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JIM LEHRER: Now another in our continuing series of reports on how American health care is changing. Tonight: cutting the length of hospital stays. Lee Hochberg of Oregon Public Broadcasting reports.
LEE HOCHBERG: Carolie Graddon could be a walking advertisement for today’s new cost-conscious medicine. Last August she had a mastectomy, the removal of a breast to excise cancer cells. She went home only an hour after the surgery ended, pain pills in hand, tubes running from her body, blood still draining from the surgery.
CAROLIE GRADDON, Mastectomy Patient: After hearing three doctors say, “You’ll be out of there in three hours,” I figured, well, they must know what they’re talking about.
LEE HOCHBERG: She recuperated just fine at home and eliminated a $1,000 per night hospital cost. Graddon says, though she was a bit woozy when she left the hospital, she was glad to return home to the care of her boyfriend and her daughters.
CAROLIE GRADDON: I might be offended by the push to get women out, but I have gone through it, and I agree, they’re right. You don’t need to be in the hospital. I’ve had root canals that were worse than this, frankly.
LEE HOCHBERG: Women used to stay five nights in the hospital. Today, most stay at least one night, but some cost-conscious health insurers are requiring the procedure be done on an outpatient basis, in by 9, out by 1. Fifteen thousand women got their mastectomies that way last year. Although that’s only 9 percent of the number of women who had mastectomies, it’s a trend that chills Seattle breast surgeon Diane Jones. She says many are being forced out the door before they’re ready.
DR. DIANE JONES, Breast Surgeon: They need the day in the hospital. I have sent patients home that I thought were well prepared to go home who did not understand some of the things they were supposed to do at home and came back three days later infected, with wounds falling apart, with bandages completely inappropriately applied, because we thought they were prepared, and they were not.
RENEE KIMBALL, Mastectomy Patient: To go back into what was happening the first day that I came home is like going back into hell–to feel out of control of your whole life.
LEE HOCHBERG: Portland resident Renee Kimball says her release–only 22 hours after a mastectomy–was a horrible experience. She had been diagnosed with breast cancer only three days earlier.
RENEE KIMBALL: If I had stayed in the hospital, I would have had an adjustment period of–of having people around who could say to me, it’s okay, everything is going to be okay; I’ve seen other women go through this, you’re going to be fine. And you don’t have any of that when you come home and you’re by yourself. You’re alone, and all you can think about is the fact that you’re going to die.
LEE HOCHBERG: Kimball had no insurance, so the decision to go home early was between her and her doctor. She now thinks she made a mistake.
RENEE KIMBALL: Had I to do it over again, damn the cost, I would have stayed in, because I didn’t know–I didn’t know anything. I didn’t know where I was. I didn’t know who I was. And so on top of all this you just had a major part of your body removed.
DR. DIANE JONES: She needs to get watched daily. She needs to clean her wounds. Where do you do that? You know, how do you do that? If you can’t stand to look at your chest because you have no breast and it’s ugly, how do you change your bandages? How do you look at it and tell me if the wound is infected?
LEE HOCHBERG: Insurers who order outpatient mastectomies often are following the advice of a Seattle-based consulting firm, Miliman & Robertson.
DR. DICK LILLIDAHL, Insurance Industry Consultant: What we’re saying with this guideline for mastectomy modified radical, this patient could have a mastectomy in an outpatient setting.
LEE HOCHBERG: And be sent home.
DR. DICK LILLIDAHL: And be sent home, discharged the same day as the surgery.
LEE HOCHBERG: The insurance industry hired the firm to research the most efficient, least expensive ways to do medical procedures. The firm developed these guidelines: goals for how medicine can be done in the best case scenarios. They conclude mastectomy patients should be ambulatory–that means, treated as outpatients. Consultant Dr. Dick Lillidahl.
DR. DICK LILLIDAHL: Yes, these patients can be managed safely as outpatients, and we see it being done all over the United States.
LEE HOCHBERG: Lillidahl says problems occur only when health plans rigidly apply the best case guidelines to more complicated cases. He says, with appropriate at-home health care and emotional support, there’s no reason for most patients to stay in hospitals. In fact, he insists hospital stays have a downside. Infections can occur; medicines can be given in error; and costs can exceed $1,000 a day. And most patients, he says, would rather be home anyway.
DR. DICK LILLIDAHL: We’ve seen it being done. I’ve managed patients who have been cared for that way. My wife had a lumpectomy in December for breast cancer and went home the same day. And I cared for her, and those people fared very well.
DR. DIANE JONES: Now, that’s self-serving to say that my wife went home. Certainly she did. He knew what he was doing. I don’t think that’s true of most of our patients.
LEE HOCHBERG: Some doctors, concerned that insurers are forcing their patients out of the hospital too soon, are trying to at least keep them nearby. In Portland, the American Cancer Society helps doctors find area motel rooms, where mastectomy patients can heal. Cancer Society’s Renata Stiles.
RENATA STILES, American Cancer Society: The treatment facility would like to keep them but can’t. And so they’re asking us, can we put them in some place to stay near the facility, so that they can keep an eye on them.
LEE HOCHBERG: The Clinton administration has put outpatient mastectomy on its health care agenda.
PRESIDENT CLINTON: Just as we ended drive-through deliveries of babies last year, we must now end the dangerous and demeaning practice of forcing women home from the hospital only hours after a mastectomy.
LEE HOCHBERG: In his State of the Union Address President Clinton endorsed a proposed congressional bill to require insurers to pay for 48-hour hospital stays. Medicare, which pays for 1/3 of all mastectomies, last month ordered insurers in its system to not limit the number of days women can be hospitalized.
TELEVISION COMMERCIAL SPOKESPERSON: Get this. Somebody decided having a mastectomy ought to be outpatient surgery, like say getting a tooth pulled.
LEE HOCHBERG: To influence Congress, the Lifetime Cable Television Network, which is targeted to women, aired a public service campaign. It prompted 17,000 viewers to petition Congress last month in support of a 48-hour law. Several state legislatures are debating similar laws. Insurance industry consultant Lillidahl says the politicians are simply pandering to the women’s vote.
DR. DICK LILLIDAHL: It has voter appeal. That’s what I’m saying. I think there’s a political hot button for women around this issue. It’s obviously not being driven by good medicine. I think some of these are pure political issues.
LEE HOCHBERG: The Congressional Budget Office hasn’t determined how much such legislation might cost, but Lillidahl says it will drive costs up.
DR. DICK LILLIDAHL: You can’t have increasing lengths of stay, which have gone down significantly in past years, you can’t have ’em increase again and have decreased health care costs, which everyone in this country is crying for.
LEE HOCHBERG: Even some critics of outpatient mastectomy are leery of a legislative solution. Breast surgeon Jones says a piecemeal fix doesn’t address the greater problem with cost-driven medicine.
DR. DIANE JONES: What’s happening is band-aid–band-aid legislation. They are fixing the problem with mastectomies. They fixed the problem with babies. And so they’re fixing the problem with the insurance industry, so it is a problem with the insurance industry that’s running on cost.
LEE HOCHBERG: A trade group representing HMO’s recently said health plans should not require mastectomy be done on an outpatient basis. The congressional bill to guarantee that is moving through committee, with a floor vote possible by summer.