No 'drive-by mastectomies'
Doctor says insurers still push for rapid discharges
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Dr. Agostino Cervone, at his Riverhead office, discussing the length of hospital stays for mastectomy patients.
While New York State law requires insurance companies to pay for a 48-hour hospital stay, there's still pressure to get women home as quickly as possible, according to Dr. Agostino Cervone, who performs such operations at both Peconic Bay Medical Center and Eastern Long Island Hospital.
Hospital social workers are required to review every inpatient daily and provide reasons why each should be allowed to continue her hospitalization or be discharged, Dr. Cervone said.
When he tells patients their hospital stays could be curtailed by insurance company requirements, the frequent answer is, "Don't worry. I've got good insurance." But many are surprised that even with "good insurance," they're being ushered out of the hospital sooner than they might feel ready to leave, he said.
Even in New York, women are typically released with drains in their bodies that have to remain for a week, Dr. Cervone said. Hospital workers, however, will arrange for a home care worker to check the drain and respond to any problems a patient may experience, he said.
"But I don't think it's for the insurance companies to determine," Dr. Cervone said about the length of a hospital stay for patients undergoing any procedures. He also objects to the many hours he and his staff have to devote to dealing with insurers to try to provide "the best care for patients."
UnitedHealthcare doesn't conduct medical necessity reviews and issue denials in evaluating either procedures or length of hospital stays, she said. The company uses Millman Care Guidelines that are "an accepted set of well-referenced guidelines" for making decisions about hospital stays, she said. Those are superseded by federal and state mandates, she said.
In years past, a patient who detected a lump in her breast would routinely have it excised, Dr. Cervone said. Today, some insurance companies will try to avoid that step unless they are convinced that the lump is malignant. And when the doctor wants an MRI, insurance company personnel will generally balk and pay only for an ultrasound, he said.
UnitedHealthcare doesn't require physicians to obtain prior approval before handling breast biopsies, Ms. McElrath-Jones said.
Dr. Cervone said he has to have someone in his Riverhead office following up on collections from insurance companies and estimates it takes between three and six months before he gets paid.
"This is the only profession that operates this way," Dr. Cervone said. If you take your car to a mechanic, he said, "you're not going to be driving" until you pay the bill.
System upgrades caused delays in paying claims in the past, Ms. McElrath-Jones said. But currently, she said, the insurer pays 20 million claims a month and 95 percent are paid within 10 days of receipt.
At the same time, there are patients who demand outpatient mastectomies. In those cases, Dr. Cervone said, it's up to him to judge the adequacy of the woman's support system at home and ability to cope. One of his patients, who had undergone a previous mastectomy and had a daughter at home able to care for her, was approved as an outpatient because she clearly knew what she would experience and could handle it, he said.
Today, because of updated operating procedures, there's often not a lot of "post-operative discomfort" for mastectomy patients, Dr. Cervone said. Former procedures required taking muscle and incisions were much larger, he said. The less aggressive surgeries today are easier on the patient, he said.
The doctor also sees a change in attitude among mastectomy patients today. In past years, older women felt they were losing their femininity if they had to lose a breast. Younger women today don't seem to have that psychological approach to the surgery, Dr. Cervone said. More than a few who could have positive results with a lumpectomy opt for the more radical mastectomy, fearing a resurgence of cancer, he said. And today, many opt for plastic surgery to replace the breast, something that wasn't as true in the past, he said.
If there's going to be post-operative pain after a mastectomy, it's likely to result from the presence of the drain, Dr. Cervone said. Otherwise, patients report feeling a tightness and numbness in the area where the breast was. To prevent infection, patients generally receive antibiotics while the drain is still in use. But concerns about overuse of antibiotics has many doctors trying to avoid them, he said.
While Dr. Cervone thinks that the advanced techniques do make it possible for patients to be released from hospitals sooner and that they benefit from not being exposed to acquiring infections in the hospital, he also would like a stronger lobbying effort to ensure that he and other doctors can render the best care possible.
Between increased costs of dealing with insurers and higher malpractice insurance rates, more doctors are opting to be "hospitalists" rather than to maintain their own practices and others are retiring earlier, he said. Those who remain in practice have higher patient loads. A secretary in his office said there are days when Dr. Cervone sees as many as 50 patients.
"At some point, there has to be a breaking point where something has to give," Dr. Cervone said.
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