There's an interesting philosophic debate being played out in a lawsuit in New Jersey over an insurance companies refusal to pay for a patients breast reconstruction surgery. You can read the news wire story here.
Short Version: Patient has double mastectomies with saline implant reconstruction almost 15 years ago. One of her implants deflates, and her insurance company is refusing to now pay for a conversion to a reconstructive procedure using her own tissue.
Replacement of her implants with either saline or silicone implants (which they would agree to cover) would be able to be performed quickly and done as an outpatient surgery with little morbidity. The type of surgery she wishes to have covered, a DIEP flap (deep inferior epigastric artery perforator) is a complex microsurgical procedure (where tissue from her abdomen is transferred to her chest wall) which would involve a long, expensive operation and a number of days in the hospital.
Last fall I profiled a case in People magazine where such a DIEP flap was performed on identical twin sisters, with one twin's abdominal tissue transferred to the other's breast. You can see that story here "Breast Reconstruction Using Your Twin."
What are the issues involved with this as I see it:
1. Should breast reconstruction after mastectomy be covered?
Well that issue was settled a number of years ago via federal legislation, the Women's Health and Cancer Act (WHCA) of 1998, ensuring that reconstruction was a mandatory obligation of insurers.
2. Should all types of reconstructive surgery be covered?
Again, that's part and parcel of the WHCA, which includes reconstruction after mastectomy for benign disease, usually done for painful cystic breast tissue.
3. In a scenario like the one involved here, should someone have the right to demand complex and expensive surgery when less expensive options are available?
I'm conflicted here. It does not seem completely outrageous to me for this company to deny this request or at least ask the patient to pay part of the balance difference given the particulars as I understand them. She had an acceptable reconstruction with implants, and needs a quick & relatively inexpensive surgery to maintain her result.
In other countries with state-funded ("universal") health care programs, I suspect there's no way in hell this would be approved. In an era of cost-containment, all health care costs are going to be scrutinized and there will be hard choices to make. Luxuries like exotic breast reconstruction almost two decades after the initial surgery seem hard to justify in that context.
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16 comments:
shd patients even sue surgeons over a supposed undesirable outcome of elective surgery?
should this boil down to doctor patient communication, professional competence, etc?
I can see why she wanted the DIEP flap surgery: she won't have to worry about leakage in the future, and most likely got a tummy-tuck effect from the procedure as well.
But after reading the article, the insurance company denied the procedure twice before she had it. I agree with you that it would be nice for the insurance company to cover the amount of the implant only surgery, then have her pay the difference between the implant and fancier surgery.
S
This is a really tough call. As a breast cancer survivor who had a double mastectomy, I understand how important reconstruction is. At the same time, I don't think insurance companies should have to pay for procedures or other things that are extravagant or unnecessary.
Example: most insurance companies will pay for wigs when a person goes through chemo. Now you can get a wig for as cheap as $15 and as expensive as $3000. Is it fair to say the insurance company has to pay for any wig regardless of the price? I don't think they should have to. I also don't think they should only provide the absolute minimum either. Something in between seems the most reasonable and fair to all parties.
So back to reconstruction: I don't blame the woman for wanting something different than what she had. Saline implants are the LEAST breast-like and natural. In my opinion they are the equivalent of the $15 wig. But was DIEP her only other alternative? Not at all. Dr. Oliver, correct me if I'm wrong but DIEP is one of the most expensive because it requires microsurgery. Even other types of tissue transfers are not as expensive - is that right? So maybe the insurance company could have paid the amount for a lesser-expensive tissue transfer surgery and let her pay the difference. I feel she deserved to have something better than the saline, but a DIEP in someone who has not had radiation and where a flap surgery is not necessary, well, I'm not so sure insurance should have to pay for that.
Implants aren't for everyone: they can leak, deflat, and need to be replaced later on. Also, using an implant for a single mastectomy will always have an asymetrical result, whereas flap proceedures can give a much better cosmetic result.
But I'm told that the real reason major facilities do free flap reconstructions is to train surgeons for more complicated microsurgeries such as reattaching fingers. Without using breast reconstruction as "training," how will surgeons be able to train for surgeries that have no alternatives?
Presumably, after the DIEP flap, she would have a stable result, and no further procedures in future, if it were to be a success. OTOH, with the implant option, she's got future implant replacement, capsule issues, etc. to worry about.
I wonder what the average total lifetime cost of the implant pathway is, compared to the autologous reconstruction pathway.
The next generation implant - the "gummy bear" implant - can't leak because there isn't any liquid. And because it's a soft solid, it can't deflate either. Now I know that after all the silicone hooplah and lawsuits, implant manufacturers won't call ANY implant a lifetime device. But I have to wonder, why would you ever need to replace a gummy bear implant? Any thoughts on that, Dr. O.? I realize these are not available to the general public yet, but they are available through clinical trial. (And from what I understand, they may be approved in the not-to-distant future.) Given this, you could say that the replacement argument doesn't hold water. (Just spewing thoughts and playing devil's advocate here - I don't necessarily agree with that.)
