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Referrals for Plastic Surgery following Mohs Surgery Are Declining: Trends and Financial Drivers
Renee Gao
*1, Goutam K. Gadiraju
3, Andrew Malek
2, Yizhuo Shen
6, Yibin Zhang
3, Alan Yang
5, Justin Broyles
41UMass Chan Medical School, Worcester, MA; 2Louisiana State University Health Sciences Center, New Orleans, LA; 3Harvard Medical School, Boston, MA; 4Brigham and Women’s Hospital, Boston, MA; 5Hospital of the University of Pennsylvania, Philadelphia, PA; 6Yale School of Medicine, New Haven, CT
Background: Plastic and reconstructive surgeons (PRS) are essential in managing complex defects post-Mohs micrographic surgery (MMS), yet national data indicates MMS surgeons increasingly perform their own reconstructions. This study investigates sociodemographic, oncologic, and economic determinants of PRS referrals within Massachusetts' universal coverage landscape.
Methods: The Massachusetts All-Payer Claims Database was queried for patients undergoing MMS for head and neck skin cancers (2016-2020). Multivariable regression identified independent predictors of PRS referral. Physician service reimbursements were analyzed and adjusted for inflation.
Results: Of 70,308 patients, 7.24% were referred to PRS. Referrals declined annually from 8.07% in 2016 to 6.38% in 2020. PRS referrals were significantly more likely for younger patients (OR 0.87 per 10 years of age, p<0.001) and females (OR 1.25, p<0.001). Melanoma and melanoma in situ (MIS) cases were more likely to be referred than keratinocyte carcinomas (OR 1.77, p=0.008). High-risk anatomical sites such as the eyelid (OR 10.40), nose (OR 2.89), and lip (OR 2.18) were strong predictors of referral (p<0.001). Publicly insured patients had higher referral odds (OR 1.08, p=0.016). Median physician reimbursement for MMS-led reconstruction was significantly higher for private vs. public payers ($206.72 vs. $51.18, p<0.001); a similar disparity was observed for PRS ($531.33 vs. $165.26, p<0.001). Patients treated within the Boston Metropolitan Area had lower referral odds (OR 0.73, p<0.001).
Conclusion: PRS referrals following MMS are declining in Massachusetts. The finding that privately insured patients are less likely to be referred, independent of tumor complexity, suggests that current reimbursement structures and value-based models like MIPS may unintentionally disincentivize interdisciplinary collaboration. Policy reforms are needed to ensure financial incentives align with the specialized expertise required for complex reconstructive care.
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