Plastic Surgery's Shifting Costs

In the Yellow Pages, Stanley Schoenbach's ad offers all sorts of plastic

surgery for prospective patients-face lifts, nose jobs, tummy tucks, breast

enlargement and even hair restoration.

"Ambulatory and Hospital Facilities Available," the Bronx plastic surgeon

promises. "Insurance Accepted When Applicable."

But managed care patients who rely on this ad and the other information in

their insurer's provider directory would have no idea of the serious problems

facing Schoenbach.

Since April, 1998, Schoenbach has been fighting a decision by state medical

authorities who revoked his medical license for improper surgeries involving

"tummy tuck" and breast reduction patients. In both surgeries he improperly

indicated on patient records that the treatments would require more than one

operation. In fact, officials charged, a "reasonably prudent physician" would

have accomplished the surgeries in a single operation.

While appealing the state's revocation order, Schoenbach has been able to keep

on practicing legally and has been carried as an approved managed care surgeon.

A court-ordered restriction on his license says Schoenbach can do major

surgery only at a hospital.

Plastic surgery has become one of the biggest areas of growth for operations

done outside of hospitals. Once paid out of pocket by patients, plastic surgery

is also increasingly being reimbursed by managed care insurers and performed

at private surgical centers.

According to the American Society of Plastic and Reconstructive Surgeons, 37

percent of patients nationally paid for plastic surgery in 1997 using managed

care insurance. Of these operations, 33 percent were done in private doctors'

offices and 21 percent in "free-standing surgi-centers," the trade group says.

The group also says 70 percent of all plastic surgery is for reconstructive

purposes, with only 30 percent for cosmetic reasons.

But patients, as in Schoenbach's case, may not learn everything from their

managed care insurers that they need to know about these surgeons. Both Oxford

Health Plans and Aetna U.S. Healthcare listed Schoenbach this year as an

approved provider more than a year after state officials voted to revoke his

license.

Both Aetna U.S. Healthcare and Oxford officials said they were waiting for

Schoenbach's legal appeals to play out in the courts. Aetna also rejects the

idea that its provider booklets make any promises about physician quality,

despite phrases such as "you can feel confident" about the doctors listed in

its directory.

"I don't believe that we make any promises," says Aetna U.S. Healthcare

spokeswoman Elizabeth Sell. "We do describe our credentialing process. But I

don't think there's an implied promise there."

In an interview, Schoenbach defended his treatment of his patients, whom he

says were not hurt from the surgeries. He blames the state probe on a complaint

lodged by a competitor in the plastic surgery field. "Obviously, they [his

patients] think the doctor is providing good care," Schoenbach says. "Just

because the doctor has been disciplined doesn't mean they are incompetent."

Managed care insurers provide little insight to customers about Schoenbach's

medical practice. But court and regulatory records underscore just how much

patients may not know about their plastic surgeon.

In April, 1997, state officials charged Schoenbach had mistreated five patients

during the late 1980s at a Westchester County hospital and that he filed false

information about his hospital credentials. In January, 1998, a hearing panel

slapped him with a $20,000 fine and suspended his license for two years. That

suspension was immediately stayed and he was put on probation.

That decision set off a lengthy appeals process before state regulators and in

the courts, but eventually officials agreed his care was poor enough to revoke

his medical license entirely in April, 1998.

The following month, his attorney persuaded a judge to let him practice while

challenging the revocation through the court system. The judge ruled he could

only do "major surgery" in an "appropriate hospital setting" and had to be

monitored by an experienced plastic surgeon.

In June, a state appellate court upheld the license revocation by state

medicial officials. Yet while Schoenbach prepares to go to an even higher

court-18 months after having his license stripped-New York officials have

agreed to leave this stay on enforcement in place. That means Schoenbach can

continue practicing medicine for what state health department spokeswoman Kris

Smith says will be "for the foreseeable future."Aetna U.S. Healthcare officials

defend their decision to keep Schoenbach in their plan.

Dr. Jerry Frank, senior medical director for Aetna U.S. Healthcare in New York,

says it was his understanding that Schoenbach's court challenge so far had

been successful in keeping his license. And as long as he has an active

license, Frank adds, Aetna U.S. Healthcare would have difficulty removing him

from their plan.

"The state has still provided him with a license to practice," Frank explains.

"We're aware of what the state has said, and aware of what Dr. Schoenbach has

responded to regarding this. Basically the decision is in the courts and we

keep a sharp eye out on these things."

Frank notes that Schoenbach had vigorously denied the charges. "His response to

the sanctions was that clearly there was no wrongdoing," Frank says.

"Patients in Aetna U.S. Healthcare will continue being referred to Schoenbach

for the time being," Frank says. "Everyone is entitled in the United States to

due process, and not to do that would open us up to legal ramifications."

Frank says that it's up to customers to check records of the state health

department, which maintains lists of disciplined doctors, and that the company

does not think it is appropriate to let customers know about doctors who have

been state disciplined.

"I'm not real sure that's our role. We tell people that we review the state

sanctions," Frank says. "What we have to do is to say-'We've looked at all

these things, gone through peer review process, and that we felt this person

could be part of Aenta U.S. Healthcare's network.' "