Key Consideration Is What’s Best For The Individual

Recent articles in the Wall Street Journal and The Spokesman-Review suggest that mastectomy patients are routinely denied hospital stays because of budgetary mandates from HMOs.

Knowing that Group Health Northwest has no such rule, I called several surgeons in town who deal with many different insurance plans, to see if any of these companies hold to this mandate.

We are very fortunate to live in a part of the country served by responsible and progressive HMOs. None of the plans that provide insurance coverage in this area denies overnight stays for this procedure.

However, there are women for whom an outpatient mastectomy is a legitimate medical option. There are benefits in getting the patient home, to comfortable surroundings. These include:

Adherence to patients’ general desire to go home as soon as possible.

Decreased time exposure to hospital bacteria.

Increased patient mobility at home, which aids in healing.

Enhanced emotional well-being.

Because of these benefits, the earliest discharge should be advocated if the right conditions make early discharge possible.

Although this surgery has serious emotional ramifications that should never be made light of or overlooked, a mastectomy is a generally successful procedure, one that results in few complications.

As the Wall Street Journal’s article reported, Milliman & Robertson, a health care research organization, has put forth guidelines regarding this procedure. The optimal recovery guideline for modified radical mastectomy has a length-of-stay goal of “ambulatory” - which means the goal is for patients to be able to return home once stabilized on the day of surgery.

M&R has analyzed many years’ worth of data on this particular surgery and follow-up outcomes. It subsequently created the optimal recovery guideline for physicians to use in managing patients who have no complications with the surgery. It’s worth remembering that most women who undergo this surgery do not experience clinical post-operative complications.

It is unfortunate that the article portrays M&R’s guidelines as a barrier to care, rather than as what they are - a tool to help physicians provide the right care at the right time and in the right setting.

This issue is far more complex than some sensationalized media reports would have the public believe. The length-of-hospital-stay decision is a very personal one, unique to each woman. Therefore, it must be arrived at on the basis of both the physician’s and patient’s perception of risk, by patient motivation, family resources, education prior to hospital admission and by the community home care resources involved.

The bottom line is that every woman must be respected as an individual.

There may be insurance companies in other parts of the country that have irresponsibly used the M&R guidelines as a mandate to refuse to pay for an overnight stay after a mastectomy. This tactic engenders outrage because it causes physicians and the public to lose control over the medical decision-making process.

It would be sad if, as a result, the media and legislators focus on mandating a minimum length of hospital stay. This will cause the most appropriate outpatient care - a successful surgery, with no complications - to be cast as the abnormal situation, and the longer hospital stay to be viewed as the norm.

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