Page 110 - When surgery alone won’t cut it - Valerie Maureen Monpellier
P. 110

Chapter 6
has been shown before 10,14,27,28.
Patients with a desire also graded their overhanging skin highest for all body parts assessed. A higher PRS score was related to lower rating of body parts in all patients, meaning that more excess skin is clearly considered less attractive. Since there are no studies assessing the prevalence of excess skin with PRS, we cannot compare our results. But we can conclude that the PRS (or a scale like this) can be used to assess how patient perceive their excess skin. Future research could then also focus on whether the perceived excess skin correlates with the estimation and/or measure- ment of the plastic surgeon.
It is striking that almost 40% of the patients who had a desire for BCS never consult- ed a plastic surgeon, although many of these patients did meet the weight criteria. Income rates were linked to the use of BCS in previous studies, and the group with a desire for BCS had the highest rating of unemployment and the lowest income 3,8,16. Thus, costs seem to be the main reason for not undergoing BCS, and/or not consult- ing a plastic surgeon 3,8. However, looking more closely at the reasons there are some distinct differences. There is a substantial population of patients (27.7%) who did not even ask for a referral, and a total of 20% of the population didn’t consult the plastic surgeon because they anticipated that they would not get reimbursement. Almost half of the patients in these groups qualified according to the weight loss results. Although we don’t know the exact amount of overhanging skin, the results do partly confirm what we see in daily practice: there is a group of patients who might be reimbursed by their insurance company, but never tries to get the surgery.
Health insurance in the Netherlands is mandatory. Patients are free to choose a pri- vate company for the basic health insurance. In addition, patients can choose a more expensive insurance which reimburses more treatments. To qualify for reimbursement of BCS there is a nationwide guideline. Patients must meet the following criteria: (a) > 18 months past bariatric surgery, (b) stable weight for ≥ 12 months, (c) a BMI < 35 kg/m2 and (d) skin excess grade 3 according to the PRS and/or serious impairment of bodily function 18,29. This information is sent to the insurance company by the plastic surgeon and the insurance company decides whether a patient will be reimbursed. Since there is great variability in rating with the PRS, reimbursement decisions are also variable. This results in an unfair situation for patients. There is a possibility for patients to oppose the decision of the insurance company, but understandably, for this the patient will need to have the resources and abilities.
The issue of unfair/unclear reimbursement is not confined to the Netherlands; several publications have described similar problems all over the world 8,16,30,31. In the United States and in Canada, BCS is usually not reimbursed by insurance companies and no clear guidelines exist 8,16. In Great Britain, decision making for reimbursement of
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