Financial Decisions and Reopening a Practice During the COVID-19 Pandemic: A Survey of California Plastic Surgeons

Expected changes in physician outpatient interventional practices as a result of coronavirus disease 2019 and recent changes in Medicare physician fee schedule

OBJECTIVE

We examined the economic and practice effects of the coronavirus disease 2019 (COVID-19) pandemic and decreased Medicare physician payments on outpatient vascular interventional procedures.

METHODS

A 21-point survey was constructed and sent electronically to the physician members of the Outpatient Endovascular and Interventional Society and the American Vein and Lymphatic Society. The survey responses were converted to a Likert scale and statistical analyses performed to examine the associations between the response variables and the characteristics and practice patterns of the physician respondents.

RESULTS

A total of 165 physicians responded to the survey, of whom 33% were vascular surgeons, 18% were radiologists, and 15% were general surgeons. For slightly more than one half (55%), their interventional practice was limited to the office setting, with the remainder also performing procedures in an office-based laboratory (OBL), ambulatory surgery center (ASC), or hospital. Almost all respondents had performed superficial venous interventions, with slightly more than one third also performing either deep venous procedures and/or peripheral arterial interventions. The COVID-19 pandemic had affected 98% of the practices, with a staff shortage reported by 63%. The most-established physicians, those with the longest interval since training completion, were the least likely to have experienced staff shortages. Almost all (94%) the respondents expected that the recent Medicare payment changes will have a negative effect on their practice. Physicians with only an office-based practice were less likely to add a physician associate compared with those with an OBL (P = .036). More than one quarter reported that it was likely they would close or sell their interventional practice in the next 2 years and 43% reported they were planning to retire early. The anticipated ameliorative responses to the decreased Medicare physician payments included adding wound care (24%) or other clinical services (36%) to their practices, with the alternatives considered more by younger physicians (P = .002) and nonsurgeons (P = .047). Only 10% expected to convert their practices to an ASC or hybrid ASC/OBL (16%).

CONCLUSIONS

The emotional and economic effects of the COVID-19 pandemic and the decreased Medicare physician reimbursement rates for vascular outpatient interventionalists have been significant. Even greater challenges for the financial viability of office practices and OBLs can be expected in the near future if additional further planned cuts are put into effect.

The financial impact of COVID-19 on a surgical department: The effects of surgical shutdowns and the impact on a health system

BACKGROUND

The COVID-19 pandemic resulted in sweeping shutdowns of surgical operations to increase hospital capacity and conserve resources. Our institution, following national and state guidelines, suspended nonessential surgeries from March 16 to May 4, 2020. This study examines the financial impact of this decision on our institution's health system by comparing 2 waves of COVID-19 cases.

METHODS

The total revenue was obtained for surgical cases occurring during the first wave of the pandemic between March 1, 2020 and July 31, 2020 and the second wave between October 1, 2020 and February 29, 2021 for all surgical departments. During the same time intervals, in the prepandemic year 2019, total revenue was also obtained for comparison. Net revenue and work relative value units per month were compared to each respective month for all surgical divisions within the department of surgery.

RESULTS

Comparing the 5-month first wave period in 2020 to prepandemic 2019 for all surgical departments, there was a net revenue loss of $99,674,376, which reflected 42% of the health system's revenue loss during this period. The department of surgery contributed to a net revenue loss of $58,368,951, which was 24.9% of the health system's revenue loss. Within the department of surgery, there was a significant difference between the net revenue loss per month per division of the first and second wave: first wave median -$636,952 [interquartile range: -1,432,627; 26,111] and second wave median -$274,626 [-781,124; 396,570] (P = .04). A similar difference was detected when comparing percent change in work relative value units between the 2 waves (wave 1: median -13.2% [interquartile range: -41.3%, -1.8%], wave 2: median -7.8% [interquartile range: -13.0%, 1.8%], P = .003).

CONCLUSION

Stopping elective surgeries significantly decreased revenue for a health system. Losses for the health system totaled $234,839,990 during the first wave, with lost surgical revenue comprising 42% of that amount. With elective surgeries continuing during the second wave of COVID-19 cases, the health system losses were substantially lower. The contribution surgery has to a hospital's cash flow is essential in maintaining financial solvency. It is important for hospital systems to develop innovative and alternative solutions to increase capacity, offer comprehensive care to medical and surgical patients, and prevent shutdowns of surgical activity through a pandemic to maintain financial security.

Plastic Surgeons and their Financial Relationships with the Industry in the era of COVID: Insights from the Physician Payments Sunshine Act

BACKGROUND

The impact of the COVID-19 pandemic on physician relationships with industry and subsequent financial implications has not been previously assessed. The aim of this study is to compare pre- and post-COVID-19 payments between industry and medical providers for all plastic surgeons.

METHODS

Payment information was collected for the 2019 and 2020 reporting periods from the Open Payments Program (OPP) database for plastic surgeons and plastic surgeon subspecialists. An analysis was performed of trends and comparison of payments for each year for all plastic surgeons and each subspecialty cohort.

RESULTS

For all plastic surgeons, there was a decrease in industry payments between 2019 and 2020 (- 30.5%). All plastic surgery subspecialties had a decrease in payments with general plastic and reconstructive surgery affected the most (- 56%) and craniofacial surgery affected the least (- 9%). Payments for almost all categories for plastic surgeons decreased along with compensation as faculty or as speakers. Total charitable contributions and grant payments increased by 61 and 273%, respectively.

CONCLUSION

Analysis of industry-physician payments available through the Sunshine Act shows that the COVID-19 pandemic has significantly impacted industry payments to plastic surgery and its subspecialties. While this study demonstrates the economic impact of the current pandemic, only time will tell whether these trends will persist in the coming years.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Modelling Stakeholder Valuation: An Example Using the Surgical Treatments for Gastroesophageal Reflux Disease

Background

Assessing the value of a treatment is of great importance. Typical methods are directed toward policy decisions. However, individual stakeholders will have different valuation based on their interests.

Methods

Formulas were developed to quantify the value of a treatment from the patient, surgeon, hospital, and private third-party payer. These formulas are based on observed factors that go into treatment decision-making for each stakeholder. Using the example of four surgical treatment options for gastroesophageal reflux disease, values for each factor were obtained from publically available documents or were arbitrarily estimated.

Results

From the patient perspective, the laparoscopic Nissen fundoplication (LNF) provided the best value at 2.99 quality-adjusted life years per $1,000 spent. From the surgeon perspective, it provided the best value at $752.20 earned per hour effort. From the hospital perspective, LNP provided the best value at $3,446 earned per episode of care. Lastly, from the third-party payer perspective, total incisionless fundoplication provided the best value at $13,336 per year.

Conclusions

Because value is measured differently for each stakeholder, there will be conflicts as to how treatment options are valued.