The Economic Burden of Out-of-Pocket Expenses for Plastic Surgery Procedures

Jessica I. Billig, M.D., M.S.; Jung-Sheng Chen, M.S.; Yu-Ting Lu, M.P.H.; Kevin C. Chung, M.D., M.S.; Erika D. Sears, M.D., M.S.


Plast Reconstr Surg. 2020;145(6):1541-1551. 

In This Article

Abstract and Introduction


Background: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients.

Methods: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars.

Results: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures.

Conclusions: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.


In 2017, plastic surgeons performed approximately 5.8 million reconstructive procedures, with insurance paying for the majority of these procedures.[1] However, even in these instances of insurance coverage, patients are becoming increasingly financially responsible for a greater portion of their surgical care. Health care reimbursement structure in the United States has changed considerably, with costs being passed on to patients through rising deductibles, coinsurance, and copayments. There is a lack of transparency in out-of-pocket expenses for health care. Patients and providers have a limited understanding of health care costs, which may lead to unintended financial burden for patients.[2,3] Large out-of-pocket expenses have been associated with treatment nonadherence and worse health-related outcomes.[4–7] Moreover, out-of-pocket expenses have implications for delays in treatment and access to care.[8–10] With a push toward patient-centered care, understanding cost from the patient's perspective has implications for shared decision-making and alleviating potential financial burden.

Recent studies have shown the substantial growth in out-of-pocket expenses for pharmaceuticals and inpatient hospitalizations.[11,12] National studies of hospitalizations have shown an average rise of 86 percent for deductibles and a 33 percent increase in coinsurance,[11] varying across different medical diagnoses. However, little is known regarding the temporal trends of out-of-pocket expenses for surgical procedures. Specifically, for plastic surgery procedures, which are largely elective, understanding changes in out-of-pocket expenses over time can help surgeons understand the financial burden placed on patients and incorporate cost in the decision-making process to mitigate this harm. Furthermore, these temporal trends in out-of-pocket expenses may impact surgical timing, treatment decisions, and access to care.

Given the possible negative effects of out-of-pocket expenses on the patient, understanding the temporal trends of out-of-pocket expenses for the most common outpatient reconstructive procedures warrants further investigation. These data will help equip providers and policymakers with vital information regarding the financial burden placed on patients. Therefore, we aim to investigate the temporal trends of the total cost and out-of-pocket expenses for plastic and reconstructive procedures and to determine factors associated with increased cost sharing.