Is the mastectomy uproar over? The future seems cloudy for providers
So far, backlash against drive-thru’ procedure hasn’t hurt industry
Health plans did an about-face in February, after attempting to impose limits on hospital stays for breast surgery patients. In the process, outpatient providers seemingly took a slap in the face following allegations of widespread pain and danger linked to "drive-through mastectomies." Payers quickly changed their minds following a public outcry.
For now, the issue seems settled.
But several factors, fueled by the controversy, are now looming for outpatient providers that could hurt them financially in years to come. Among them:
• Congressional legislation.
Lawmakers were quick to respond to the outpatient controversy. In Congress, HR 135 authored by Rep. Rosa L. DeLauro (D-CT) and a companion bill SB 143 written by Sen. Tom Daschle (D-SD) would ensure 48 hours of hospital care following a mastectomy if necessary and 24 hours following a lymph node removal.
The second, SB 249, authored by Sen. Al D’Amato (R-NY) and its companion HR 616 from Rep. Susan W. Kelly (R-NY), don’t set a minimum length of stay. But the measure leaves open the time period to be decided by physicians and their patients.
Neither measure discourages outpatient choices. But if enacted, they could easily reinforce a negative message about outpatient breast surgery, says Lillie Shockney, RN, MAS, director of performance improvement and utilization review at Johns Hopkins Hospital’s Breast Center in Baltimore.
They may discourage valuable clinical research and advancements in outpatient mastectomies and hamper welcomed growth in the outpatient sector, Shockney adds.
• Growing consumerism.
"Nationally, there are too many mastectomies being performed anyway," complains Richard Taylor, PhD, president of Cancer CarePoint, an Atlanta-based cancer treatment consulting firm. Growing patient education could reduce those numbers, Taylor adds.
As patients become better informed, their choices change, Shockney adds. A large number of women choose surgery out of wisdom, fear, convenience, or lack of information.
The controversy may have sparked greater public awareness. And with better guidance, many patients could either postpone or rule out surgery entirely in favor of chemotherapy, Taylor observes.
• Cost concerns vs. patient safety.
Women who have had major breast surgery still undergo an overnight hospital stay about 95% of the time, Taylor says. With federal laws imminent, physicians are likely to err on the side of safety and forgo cost factors in favor of ensuring patient satisfaction.
The number of hospital stays for even simple mastectomies, which usually don’t require overnight stays, could therefore go up, Shockney says.
• Rising specialization.
According to The Medstat Group, an Ann Arbor, MI, research firm, capitated health maintenance organizations (HMOs) covered less than 10% of radical mastectomies on an outpatient basis between 1993 and 1994. The rest were done on an inpatient basis. The rate for the simpler, less serious mastectomies was higher at 21%.
Radical mastectomies without breast reconstruction represent the most common type of breast surgery performed today. They can still be done without problems on an outpatient basis, Shockney says. (For additional data on surgery rates, see charts, p. 51.)
Despite the public alarm, outpatient breast centers such as Johns Hopkins have had a high success rate with outpatient radical mastectomies.
In three years, only one out of 900 Johns Hopkins breast patients visited the hospital’s emergency department with complications following outpatient surgery. The rest went home without problems. Most of the alleged "horror stories are unfounded," Shockneys says.
For now, outpatient centers emerge OK
The coverage controversy has apparently not led to any startling increases in hospital stays, according to breast surgery professionals. And the horrors alleged by critics haven’t blunted patients’ choices either, says Taylor. Many are still choosing outpatient settings for their surgeries.
One possible reason is providers have been successfully performing these procedures for years, Taylor says. For many facilities like Johns Hopkins they have become a clinical specialty.
Nevertheless, the public’s perception of in-and-out mastectomies has raised concerns. Does this mean far fewer outpatient procedures will be performed in the future? What about pre-authorization criteria? Will they get tougher? Will this mean more red tape?
At least for now, the answer is no, according to same-day surgery administrators interviewed by Outpatient Reimbursement Management. The issue has had little or no effect so far on patient business.
Here are two examples:
• Universal Surgery Centers, Fort Worth, TX.
"We have not felt pressure from managed care organizations either way," reports Michael G. Urbach, senior vice president of Universal Surgery Centers.
In Universal’s patient markets throughout the South and Midwest, health plans aren’t pushing for overnight stays. But neither are they urging the less-costly outpatient alternative, Urbach says.
"And on our part, we’re not doing anything differently either," he adds. Even before the controversy arose, the policy at the 14 ambulatory surgery centers (ASCs) under Urbach’s wing was to check with the payer regarding coverage. But as a rule, administrators left questions about the appropriateness of outpatient care to the patient, physician, and the clinic medical director. That policy has not changed, Urbach adds.
• The Breast Center at Johns Hopkins Hospital, Baltimore.
The hospital performs more than 70% of lumpectomies and modified radical mastectomies (excluding breast reconstruction) as outpatient procedures. The center does 300 mastectomies per year.
Nearly all of the Breast Center’s patients are insured either by private health plans or Medicare, Shockney says. Seven percent of patients are self-pay. So far, payers have avoided raising a point concerning the site of service, Shockney adds.
What they are doing is keeping track of hospitals in the Baltimore area that have high outpatient rates. Shockney hopes the hospital’s strong outpatient volume and good outcomes will lead to more favorable contracts for the Breast Center.
And administrators expect the proportion of outpatient to inpatient procedures to increase, according to Shockney. The reason for the growth in demand, physicians say, is the development of a way to reduce post-surgical pain and discomfort.
Severe nausea, vomiting, and pain are common following mastectomies. They’ve been the main reason for most hospital stays, says Shockney, a three-time breast surgery patient.
By using a process combining milder doses of anesthesia and shorter operating time, physicians have been able to reduce the nausea, vomiting, and pain. Administering Tylox and Decadron for pain and inflammation and cancer drugs such as Zofran has helped patients recover faster.
Despite the controversy, Shockney hopes that similar advancements in outpatient breast surgery will result in higher coverage by HMOs. "We’re really the odd ducks in all this. We do think that outpatient mastectomies are right for most patients," Shockney says.
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