Orthognathic Surgery: is there a future?Andrea Moreira Gonzalez, MD, James E Zins, MDIntroduction: Orthognathic surgery has evolved from an infrequently performedextraoral procedure to a commonly performed intraoral procedure with a high degreeof predictability over the last years (1,2). Technical advances, such as rigidfixation techniques, new bone graft harvesting techniques, and new bonesubstitutes, have further enhanced surgical success (1-4). Despite significantimprovement in technique and technology, we previously reported a perceivedregional decrease in orthognathic cases in Ohio (3). It is suggested this may betrue throughout the country. In an attempt to document this possible decrease inincidence of orthognathic surgery and to detail the possible reasons, a survey wassent to plastic surgeons in the American Society of Maxillofacial Surgery (ASMS)and oral surgeons in the American Association of Oral & Maxillofacial Surgeons(AAOMS) practicing in US. The purpose of the study was to assess the number oforthognathic surgical procedures performed over the 5-year period.Method: This study was approved by Cleveland Clinic Institutional Research BoardCommittee. Lists of plastic surgeons in the ASMS and oral surgeons in the AAOMSpracticing in the US were obtained from their databases. A total of 3273 activeprofessionals (482 plastic surgeons and 2791 oral surgeons) were surveyed. Thesurvey was an anonymous, two-page questionnaire with the responses designed so thatparticipant could either circle answers or circle yes or no. The survey documentedan increase, a decrease, or no change in the number of orthognathic operationsperformed by each respondent over the previous 5 years (from 1999 to 2003), andsecondarily to query the respondents as to why such an increase or decrease hadoccurred. Orthognathic procedures were defined as those surgical procedures used toaddress malocclusion and/or dentofacial deformities of the maxilla and mandible.Current and previous levels of reimbursement for single-jaw or double-jaw surgerywere asked, and whether insurance coverage or other reasons were the respondents’presumed cause for reduction or increase. If reimbursement was the issue, questionswere related to how much reimbursement would need to increase before the respondentwould actually seek out these cases. Statistical analysis was performed usingdescriptive statistics initially; for quantitative variable the mean, median andstandard deviation were calculated. Comparisons of categorical measures wereperformed using Chi-Square tests, while ordinal measures were compared usingWilcoxon Rank Sum test. To compare whether the trend in surgeries differed bysurgeon type, a repeated measure ANOVA model was used. A significance level of0.05 was used for all tests.Results: 3273 surveys were mailed, 883 were returned (response rate = 28%). Thosesurveyed had mean experience of 19.8 years. Both the mean and median number ofsurgeries decreased every year. The median number of surgeries in 2003 was 43% ofthe median surgery total in 1999. There was a significant decreasing trend in thenumber of surgeries performed from 1999 to 2003 (p<0.001). Of the responders,42.2% had a solo practice, while 39.6% were in a group practice. More than 70%observed a decrease in the number of surgeries in the past 5 years (Table 1). Ofthose, more than 77% identified either lack of approval or low reimbursement levelsfrom insurance as reasons for the decrease (Table 2). Almost 70% of thoseresponding currently use fee-for-service, and 65% plan on using fee-for-service inthe future. A majority of responders (more than 65%) that indicated insurancecoverage was a problem said that an increase in reimbursement of at least 100% wasnecessary for them to expand their practice. There was a significant decrease inthe reimbursement levels for both single and double jaw surgery (p<0.001) (Table3). In 1999, 51% of responders received over $2,500 for a single jaw. Currently,only 18% indicated that level of reimbursement. Those receiving more than $2500reimbursement per case are significantly more likely to be using fee-for servicethan those who are reimbursed less (p<0.001). When the two specialties werecompared, plastic surgeons were more likely to work at a university, less likely toobserve decreases in the number of surgeries performed, and less likely to viewproblems with insurance as the reason for a decrease. They also were less likely tocite insurance (ability to obtain approval, low reimbursement) as reasons for a
decrease. There were no differences in reimbursement levels among the two surgicalspecialties.Conclusions: Our study documents a reduction in number of orthognathic proceduresperformed in the U.S corroborated by a significant majority of oral surgeons andplastic surgeons members of the ASMS and AAOMS. The main reason noted for thisreduction in the incidence of surgery, as perceived by the surgeons, was related tothird-party reimbursement. This is a potential problem that may significantlyaffect the quality of health care delivered to patients with dentofacialdeformities.References: 1. DeLuke, D. M. Orthognathic surgery: The state of the art. N. Y. State Dent. J. 64: 30, 1998. 2. Hausamen, J. E. The scientific development of maxillofacial surgery in the 20th century and an outlook into the future. J. Craniomaxillofac. Surg. 29:2, 2001. 3. Zins JE, Bruno J, Moreira-Gonzalez A, Bena J. Orthognathic surgery: is there a future? Plast Reconstr Surg 116:1442-50, 2005. 4. Kelly, J. F., Helfrick, J. F., Smith, D. W., and Jones, B. L. A survey of oral and maxillofacial surgeons concerning their knowledge, beliefs, attitudes, and behavior relative to parameters of care. J. Oral Maxillofac. Surg. 50:50, 1992.Table 1. The frequency and percentage of responders to general questions. Question Level N (%) Surgeon Type Plastic Surgeon 112 (12.7) Oral Surgeon 771 (87.3) Clinical Setting University 64 (7.7) Private Practice Solo 352 (42.2) Group Practice 329 (39.4) Private Practice and 90 (10.8) University Change in Increased 63 (7.7) Surgeries in the Past 5 Decreased 573 (70.0) Years Stayed the Same 182 (22.2) Problems with No 130 (22.7) Insurance a Yes 443 (77.3) Cause Fee-for-Service Currently Use / Will 435 (60.2) Continue to Use Currently Use / Plan to Stop 64 (8.9) Do Not Use / Plan to Start 36 (5.0) Do Not Use / Do Not Plan to 187 (25.9) Start Use Fee-for- Do Not Use 223 (30.9) Service Now Currently Use 499 (69.1)
Question Level N (%) Plan to Use Fee- Do Not Plan to Use in the 251 (34.8) for- Future Service in Plan to Use in the Future 471 (65.2) Future Amount of 25% 4 (1.0) Necessary Insurance 50% 61 (15.1) Increase For Expansion 75% 60 (14.8) 100% 125 (30.9) 200% 155 (38.3)Table 2. The frequency and percentage of responders to the reasons for a change insurgeries performed are presented. Primary Valid Reason Question Level Reason N (%) N (%)Reasons For Unable to obtain approval 267 (47.0) 287 (50.1)Decrease Able to get approval; low 165 (29.1) 221 (38.6) reimbursement Reduce professional workload 32 (5.6) 42 (7.3) Cases are too complex/time 20 (3.5) 37 (6.5) consuming Medico-legal issues 10 (1.8) 27 (4.7) Poor long-term predictable 0 (0.0) 5 (0.9) results Reduced orthodontic referrals 43 (7.6) 75 (13.1) Other Reasons 31 (5.5) 34 (5.9)Reasons For Better Fixation Technique 1 (1.7) 1 (1.6)Increase Ease of Approval Process 9 (15.3) 11 (17.5) Acceptance of dentofacial 9 (15.3) 12 (19.1) deformalities Other Reasons 40 (67.8) 44 (69.8)Table 3. The frequency and percentage of reimbursement levels currently, and 5years ago are presented.