Can you make a decent living without cosmetics?

[Addy k]

So although I'm just starting med school, I've been working on a research project in Plastics the entire summer and am having the paper submitted for publication in the upcoming week. It should be accepted and we will likely be presenting it later this year. I have another opportunity to do another project during the year which would lead to another publication + presentation. I've also made some good contacts for plastic surgery and if I continue on pursuing plastics I'm sure I'll have a good chance come residency time (especially here in Canada where it's just about reference letters/contacts/research).

Anyway, before I fully commit myself to plastics I wanted to know if it's possible to make a decent (let's define decent as $300,000+) a year as a plastic surgeon without doing ANY cosmetic work? From what I can tell, it seems like almost every plastic surgeon does some private cosmetic work on the side - I guess because it's so lucrative. However, for personal reasons I just don't want to do cosmetics, but focus more on reconstructive/hand/microvascular surgery. I'm thinking that maybe plastics isn't right for me since it seems like cosmetics is a component of it even if you work in an academic centre. But I mean if I did a fellowship in microvascular or burn related stuff, would I really need to do cosmetic surgery on the side to make a decent living? If anyone has insight on this, I'd greatly appreciate it.

Thanks.

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[rongeur]

You're in Canada so it's harder to say. In the US it isn't very hard to exceed that number without cosmetic (eventually, obviously, not starting out), especially if you're willing to do less-desired but well-paying cases (burn).

Your attitude is very common among students and jr residents. It usually goes away when they get hands on experience and see why their attendings like cosmo. You don't need to do any cosmetic in your eventual practice, but you do need to be trained it in so if you have some kind of rabid objection then yes, that would block you.

 

[igap]

Anyway, before I fully commit myself to plastics I wanted to know if it's possible to make a decent (let's define decent as $300,000+) a year as a plastic surgeon without doing ANY cosmetic work?

Yes.

 

[droliver]

Anyway, before I fully commit myself to plastics I wanted to know if it's possible to make a decent (let's define decent as $300,000+) a year as a plastic surgeon without doing ANY cosmetic work?

It would be hard and getting harder as you're getting squeezed on both the revenue and the overhead sides. You have to consider that to net $300K you're going to have to bill close to $1.2M+ with expectations on collecting $500-700K depending on your payor mix. That is a LOT of cases at insurance rates to get to that figure, and probably not a sustainable practice for most people. Going forward, you're more likely to get to $300K as an employee of a hospital or multispeciality group but there will be little room for much more salary wise

 

[Tristero]

i have been following this board for quite some time and I find that dr olivers opinion tends to be on the pessimistic end of the spectrum. whether or not you bring in 300k a year doing reconstructive surgery is highly dependent on where you practice; what your payer mix is; what procedures you do; and well and accurately you do your coding.

i am currently a plastics fellow but I come from a private practice surgeon family and also know several plastic surgeons in practice in several states. some do exclusively cosmetic, while some do as much as 80-95% reconstructive.

what I have gleaned is that in certain areas, breast microsurgery reimburses well; elective hand surgery with a rehab center can also do well. burns as was mentioned also can reimburse well. mohs reconstruction and office procedures can also reimburse well. certain muscle flaps also reimburse well. the key to maintaining profitability with reconstructive procedures is knowing what reimburses well and minimizing your overhead.

from the surgeons I know, 300k is not unrealistic if you are efficient and probably more realistic if you have a partner/operate in a group practice. i would take dr olivers advice with a grain of salt. i greatly value his opinion and input but have found in my personal experience that is lies on one end of the spectrum. the impact of the new health care act could change all of these dynamics, but I hope they do not because I hope to be busy with reconstructive surgery as well.

 

[droliver]

what I have gleaned is that in certain areas, breast microsurgery reimburses well; elective hand surgery with a rehab center can also do well. burns as was mentioned also can reimburse well. mohs reconstruction and office procedures can also reimburse well. certain muscle flaps also reimburse well. the key to maintaining profitability with reconstructive procedures is knowing what reimburses well and minimizing your overhead.

I think you have some misconceptions on those procedures, particularly in the context of where things are and where they're going. None of those procedures reimburse exceptionally well, there are just some that are more time efficient then others. At insurance rates, we're collecting 40-50% of what we did in 1985 for them even before inflation.

There are some areas of the country (metro NYC for example) where you have a large % of plastic surgeons that do not participate with insurance ("out of network") and have continued to do fairly well doing fee for service reconstructive procedures or billing crazy high OON charges. This scenario is not sustainable and eventually you're seeing more and more patients not being able to afford the out of pocket expenses. A number of states have actually legislated OON charges for ER patients out of existence (ie. even if you're not contracted with a carrier and have to see one their patients in the ER, you're limited to getting paid on their fee schedule rather then your "usual and customary" (UC) charges). You don't have to be a genius to see that eventually with whatever shakes out with healthcare reform that we're going to see restrictions on charges somehow pegged to medicare rates even for providers completely OON.