Also, it seems insurance companies only care about what something is going to cost them NOW. They don't seem to care what the lifetime cost will be. If they did they would pay for laser eye surgeries - the cost of glasses and/or contacts over a lifetime FAR exceeds the few thousand dollars for eye surgery. A different scenario, I know, but I think it correlates to why they would rather pay for implants than tissue recon.
sorry all this is totally unrelated:
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This is a waste of health care dollars. In these rare moments, I long for socialized medicine. As a woman,I want to sympathize but it is totally irrational.
Why not get the Gummy Bear silicone type implants?
The form-stable ("gummy bear") gel implants do change the calculus somewhat. It certainly appears that the lifespan of those kind of devices is indefinite, but our track record of long-term forecasts on how long an implant lasts has been spotty.
It's really only been in the last few years we've been able to point to good data on rupture rates for contemporary devices (not including the gummy bears) at a little under 10% at a decade. My impression of the pending devices is that the only way they fracture (as they don't really rupture per se) is from trauma during the insertion.
It is really amazing (but not surprising) that the FDA has been so slow on this, as Inamed's 410 implant BLOWS AWAY every index of performance and safety data on existing devices. The implant activistas have been successful in making this issue radioactive enough that the beurocracy is moving very,very slowly in acting on their application for wide-spread use.
So the DIEP flap surgery is "exotic" now? Wow, who knew?
Dr. Oliver, I think you (ONCE AGAIN) fail to see things from the patient's perspective. You have an obvious bias towards Plastic Surgeons and what benefits them most and are also slanted towards big corporations. This is not what makes a well rounded surgeon. A doctor who has the ability to put him/herself in the shoes of a patient has that rare quality that is lacking in so many.
Anon,
Exotic meaning "not widely performed" is a pretty accurate descriptor of DIEP flaps or even microsurical free TRAM flaps. It's a very small % of practicing surgeons doing that kind of microsurgery.
I'm not making a professional or moral judgement about this kind of surgery (it's a very elegant procedure), but I'm pointing out the real world implications of a case like this.
Large health care expenditures don't happen in a vacuum, they ripple thru the system. When you're confronted with this, you'll have to make some decisions about what's a sustainable practice and what's not. If it comes down to affording vaccines or mammograms versus the luxury of super-complex and expensive breast reconstruction (when acceptable alternatives exist), I can tell how the population at large is going to vote.
Implants after bilateral mastectomy give great cosmetic results. But putting in an implant after a single mastectomy will always results in asymmetry, because implants only come in a few sizes and will never be the same shape as the other natural breast.
Although I think Dr. Oliver is a very caring physician, I wonder if he really appreciates the psychological distress that asymmetry after mastectomy can cause.
I am going to have a second mastectomy in order to to correct my asymmetry. I don't want to do this surgery, but feel that it's my only choice. I'm only 40 years old - why is it OK for me to look like a freak the rest of my life? To save insurance companies some money? For this I should be offered a generic implant rather than a surgery that would make me look normal? To save money, I should be reminded that I have cancer every time I look in the mirror???
Anon,
In a perfect world where cost was no object and we didn't live under budgets I'd echo your sentiment. Unfortunately we do, and if you read the writing on the wall, we're headed towards signifigant restrictions on our health care choices as we move inevitably towards a single-payer system.
I only highlighted this topic as the economics of healthcare are interesting to me. If someone wants a DIEP flap, I encourage that as autologous tissue ages better, particularly on unilateral reconstructions (as you point out). However, the specifics of this lawsuit become a little muddy as essentially this is a cosmetic issue masquerading as a patient's rights issue. At some point (as a society) you've got to say enough
If you are going to go down the cosmetic surgery road...check out www.thepatientsadvantage.com. What I liked the most was that my profile remained anynomyous until I was ready to decide what to do. I received replies from four surgeons that met all the things I was looking for. I liked having that complete control without the sales pressure that some of these places can be known for. Check them out. Better to be safe than sorry.
I would like to post my comment about this discussion....I had the twin to twin diep flap surgery done in 2006. This was not my first choice in breast reconstruction. I tried to do the conventional surgery with expanders, but they became infected and I lost them. I could not do trams because of a prior surgery. My sister, who is closer to me than just about anyone on the planet....offered to be a donor. This sounded crazy to me at first...but...we actually found a doctor who had done this in the past...what where the chances??? As I see it; it is hard to make judgements against someone unless you yourself have walked a mile in their shoes.
I would like to comment on this discussion. I had the twin to twin surgery in 2006. This was not my initial choice in reconstruction. I tried the least invasive surgery by using expanders but they failed me miserably...capsular contraction and infection...I lost them both. I wasn't a candidate for tram flap surgery because of a prior surgery. Well...you can read the story. My sister, who is the closest person to me on the planet, offered to be a doner...which I thought was crazy in the beginning, but, we researched the idea and we actually found a doctor who had done this sort of thing in the past...what were the chances??? All I can say is...it is hard to judge what other people do unless you yourself have walked a mile in their shoes. You can't put a price tag on everything!!!
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