Moving quickly to quell a mounting controversy over another so-called "drive-through" procedure, the American Association of Health Plans last week declared that HMOs do not require mastectomies be performed on an outpatient basis.
"AAHP member plans believe decisions about a hospital stay for a mastectomy ought to be made by the physician in consultation with the patient," the group said.
The AAHP's stand is the result of a formal board action, which Susan Pisano, communications director, called "unprecedented." Usually AAHP policy is developed through a longer process, she said, but the need for clarification was urgent.
In releasing the AAHP board declaration last week, group officials said they were acting to pre-empt legislation that could mandate inpatient stays for mastectomy patients.
They acknowledged they were also reacting to a defeat earlier this year on a federal law mandating 48-hour hospital stays after normal childbirth. Such legislation could set a precedent for future mandates, such as requiring inpatient stays for mastectomy patients.
"What we could have done much better as an organization (in reacting to the 48-hour maternity-stay legislation) we are doing today," said Karen Ignagni, the AAHP's president and chief executive officer.
So-called "best-practice guidelines" adopted by some plans have been mischaracterized as "rules," Pisano said. A Wall Street Journal story earlier this month and a report on the "CBS Evening News" last week implied that HMOs denied physician requests for inpatient stays.
The guidelines suggest that some mastectomies can safely be performed without a hospital stay. Pisano said, however, "We don't know of any health plan that has ever required this procedure be done on an outpatient basis." Requiring a doctor to telephone the plan to attest that a hospital stay is medically necessary is not the same as ordering an outpatient procedure, she said.
An AAHP spokesman conceded that doctors may become resentful if it takes repeated telephone calls to get the approval. "Some plans may make it more difficult than others," he said.
The controversy erupted last summer in Connecticut when doctors charged that Cigna Healthcare and ConnectiCare were denying an overnight hospital stay for women who had undergone mastectomies unless doctors said the stay was "medically necessary." Connecticut legislators are planning to introduce bills requiring hospital stays for mastectomies.
In the "CBS Evening News" segment aired last Monday, medical reporter Bob Arnot, M.D., concluded by saying: "The biggest downside for many women is they are physically and psychologically traumatized by the procedure and then sent home frightened about the outcome without the reassurance of their doctors and the hospital staff."
Pisano said the facts presented in the CBS segment "didn't add up" to Arnot's sweeping conclusion.
Carol O'Brien, an attorney for the American Medical Association, said, "We have learned that this practice is not terribly widespread yet, but there is concern that it is a small but growing trend," and the AMA is monitoring the situation.
Some physicians have told the AMA that "some (mastectomy) patients do well on an outpatient basis," but the AMA is concerned about plans providing adequate home care, she said.
Cigna said in a written statement that some mastectomies "can be safely planned on an outpatient or same-day basis" where adequate home care is provided.
"Most modified radical mastectomies require a hospital stay," said Carolyn Yancey, M.D., medical director of Cigna Healthcare MidAtlantic in Baltimore. "During the first part of 1996, in fact, most Cigna Healthcare patients requiring a modified radical mastectomy stayed in the hospital for two to three days," she said.
In California, where medical groups typically take more financial risk and manage more of the care than on the East Coast, no HMO has made outpatient mastectomy a requirement, said Thomas Early, M.D., medical director of United Physicians of Santa Monica (Calif.), a 100-member IPA affiliated with Santa Monica-UCLA Medical Center. All mastectomy patients spend at least one night in the hospital, he said.