Medicare Bars Limits on Stays for Mastectomy

The federal Medicare program has ordered doctors, hospitals and insurers not to limit the number of days a woman may remain in a hospital after a mastectomy or to require that the surgery be performed on an outpatient basis.

Because Medicare pays for one-third of all mastectomies, the order by the Health Care Financing Administration is likely to have a major impact on the way private insurers and health maintenance organizations handle the issue.

Controversy has arisen over cases in which mastectomies and other surgeries for breast cancer were performed on an outpatient basis, with women being sent home within a few hours. There is growing support in Congress for legislation that would guarantee women the option of staying in a hospital for 48 hours after mastectomy surgery.

About 250,000 mastectomies were performed in the country last year.

Notification of the mastectomy policy has just been mailed to health providers participating in the Medicare system, Bruce Merlin Fried, an official of the health-care financing agency, told a congressional hearing Thursday. The far-reaching policy affects the vast majority of Medicare beneficiaries, the 87% who are in the traditional fee-for-service system, under which patients may choose virtually any doctor or hospital.

Fried’s disclosure means that Medicare has gone beyond its action last month, when it notified HMOs, which cover 13% of Medicare beneficiaries, that they could not impose arbitrary limits on the length of hospital stays for mastectomy patients.

The policy forbidding restrictions on length of stay now provides added protections to all 21.6 million women enrolled in the Medicare program, which covers people over 65 and the disabled of all ages.

“The decisions about what is medically necessary should be made by a woman and her doctor,” Fried told the Senate Labor and Human Resources Committee.

Medicare patients “who receive mastectomies are entitled to coverage for all medically necessary care,” he said.

Medicare is responding to widespread concern over the issue, Fried told the hearing. “The national attention given to coverage of mastectomies indicates there is a need for greater oversight,” he said.

“Patients should be given the right to choose the kind of care they want,” said Dr. Ronald E. Iverson, president of the Society of Plastic and Reconstructive Surgeons, who said that he believes legislation ensuring patients the choice of staying in the hospital as long as 48 hours after surgery would be “reasonable.”

“The best thing is for the patient and physician to have a choice,” the Pleasanton, Calif., surgeon said in a telephone interview.

The appropriate length of stay depends on the individual patient and the surgery, Iverson said, adding, “There are times when it is fine” for someone to go home without staying overnight in the hospital.

The American Assn. of Health Plans, the HMO industry’s trade group, has issued a formal policy statement opposing any restrictions. “Decisions about the length of stay should be made by physicians in consultations with the patients themselves,” said Susan Pisano, a spokeswoman for the group.

The issue had been perceived mistakenly as a problem particular to HMOs or other forms of managed care, said Pisano. However, she noted, a review of 74 out-patient mastectomies under the Medicare program in New York state showed 72 of them were performed by doctors working in the traditional fee-for-service arrangement.

Thursday’s hearing was devoted to the subject of assuring quality care while protecting consumers.

The day’s final witness, Peter M. Berman, said delays by a physicians’ group and the Health Net HMO in treating his wife Renee for cancer “may cost my wife her life.”

After initial surgery, there was no follow-up care, chemotherapy was delayed and an oncologist refused to authorize further surgery, Berman said. HMO’s “are set up to bribe and threaten doctors into withholding expensive treatments,” added Berman, who is suing Health Net.

His wife is undergoing experimental drug treatment for the cancer, which has spread from her colon to her brain, ribs, spine and pelvis.

Health Net “made every effort to do our job,” said David Olson, vice president for investor and public relations at the Woodland Hills-based HMO.

“We feel very strongly for the Berman family,” he said. “Unfortunately, this case has become the subject of a legal action which limits my ability to comment. We’ve made every effort to see to it that all the necessary treatment was provided and provided in a timely fashion.”