Magazine article Medical Economics

How One Physician Can Make a Difference

Magazine article Medical Economics

How One Physician Can Make a Difference

Article excerpt

When the drive-through mastectomy becomes a thing of the past, this surgeon will be the main reason.

At 5:45 a.m. on April 9, 1996, a nurse awakened Sharon Faucher in her hospital bed in New Britain, Conn., and told her that she had 15 minutes to leave. Faucher had checked in 23 hours prior and undergone a mastectomy that day, but her insurance wouldn't cover an overnight hospital stay, defined as 24 hours.

Overwhelmed with pain and exhaustion, Faucher, the mother of a 10-year-old daughter, was shuttled away in tears, with two drains still hanging from the incision area. On the way home, she vomited three times. Worse, her only nursing care would come from her husband; she'd be without professional help.

The so-called drive-through mastectomy has been on the rise. In 1991, only 1.6 percent of mastectomies performed in the U.S. were done on an outpatient basis, but by 1995 this figure had increased almost fivefold, to 7.6 percent.

Kristen Zarfos, a surgeon in Middletown, Conn., had been viewing the drive-through mastectomy trend with growing alarm. Then, in May 1996, she was told that two major HMOs in her state-MD Health Plan and ConnectiCare-intended to adopt new coverage guidelines suggesting that even modified radical breast surgery could be done on an outpatient basis. A third large HMO, Cigna HealthCare of Connecticut, had already embraced those guidelines, which were written by clinicians at the Seattlebased consulting actuarial firm Milliman & Robertson.

At the time, none of Zarfos's mastectomy patients had been denied an overnight hospital stay, but she expected more HMOs to jump on the drive-through bandwagon. Unless something was done, she reasoned, outpatient mastectomies and lymph-node dissections would become commonplace in Connecticut, where HMO penetration is already about 40 percent.

Although Zarfos knew that protesting the insurance guidelines would make her a prime candidate for HMO "deselection," she felt that proceeding was a matter of professional ethics. "Every physician has a limit to what she will tolerate, and this was mine," she says. "I've given in on some types of care, but I couldn't believe the HMOs would have the audacity to antagonize women who have breast cancer, with all the pain and the incredible emotional and psychological aspects of this complex disease."

To buttress her case, Zarfos sent a letter to 225 women she had treated for breast cancer, asking how they felt about the Milliman & Robertson guidelines and whether being hospitalized after surgery had helped in their recovery. She left a large space for comments, and enclosed a self-addressed envelope.

Her colleagues who knew about the mailing showed little interest, and initially Zarfos was unsure whether patients would show much either. So she was astonished to find that within just three days she had more than 100 responses. "People poured out their hearts," she says. "I was speechless at the degree of anger and outrage patients expressed. Some of their comments brought me to tears."

In the political arena, the surgeon finds many allies

Convinced she had to do something but uncertain where to turn, Zarfos consulted a colleague who gave her some names at the U.S. Department of Health and Human Services. Her first efforts, however, were more frustrating than productive. "Everyone I called referred me to someone else, who referred me to someone else, and it led nowhere," she says. Trying a new tack, she sent letters to eight HMOs in Connecticut, inquiring about their length-of-stay policies for mastectomies and lymph-node dissections, and whether they used the Milliman & Robertson guidelines. MD Health Plan was noncommittal and five HMOs said they didn't follow the new guidelines, but Cigna and ConnectiCare acknowledged that they did.

With this written confirmation in hand, Zarfos approached U.S. Rep. Rosa DeLauro, a Connecticut Democrat with a strong interest in health-care issues, and a survivor of ovarian cancer. …

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