A Cross-sectional Analysis of Insurance Coverage of Extremity Contouring After Massive Weight Loss.

INTRODUCTION: After bariatric surgery, patients often experience redundant skin in the upper arms and medial thighs as sequelae of massive weight loss. Insurance companies have unpredictable criteria to determine the medical necessity of brachioplasty and thighplasty, which are often ascribed as cosmetic procedures. We evaluated current insurance coverage and characterized policy criteria for extremity contouring in the postbariatric population. METHODS: We conducted a cross-sectional analysis of insurance policies for coverage of brachioplasty and thighplasty in January 2019. Insurance companies were selected based on their state enrolment data and market share. A web-based search and direct calls were conducted to identify policies. A comprehensive list of standard criteria was compiled based on the policies that offered coverage. RESULTS: Of the 56 insurance companies assessed, half did not provide coverage for either procedure (n = 28). No single criterion featured universally across brachioplasty and thighplasty policies. Functional impairment was the most commonly cited condition for preapproval of brachioplasty and/or thighplasty (94%). Conversely, minimum weight loss was the least frequent criterion within the insurance policies (6%). Only 5% of the insurance companies (n = 3) would consider coverage of liposuction-assisted lipectomy as a modality for brachioplasty or thighplasty. CONCLUSIONS: We propose a comprehensive list of reporting recommendations to help optimize authorization of extremity contouring in the postbariatric population. There is great intercompany variation in preapproval criteria for brachioplasty and thighplasty, illustrating an absence of established recommendations or guidelines. High-level evidence and investigations are needed to ascertain validity of the limited coverage criteria in current use.

The implications of "pay-for-performance" reimbursement for Otolaryngology-Head and Neck Surgery.

OBJECTIVE: To introduce otolaryngologists to outcomes-linked reimbursement ("pay-for-performance"), identify clinical practice implications, and recommend changes for successful transition from the traditional "pay-for-effort" reimbursement model. STUDY DESIGN: Policy review. RESULTS: Payers are actively linking reimbursement to quality. Since the Institute of Medicine issued its report on medical errors in 1999, there has been much public and private concern over patient safety. In an effort to base health care payment on quality, "pay-for-performance" programs reward or penalize hospitals and physicians for their ability to maintain standards of care established by payers and regulatory groups. More than 100 such programs are operational in the United States today. This reimbursement model relies on detailed documentation in specific patient care areas to facilitate evaluation of outcomes for purposes of determining reimbursement. Because performance criteria for reimbursement have not yet been proposed within otolaryngology-head and neck surgery, otolaryngologists must be involved to ensure the adoption of reasonable goals and development of reasonable systems for documentation. CONCLUSION: "Pay-for-performance" reimbursement is increasingly common in the current era of outcomes-based medicine. It will assume an even greater role over the next 3 years and will directly affect most otolaryngologists.

[Hospitals with the covering physician system in agglomeration]. / Die Spitäler mit Belegarztsystem in der Agglomeration.

In Switzerland there are more than 700 practising surgeons. About 50% work at private hospitals as independent doctors and have special arrangements with the clinics. Independent surgeons and private hospitals represent a mutually dependent unity, which has stood the test for over 100 years. In Zurich, there are 120 private doctors practising as general surgeons or as specialists. Independent surgeons have about 600 beds available at clinics throughout Zurich. The increasing demand for additional insurances indicates that there is a trend among patients to get private treatment. To meet this growing demand, existing hospitals must expand and new clinics have to be built. Unfortunately, independently practising doctors can only treat a limited number of hospitalized general patients. There is a balance between doctors at public hospitals and independent surgeons. In order to conserve a free, independent medical profession, this balance has to be fostered in a mutually understanding way.