection must have optimal reconstruction for coverage on important structures and for eating. Helping this population can bring much gratification to the surgeon. In much of the public eye, plastic surgeons have come to be misconceived as surgeons who provide for the vain. Restoring life is the ultimate benefit to our field's image. The effects of this surgery can bring immense value to the society and our economy by helping preserve functioning, productive members who one day can contribute to the production of goods and services. Fig. 1 illustrates the different tiers of value attributed to disease processes. Tier 1's focus is survival; Tier 2's efficiency of recovery; and Tier 3's ability to sustain health. Porter correlated these tiers to the practice of orthopaedic and breast surgery, as seen in Fig. 2 . ²

Fig. 1.

The three-tier model for outcomes.

Fig. 2.

Outcomes hierarchies for breast cancer and knee osteoarthritis.

Restoration of Form and Function

Lower extremity trauma patients require free flaps for soft tissue coverage and a concert pianist suffering from multidigit amputation requires replantation that preserves dexterity. Procedures like these, along with carpal tunnel release, provide functional relief to patient who suffers debilitating disease. As a surgeon, one can appreciate the importance of one's dominant hand. Livelihood and quality of life is dependent on such a thing. Cost-effective analysis calculated in orthopaedic literature has demonstrated the value provided to economies as a whole with timely, and age-specific therapy in joint replacement surgery. ³ Time to surgery also plays a role in providing value to this patient population. A study comparing cost-utility analysis for carpal tunnel release in the United States and Canada showed significant health-related quality of life improvements calculated to be $7,758/quality-adjusted life year greater in the U.S. population compared with Canada's due to shorter wait times. ⁴ Cleft surgery, as measured in a Smile Train study of 548,147 primary cleft procedures performed in 83 countries estimated that the mean economic impact ranged between $5,510 and $50,634 per person, amounting to between $3 and $27.7 billion over a 10-year period. ⁵

Instant Surgical Results

The benefit of surgery, when weighed against medical management of pathologic conditions, is the instantaneous correction of outcomes. Many patients who suffer migraines endure failed medical treatment consisting of pill regimens and cocktails—sometimes years on end. Botox injection or surgical nerve decompression can alleviate these patients' suffering overnight. ⁶ For the patient, this can be priceless. For the surgeon, eagerness and encouragement are drawn from the instant gratification taken from on-table results. The industry benefits from the more effective use of resources, less reliance on pill therapy, and avoidable hospital admissions.

Restoration of Psychological Deficit

A trauma patient with a disfigured face may stay unemployed hiding in the shadows of their home. ⁷ A patient with facial nerve deficit may feel as if the world is staring and avoid public places. Physical discrepancies can translate into psychological handicaps. The majority of services plastic surgeons can offer are externalized outside the human body. Surgical restoration/enhancement of physical attributes can offer a patient the mental clarity necessary to contribute to society—seeking jobs, searching for a life companion, spending and generating value within their own economy. ⁸ For the physician and hospital, the patient will associate these positive emotions with their name and industry, generating enthusiasm for their service.

Convenience of Access

It is argued that the most important employee of the physician practice is the person who answers the office phone, in essence, standing as the gatekeeper to the patient's care. In this age, there are multiple modalities that physicians and hospitals can utilize to provide their patients with access to care with relative ease, such as telemedicine, consultation apps, phone lines, email, and websites. As a plastic surgeon, it is important to know your patient demographics and accommodate to their access capabilities. A county hospital facial trauma surgeon can improve their availability by coordinating with the hospital system and their website, while a private practice cosmetic surgeon may find it better suited to utilize telecommunication and smartphone application services. The hospital itself can benefit in the same way. For patients, much anxiety and direct and personal questions/medical concerns can be addressed in a prompt manner. Current smartphone apps with portals to patient education, appointment reminders, and means for communication with the physician have proven successful—reported patient satisfaction with these apps comes mostly from the ability to communicate with the health care professional. ⁹ Customer satisfaction is crucial in sales/retail when the customer has access to different suppliers. A happy and informed patient is a powerful marketing tool for the physician/hospital system.

Outcomes

Devotion to one's practice, continual education, selecting the appropriate surgical procedure and candidate, and minimizing known risks are factors that can help ensure a successful outcome. Infection can be the bane of plastic surgery. Appropriate measures from all parties to ensure hygiene standards are crucial. Attempting to control behavior without measuring outcomes hinders progress in improvement. The purpose of measuring outcomes is to create a feedback loop that enables innovations in care. Successful outcomes result in happy patients. As discussed before, happy patients with good outcomes serve as a powerful marketing tool for the physician and their practice. The most important users of outcome measurement are providers, for whom comprehensive measurement can lead to substantial improvement.

Cost Accounting

Managing one's practice can be a daunting feat; however, unlocking accounting tools to improve bottom lines can generate value for all parties. Decreased overhead means improved costs for patients, more contribution for reinvestment into supplies and facilities, and better salaries for employees. A large majority of surgeons lack knowledge regarding the costs of items used in the operating room. Often underestimating the cost of high-cost items and overestimating the cost of low-cost items. ¹⁰ As a physician, tying outcomes and accounting together provides value to the industry as a whole. Porter notes, “Measuring, reporting, and comparing outcomes are perhaps the most important steps toward rapidly improving outcomes and making good choices about reducing costs.” ²

Research

Through data collection and information sharing, physicians can offer evidence-based methods and techniques. Much of the field of plastic surgery is nonprotocoled. Different approaches from one physician to the next allows for data to compare. Hospitals pooling data can lead to information that can be translated across all fields of medicine, boosting academic reputation.

Compassion/Bedside Manner

A powerful tool outside of the operating room, physician compassion and interpersonal engagement can instill confidence to the patients. A public relationship between patient and physician has been shown to decrease chances of physicians being sued in the face of a complication. Good interactions with nursing and other hospital staff will help patients associate a pleasant experience with the hospital facility.

Conclusion/Value Creation

As members of the service industry, it is important for plastic surgeons to identify what their customer value. As Porter describes, “The fact that health care delivery is not organized around value works against excellent care and drives up cost. The fact that reimbursement is not aligned with value cripples the process of innovation while rendering the profit motive a destructive force rather than a value driver.” Health care is no stagnant industry. Technological booms provide a new interface for health care delivery, new tools for the operating rooms and clinics. Feedback systems are a valuable tool for identifying demand from customers. Physicians and hospital settings should habitually seek improvement. Who better to ask than the patient?