Mastectomy Legislation

Re: boy oh boy!

In a previous Social Work incarnation I too hard frequent dealings with insurance reviewers. While there were some few individuals you could count on to be reasonable and even-handed, most were dedicated to approving absolutely zero services. They were frequently callous to the patient's problems and were sometimes offensive, calling into question the MD's judgement (The MD's were uniformly more qualified than the reviewers). The most interesting part was that reviewers from the same insurer would behavior differently leading you to believe that it wasn't simply a matter of them following stated policy. We speculated that each reviewer was given a quota of "hospital days" that they could approve each month. We would try to track whether they were more generous at the beginning of the month and more stingy at the end. My point is this, whatever the philosophy or the policy of a given insurance company might be, this policy is implemented by fallible humans. There are assholes everywhere and some of them work for insurance companies.
Jack

 

Fair enough. I thought you were making a point about medical care in general. You are correct in that my comments have nothing to do with the proposed legislation.

But aren't you advocating leaving it up to the doctor, the patient, and the insurance company -- with the insurance company holding the trump card if the patient does not have means to pay for treatment recommended by the doctor but not approved by the insurance company?

 

No, under every state law the doctor always has the final decision and the final malpractice responsibility.

One thing that seems to get lost in these discussions is the proposed legislation has nothing to do with medical necessity. It simply would mandiate the extra day whether the patient needs it or not.

If one extra day is good, wouldn't two be better?

 

Re: boy oh boy!

Dr. Gina - I respect your good intentions. I just don't believe government mandates are the way to address the problem. Hope you had a nice vacation.

 

Well, Randy, it probably gets lost in the discussion because you are making it up.

From the text of the bill:

(1) Nothing in this section shall be construed to require a woman who is a participant or beneficiary--

...

(B) to stay in the hospital for a fixed period of time following a mastectomy or lymph node dissection.

 

I made up nothing. I never said the patient would be forced to stay the extra day. The mandate is allowing the patient the extra day.

If you like the legislation, fine, call your representative. But don't intentionally distort what I said.

You should contact Gray Davis. I'm sure you would blend in well with his speak writers.

 

Just a few days ago, in a response to Jeff, Randy wrote:

One thing that seems to get lost in these discussions is the proposed legislation has nothing to do with medical necessity. It would simply mandate the extra day whether the patient needs it or not. (Randy Miller, 08/21/03, 1:58 pm) I believe that the phrasing "whether the patient needs it or not" is a contradiction of your statement above where you claim that you never said the pateint "would be forced to stay the extra day." It's amazing what you can miss when you're backpeddaling.
Jack

 

I don't know what Randy meant but I do think this legislation will effectively mandate an extra day so as to ward off potential malpractice suits.

 

As I understand it, the legislation language specifies that it does not require the additional day. It makes it an option. If, the doctor, in consultation with the patient deems it to be the prudent course of action so as to more effectively guarantee a positive outcome, this is the most important thing. Your idea that the purpose is to "ward off lawsuits" presupposes a poor outcome (which might be avoided by granting the additional medical supervision.)
Jack

 

The outcome may well be negative as the risk of infection is often greater in a hospital than at home. But the risk of lawsuit is minimized for the apparent giving of greatest medical care.

 

There are two criticisms I'd make of the above statement:
1) the term "best possible" should replace the word "greatest" as it emphasizes quality, not quantity.
2) the word "apparent" should be eliminated as it clearly is meant to suggest medical care is seemingly given but not actually given.
Beyond those criticisms your point is painfully obvious: Doctors and other medical professionals will minimize the risk of lawsuits by providing the best medical care possible.
Jack

 

This is the point where I speak up from the peanut gallery. Speaking as someone who has done malpractice defense/risk management for a living for the past twenty years, I can assure you that any proposed legislation mandating a minimum length of stay post mastectomy will have virtually no effect on malpractice claims related to mastectomies.

While breast cancer is a growth industry in the malpractice arena, just about all the cases have to do with a delayed or missed diagnosis, usually against a primary care physician or a radiologist. About the only few cases I am aware of related to the actual mastectomy surgery have to do with missing a diagnosis on a frozen section, thus requiring an unnecessarily extensive mastectomy (total vs. radical vs. lumpectomy). These cases are primarily against pathologists. In some rare cases, surgeons may have claims against them for not removing all positive lymph nodes during an axillary node dissection. Rarely do surgical complications happen during the mastectomy itself.

Length of stay as it is related to post-op complications is not even on the radar screen from the malpractice standpoint. So whatever arguments one may make for or against minimum length of stay legislation in mastectomies, reducing malpractice claims should not be one of them since there is no data I am aware of that supports this.

My observation based on twenty years of experience with health care providers of all levels is that most physicians are not particularly keen on the idea of non-clinically trained people mandating minimum or maximum length of stay. They rightly feel that this is an individualized clinical decision by the attending physician based primarily on the patient's condition and secondarily on the resources available to the patient. What the insurance will pay for, however, can be a whole other issue.

The juxtaposition of health care economics and medical ethics is a fascinating field.

Regards,

Michael Lloyd
Mill Creek, Washington USA