Published in the San Francisco Chronicle, March 7, 1997, page A1.

Because Medicare pays for one-third of all mastectomies, the order by the Health Care Financing Administration is likely to have a major impact on the way private insurers and health maintenance organizations handle the issue.

Controversy has arisen over cases where mastectomies and other surgeries for breast cancer were performed on an outpatient basis, with women being sent home within a few hours. There is growing support in Congress for legislation that would guarantee women a choice of staying 48 hours in the hospital after the surgery.

Notification of the mastectomy policy has just been mailed to health providers participating in the Medicare system, Health Care Financing Administration official Bruce Martin Fried told a congressional hearing yesterday. The far-reaching policy affects the vast majority of Medicare beneficiaries, the 87 percent who are in the traditional fee-for-service system, under which patients can choose virtually any doctor or hospital.

Fried's disclosure means Medicare has gone beyond its action last month, when it notified HMOs, which cover 13 percent of Medicare beneficiaries, that they could not impose arbitrary limits on the length of hospital stays for mastectomy patients.

The policy forbidding restrictions on length of stay now provides added protections to all 21.6 million women enrolled in the Medicare program, which covers people over 65 and the disabled of all ages.

"The decisions about what is medically necessary should be made by a woman and her doctor," Fried told the Senate Labor Committee.

Medicare patients "who receive mastectomies are entitled to coverage for all medically necessary care," he said.

Medicare is responding to widespread concern over the issue, Fried told the hearing. "The national attention given to coverage of mastectomies indicates there is a need for greater oversight," he said.

"Patients should be given the right to choose the kind of care they want," said Dr. Ronald E. Iverson, president of the Society of Plastic and Reconstructive Surgeons, who believes legislation ensuring patients the choice of staying up to 48 hours after surgery would be "reasonable."

"The best thing is for the patient and the physician to have a choice," the surgeon, who is from Pleasanton, said in a telephone interview.

The appropriate length of stay depends on the individual patient and the surgery, Iverson said, adding, "There are times when it is fine" for someone to go home without staying overnight in the hospital.

The HMO industry's trade group, the American Association of Health Plans, has issued a formal policy statement opposing any restrictions. "Decisions about the length of stay should be made by physicians in consultations with the patients themselves," said Susan Pisano, a spokeswoman for the group.

The issue has been perceived mistakenly as a problem particular to HMOs or other forms of managed care, said Pisano. However, she noted that a review of 74 outpatient mastectomies under the Medicare program in New York state shows that 72 percent were performed by doctors working in the traditional fee-for-service arrangement.

Yesterday's hearing was devoted to the subject of assuring quality care while protecting consumers. "We need a health system that encourages competition based on quality, not just on price," said Senator James Jeffords, R-Vt., the committee chairman.

The day's final witness, Peter M. Berman, said delays by a physicians' group and the Health Net HMO in treating his wife, Renee, for cancer "may cost my wife her life."

After her initial surgery, there was no follow-up care, chemotherapy was delayed, and an oncologist refused to authorize further surgery, Berman said. HMOs "are set up to bribe and threaten doctors into withholding expensive treatments," said Berman, who is suing Health Net.

His wife is undergoing experimental drug treatment for the cancer, which has spread from her colon to her brain, ribs, spine and pelvis.

Health Net "made every effort to do our job," said David Olson, vice president for investor and public relations at the Woodland Hills, Calif.-based HMO.

"We feel very strongly for the Berman family," Olson said. "Unfortunately, this case has become the subject of a legal action which limits my ability to comment. We've made every effort to see to it that all the necessary treatment was provided and provided in a timely fashion."