Friday, May 06, 2011

In office breast cancer surgery, just a matter of time?

This is kind of a post I've been sitting on for about 7-8 months that I though would be kind of interesting. Last Fall there was an article in a New York business magazine about a small trend in some breast cancer surgeries being performed in plastic surgeon's offices in Manhattan. The article, "Mastectomies check out of the hospital" describes this phenomena and I found this quote interesting,

"Dr. Evan Garfein of Montefiore Medical Center was the driving force behind the new state law requiring that patients be informed of their surgical options. The breast surgeon says his effort was meant to correct a disparity: Poor minority women are less likely to get reconstructions because they often aren't told that federal law requires their insurers to cover the procedure.

But Dr. Garfein says he never thought the law's passage might drive a boom in office-based breast cancer surgery.“With the right doctor and the right patient, reconstruction can be safely done in an office,” he says. But not a mastectomy. “To me, that's the type of operation that should happen in a hospital.”

Dr. Garfein questions the motivation of plastic surgeons offering such procedures. The specialty has been hit hard by a drop in business during the recession. “When you look at the economics, you know that if a plastic surgeon owns his own operating room, it's [financially] better for him to do the surgery there,” Dr. Garfein says. “You have to ask, 'Why is this being done?' If there's a trend like this, it should be because patients are demanding it. Plastic surgeons shouldn't be driving a trend to get patients out of hospitals.” "

As someone with an interest in office based surgery, I found Dr. Garfein's comments kind of puzzling. Our office is equipped with a large hospital-grade operating room and is accredited for surgery by one of the same groups that reviews hospital and free-standing ambulatory surgery centers (ASC). We routinely do operations significantly longer and more difficult then breast cancer surgery (which is neither particularly long or difficult in most instances) at 1/2 the cost of the hospital with an infection rate close to 0% (our's is actually zero for over the 2 1/2 years we've been up and running). While there's a selection bias in outpatient surgery candidates towards younger, healthier patients there are many,many breast cancer procedures (both tumor removal and reconstruction procedures) we could absolutely do safely if we choose to.

The big hold up here in Alabama is the dysfunctional Certificate of Need (CON) process and the reluctance of insurance carriers to upset the hospitals (who would lose some cases).  State's with CON's are essentially franchise cartels that try and protect their exclusivity of where surgery can be performed. Predictably, CON  states become a political quagmire of competing hospital systems suing each other to prevent the other from outmaneuvering their business model. In Birmingham we currently have 4 hospital systems in court trying to prevent the state CON board from either allowing a hospital to move from one area to another in town (see here) or building new hospitals in attractive demographic areas where none exists nearby. As a direct result of the CON fights here, we actually have a former Democratic golden boy and governor, Don Sielgelman,  sitting in federal prison for taking bribes to appoint a requested person to the CON board (that's a post for another day).

In an era where we're pinching pennies to come up with cheaper ways to deliver care, it's mind boggling to dismiss a simple (and safe) way to do many procedures. I take issue with Dr. Garfein's suggestion that it's a financial incentive on the surgeon's part as if you actually expense running an office OR like an accountant would, it's likely a break even proposition (at best) with better paying insurance companies and likely in the red for Medicare and other low-paying insurers. While it's certainly helpful to 1) my efficiency and 2) the patient's experience (as they much prefer the office to the hospital), the main beneficiary in all that is the system which is likely to see equal or better outcomes at reduced cost. What's not to like?