If you're under the impression that microsurgery and muscle flaps pay so well, ask yourself why Rolin Daniel and Foad Nahai (the 1st microsurgeon and the author of the definitive muscle flap books respectively) quit doing the procedures they popularized decades ago. ie. They wanted to maintain their income at levels they used to get paid to do reconstructive surgery at UC rates and went 100% cosmetic. When you got paid $10-15K to put an amputated digit back on or do a TRAM flap, people did a lot of those procedures. When you get paid $1500-2500 you've see a lot of revision amputations and tissue expander breast reconstructions. There are not a lot of private practice microsurgeons (whom aren't subsidized or OON) for a reason.

Long story short, you can definitely still eek out a living doing reconctructive surgery but you're getting pinched on all sides (like all specialties) and the previously lucrative niches of OON status, fee for service micro practices, etc... are disappearing quickly. There is going to be tremendous downward salary pressure on all physicians

 

[Tristero]

Well I can't argue with many of the points you make. I don't know if poor reimbursement is the reason why Nahai transitioned to cosmetics only. Mathes certainly didn't.

You're obviously not going to be paid at the same rates as 1985. No one is. The examples you cite - replants and TRAMs are old procedures with CPT codes and will be reimbursed as such. The guys making money in micro now re doing ALTs, DIEP flaps. The guys making money in hand have surgery centers and rehab facilities and are charging facility fees. They are doing Xiaflex injections and getting paid at the rate they charge because its a new therapy. They are performing with high volume practices, and in some instances incorporating imaging services into their practices to beef up reimbursement.

You wanna talk Medicare rates for Mohs reconstruction - 500 for a nasolabial flap and 200 for the excision. 700 for a forehead flap and 200 for the excision. These are the lowest reimbursement rates in the entire state of Florida. I know this firsthand. And I know people who have no problem pulling in 300k after their overhead is paid for at these rates.

I don't think I have any misconceptions regarding reimbursement. I think we are viewing the same situation in different ways, and as I mentioned you have focused on a gloom and doom scenario - which has been posited decade after decade after decade. I don't know how the Healthcare act will affect reimbursement, but I know one thing: efficient and business savvy surgeons will continue to do well.

 

[droliver]

I don't think I'm pessimistic, but I think (as a fellow) you just haven't gone to work yet and have had to sit down reading your EOB statements from carriers for insurance work. It's a real eye opener when you get paid 30-40% of your charges and every line item and modifier is an arm wrestling match over getting paid.

1) A free TRAM, DIEP, ALT, or GAP flap code are all reported with CPT 19364. Medicare reimbursement (which most privates index their rates to) for that in FL is ~ $3435 (which you can look up here on the AMA CPT website) . There is no other recognized code (nor is there likely to be one) for perforator flap breast reconstruction and ASPS is not pushing for one as it would lower reimbursement for other codes to maintain budget neutrality. That DIEP is frequently a 6-10+ hour surgery that ties up a whole day, 4-5 days of rounding in a hospital (assuming no complications), and 90 days hand-holding under the global. YOUR PRACTICE WILL GO BROKE PRODUCING GROSS REVENUES OF $300-400/hour on your O.R. days. Whatever you've heard about how so & so has a carve out where there getting paid sky high fees, remember that it is not going to last.

2) Forehead flaps actually are one of those things that pays well per time involved, but I can tell you as the plastic surgeon that likely does the most skin CA in our state (and shares an office with one of the highest volume MOH's surgeons in the country) there aren't a lot of people showing up with cancers where you whip out forehead flaps on. Very few in fact. You're also not going to get $500 from most carriers for the local flap code for reporting NL flaps. Think $250-350 maybe with better payors with much less then $200 for the excision, even without the multiple procedure discount.

3) don't be expecting to be helped out with the Xiaflex train as:
a) it's a pain in the ass to get paid for it
b) the procedural part of the injection is going to get clipped $ wise
c) family practice docs and NP/PA's are going to start doing it


The point of all this is to explain that your not going rich doing these kinds of cases as they don't (with the exception of hand surgery mills) lend themselves to much efficiencies of scale. We don't have a surgery like arthroscopy, arthroplasty, or ear tubes/tonsils where you can whip out 10-14 surgeries a day to maintain income thru productivity. As noted, the opportunities to carve out some fee for service DIEP flap practice or the like is largely gone.

 

[Addy k]

Thanks a lot for the posts guys and the great discussion. Seems like there is some disagreement, but at least I have some information to get me thinking about all this.

 

[Moravian]

I mentioned you have focused on a gloom and doom scenario - which has been posited decade after decade after decade.

There is a reason for the gloominess. Incomes have steadily decreased over the past 20 years and they are continuing to do so. As near as I can tell from conversations I've had with those who've been around a while, everyone is working harder and making less money.

I will agree with droliver in that it is an eye opening experience when you find out what you're actually getting paid. I remember getting a check from the State (should have gone to billing but came directly to me instead) for $5.90. It was for a level II consult. I don't even know why they bothered.

I think the surgeons who are doing the best are in the smaller markets with lower overhead costs and general lower cost of living. And those that are employed by hospitals. For instance, they docs who work for Kaiser (not a hospital but a health plan) make almost twice as much as I do and work half the hours. Why am I then not working for Kaiser you ask? Because some things are more important than money. I would absolutely kill myself if all I did were panniculectomies and breast reductions.