This episode of the DiepCJourney podcast covers two very important topics. It includes the value of the co-surgeon model in microvascular breast reconstruction. We will also tackle a subject matter I am not an expert on but have a great deal of experience in. I will admit it is an uncomfortable topic for me because I am not an expert.
The topic is insurance coverage in breast reconstruction. I want to say that I have NOT come to understand the complexities of insurance but have gained a great deal of empathy for those in the breast cancer community who deal with these complexities, and that includes patients and surgeons. My guest, Dr. Minas Chrysopoulo, discusses the value of the co-surgeon model in breast reconstruction and insurance coverage concerns.
Why this Topic and Why Now?
I have chosen this topic not to appear to be controversial. It is a topic that can stir emotions, and I have seen it presented in what I can only describe as a dramatic way. That will not be the type of presentation on this podcast today. I am discussing this topic now because of a heightened sense of concern regarding insurance coverage using the two-surgeon model in DIEP flap.
Before the podcast I researched this topic to see if there are studies showing the efficacy of using a two-surgeon model in this intricate microsurgical procedure that restores the loss of breasts, often and appropriately referred to as an amputation. Along with Dr. Chrysopoulo, we want to discuss the information in these studies as well as offer patients some guidance if they encounter difficulties getting coverage or are spending countless hours on the phone working for approval of surgery.
Studies on the Co-surgeon Model
There are indeed studies on the efficacy of the two-surgeon model in microvascular breast reconstruction. I find these studies to be very useful to our conversation today. But from a patient advocacy perspective, what I also find valuable are real-life comments from patients who have had or are considering microvascular breast reconstruction.
I recently posted a video in a private Facebook group with global members. The video was with notable microvascular surgeons in Charleston, SC, Dr. James Craigie, and Dr. Richard Kline in an interview on the DiepCFoundation YouTube channel discussing a consistent surgical team approach and what value it brings not only for the surgical team but for the patient.
Here are some comments from patients on the video posted on The DiepCJourney Facebook page.
“I didn’t realize there are surgeons who do it solo.” The response to this comment was, “Kind of terrifying.”
Another comment from a patient, “I can’t see how it could be any other way if you’re factoring in patient safety and achieving the healthiest flaps.”
“I had three surgeons.” The third surgeon in this remark may have a breast surgeon. She followed with, “At first, my insurance company refused to pay one of them.”
These are stories from the front line. There are in fact surgeons who perform DIEP flap alone, as a single surgeon and it is for several reasons. This is not to criticize their outcomes or practice. This conversation focuses on the value of the two-surgeon model.
Why Insurance Concerns in Breast Reconstruction are So Important to Patients
It is odd over time that issues with insurance have continued and yet taken on a whole new dimension with different concerns. I remember sitting at my desk during my first diagnosis quite a few years back, fighting to get a prosthetic wig covered, some days in tears, and feeling angry and betrayed.
These are quality of life issues. I have spoken to women who want to work during treatment, return to work as soon as possible after surgery, and some want to remain private about their surgery and diagnosis. These are revenue generating society members who I feel deserve the comfort of knowing their insurance will be there to compensate them fairly and allow them to normalize their lives as much as possible after such events. It feels like it all revolves around money at times for patients. I don’t run insurance companies but when you look at their yearly revenues it gives one pause to ponder such thoughts.
As I said in my opening comments, this is an uncomfortable space for me to be in because of the complexity of this topic. But here we are, and I don’t think it will be the last conversation I have on this.
Honoring a Champion in Patient Advocacy in Breast Reconstruction
I was certain I needed to invite a guest I was completely comfortable discussing this topic with. We go back a bit. I have built trust in his principles over time and his focused passion on patient education. You have heard him on the podcast before, but he has gained a great deal of respect in the global community of microvascular breast reconstruction. I honor our listeners by introducing a friend, a patient-advocate champion, and someone I know will help me feel more comfortable tackling the subject matter and discussion today.
Dr. Minas C. is the current president of PRMA in San Antonio Texas. He knows a thing of two about microvascular breast reconstruction having performed thousands, as in over twelve thousand, various breast reconstruction flap procedures with his team of colleagues at his practice. He is the Founder and Developer of the award-winning Breast Advocate®, a free breast cancer healthcare app providing the user with all your surgical options, a plethora of evidence-based resources, and a customizable and adaptable patient experience through the wizard, along with a community feature of like-minded users to share information with.
Highlights from the Interview on the Co-Surgeon Model
- The co-surgeon model: You as a patient will primarily be taken care of by one surgeon in clinic. If you decide to have surgery, two surgeons will perform your surgery along with a team of other specialists.
- Time stamp: 9:00 minutes: “This is a continuation of the S-code debacle.”
- Time stamp 10:10 minutes: Without adequate reimbursement to microsurgeons for performing this intricate surgery, removing the S-code risks access to care for those considering breast reconstruction after mastectomy.
- Time stamp 10:36 minutes: This feels like winning the battle but not necessarily winning the war.
Value of the Co-Surgeon Model in the OR
The key components of the surgery are divided up between two specialists at the same time. Things happen in tandem rather than sequence. In other words, one surgeon can be harvesting the abdominal blood vessels and whilst the other surgeon is preparing the chest to receive the flap. Dr. C goes into detail in the podcast. This shortens time in the OR for the patient and surgeon. This takes long hours in many cases. If you have two surgeons dividing up the workload, all the details he discusses happen in unison rather than one after another. The literature in plastic surgery shows that the co-surgeon model improves efficiency. This model shows:
- Time efficiency for surgeons and OR staff.
- Less anesthesia for the patient decreases the risks associated with being under anesthesia for a longer period.
- Shorter time under anesthesia translates to shorter hospital stay, especially when ERAS (Enhanced Recovery after Surgery) is used.
- Lower rates of major complications.
When things are more complex, if something is unforeseen, when something doesn’t go as planned, there is no better time when the co-surgeon model is deemed valuable to work as a team to mitigate problems.
Patient Voices Matter for Insurance Coverage Issues
Dr. C and I both ask our readers and listeners this important question.
Do you really want to be that patient when your surgeon in dealing with something on their own when they could have had help? Patients need to know it’s in their best interest to seek out two surgeons, especially for longer complex cases and bi-lateral DIEP flap breast reconstruction.
Dr. C points out he is NOT saying to forego reconstruction if there is only one surgeon. Can surgeons do these complex cases on their own? Of course, but is that really pro-patient advocacy? Is that really putting the patient first just because they can? No, it’s not!
The co-surgeon model is being squeezed by insurance coverage. What is unethical is messaging from some surgeons who are turning this around and saying “this is better” referring to performing complex breast reconstruction surgery alone. Patients deserve the best outcomes and the best safety measures available in breast reconstruction.
I leave you with a call to action before listening to the entirety of the podcast.