ANNAPOLIS – Women who go to major Maryland hospitals for mastectomies can expect to stay just one night — a stay that in some cases is 75 percent shorter than it was just three years ago.
While Maryland doctors say the shorter stay isn’t adversely affecting the women’s recoveries, some breast cancer advocates say the shorter stay is not appropriate for all women.
According to a Capital News Service analysis of Department of Health and Mental Hygiene data, women three years ago remained in the hospital as many as 4.56 days. Today, women stay as little as 1.14 days. CNS reviewed data on 25 Maryland hospitals that performed 15 or more mastectomies.
In response to what he called a growing trend of “drive-through mastectomies,” Gov. Parris N. Glendening introduced a bill in this year’s General Assembly session that included a provision mandating insurance companies cover a minimum 48-hour stay for mastectomy and testicle removal patients.
But House members, saying length-of-stay decisions should be made by the patient and physician and that such mandates increase costs, rejected the idea.
The final compromise, in a bill signed April 27, requires insurance companies to pay for a home health care provider visit if the patient is released earlier than 48 hours after surgery. The home visit must take place within 24 hours of release; a second visit would be covered if approved by a physician.
While Glendening said he was satisfied with the alternative, breast cancer advocates disapproved.
“I don’t think this is a good compromise,” said Annette Drummond, a breast cancer survivor and board member of Arm-in-Arm, a Baltimore-area breast cancer support group with 500 members. “In some cases a home visit will not be sufficient after a mastectomy.”
Home visits are helpful for elderly women and women with no family at home, Drummond said, but a hospital stay is more appropriate for women who experience pain or need help with a post-mastectomy drainage device. The group, along with the American Cancer Society Mid-Atlantic division, also believes length-of-stay decisions should be left up to women and their physicians.
Among the 25 Maryland hospitals reviewed, the biggest drops in average length of stay from 1995 to 1997 were seen at Good Samaritan Hospital, from 4.56 days to 2.13 days, a 53 percent decrease; Washington County Hospital, 4.06 to 1.96 days, a 52 percent decrease; and Frederick Memorial Hospital, 3.05 to 1.64 days, a 46 percent decrease. These figures include women who have undergone total simple mastectomies and modified radical mastectomies.
Women receiving partial mastectomies also may expect a one-night stay. Average stays for this procedure have declined from about 1.56 to 1.00 days. Mercy Medical Center in Baltimore reported the largest drop, from 2.55 days in 1995 to 1.07 days in 1997.
Hospitals defend the shorter stays by citing improved surgery, changes in anesthesia techniques and better anti-nausea drugs. They also point to another factor — insurance companies that are unwilling to pay for additional overnight stays.
Dr. Neil B. Friedman, a breast-care surgeon for the Breast Center at Mercy Medical, lamented that insurance companies are making it a “battle” for hospitals that want a woman to stay for more than 24 hours.
“Insurance companies are a real pain in the ass to deal with,” Friedman said. “Why do I have to justify to (insurers) why a woman has to stay in the hospital? The hoops they make us go through are unbelievable.”
Most women, Friedman explained, are well enough to go home after a one- night stay, but there are a few cases — 1 to 2 percent — where they are not ready to leave.
He gave one example of a 70-year-old woman who had a mastectomy and asked for an extra night stay. She had no medical problems, but wasn’t emotionally prepared to go home. Without a medical reason, the insurance company wouldn’t pick up the tab for an extra night, he explained. In the end, the woman was allowed to stay because of her age and grief.
Dr. Thomas Barsanti, a medical director for CareFirst BlueCross BlueShield, said he is aware of the backlash against insurance companies by physicians and hospitals, but pointed out that there are no “hard and fast rules” followed for mastectomies or any other medical condition.
Carefirst’s guidelines allow for a two-night stay for simple mastectomies, three days for mastectomies that involve certain transplant reconstruction and four nights if vascular surgery is performed.
“If a woman does not recover as expected and still requires in-patient services, then we will see if quality care is being administered and authorize it,” Barsanti said.
Medical reasons for authorization include adverse reactions to anesthesia, pain, immobility, and other physical and emotional problems.
“I can’t remember having to do any denials for any stage of mastectomy,” within the last year, Barsanti said. Which, he said, “tells me that the system is working well.”
Friedman could not specify an exact number of insurance denials for extra stays at Mercy, but said the amount is small.
Despite his conflict with insurers, Friedman said most women don’t need an extra night stay in the hospital, which he adds, does not cause “undue harm to patients.”
“A majority of my patients go home the next day and are fine. I’m not shoving my patients out the door, and they don’t feel that way. They go home and recover physically and emotionally with their families and not with strangers in a hospital,” he said.
Salvatore J. DeMarco, III, chairman of the Department of Surgery for Good Samaritan Hospital, said the sharp decline in his hospital’s length of stay is due to a combination of medical strides, insurance guidelines and patient education.
At Good Samaritan, Mercy Medical and various other hospitals, women get an educational session before and after the mastectomy, so they know what to expect. Topics covered range from what the surgery will entail to how to care for the breast after the surgery.
Families are encouraged to attend the sessions. The hospital also arranges home health visits for mastectomy patients who are elderly or don’t have family to care for them. Home visits also are arranged by Mercy and other hospitals.
Most women recover quickly and are discharged after one night at Good Samaritan. If problems arise, however, patients are kept at the hospital, even if an insurance company denies a second-day stay, DeMarco said.
“If an insurance company denies them, it’s not like patients are dumped out the door sick and sent home,” he said. “The hospital keeps them, absorbs the costs and suffers monetarily for it.”
But not all hospitals have the budget to keep patients.
Dr. Richard Damewood, a member of the Comprehensive Breast Center at Greater Baltimore Medical Center, said his greatest complaint is that insurance restrictions are preventing physicians from practicing “humanitarian medicine.” Greater Baltimore experienced a 26 percent decrease in mastectomy length of stay, from 2.54 days in 1995 to 1.89 days in 1997.
“I’ve had to gently tell women there is no medical reason for them to stay. In these scenarios, the patient ends up leaving,” he said. “But if a woman is in tears and begs not to go home, we will keep that patient,” he said.