Politics of Breast Care

Waste, Fraud & Abuse

What a convenient phrase.  There is no doubt extraordinary situations that constitute Medicare Fraud.  However, it is becoming clear that this catch-all, very political phrase is being used to both demonize legitimate and ethical Medicare providers as well as to provide an excuse to reduce Medicare benefits. 

In a recent conversation about post-mastectomy benefits, I was faced with horror stories of beneficiaries being contacted about the silicone breast prostheses they had received and these same beneficiaries were told that,  "if they really didn't need these prostheses, Medicare Auditors would find out" and "they would loose their benefits". This type of "cost re-coupment action" is classified as "waste, fraud & abuse investigations" and heralded in triumph by politicians and administrators alike as cost savings events. But are denial of services or re-coupment of payments for legitimately and appropriately provided services, a "cost savings"?

Another growing trend is of Medicare developing unpublished, internal policies that reduce the allowed quantities of medically necessary physician prescribed items based on "opinions" not based on medical necessity or published payment policy. Internal edits, external audits of varying degrees including RACs, ZPICs and others have fostered a "guilty until proved innocent" atmosphere within the CMS Medicare Program that has the very real potential to quietly reduce post-mastectomy benefits and services.

It seems interesting to me that of the 25 some odd bills introduced before Congress in 2009 & 2010 pertaining to to the subject of "breast cancer", only 4 actually had anything to do with treating, increasing benefits coverage or providing for meaningful studies for breast cancer. Dont mistunderstand, raising awareness is important; honoring those that serve the greater good is admirable. But Congress has unique opportunities to insist by legislative means that treatments are recognized, provided, and paid for. It is of course only January, hopefully more will be done in 2010 to ensure women survive breast cancer and that their are allowed a Quality of Life no less expected by all women.

Cadillac vs Chevy?

Ah, the Cadillac.  A car that epitomizes personal success, classic style and a unique type of American luxury. But what does "Cadillac" have to do with health care? 

It’s not a new phrase.  Insurance companies and payor entities have used it for decades as a catchall to mean "too expensive" or "un-necessary from a cost point of view".  It never takes into consideration medical necessity and is usually subject to someone else's point of view or economic standards.

Over the years, those providing medical services of all types have become all too familiar with the phrase, "why pay for a Cadillac when a Chevy will do?" 

In one practitioner's office, an organization was contacted about the substitution of an item on a physician's prescribed treatment protocol, the Texas State government official said that, "either item [sic] listed replaces the amputated part, and we will only pay for the less expensive one [the Chevy]."  When the practitioner explained that each item has its own purpose and that the more expensive one was the one prescribed as medically necessary to treat that individual's condition, the official stated, "Why should we pay for a Cadillac, when a Chevy will do?"

Invoking the term "Cadillac", recent media reports have advanced the belief shared by many in insurance and government that the services paid for and provided are: a unnecessary luxury, over priced or undeserved and fraudulent. 

Postulating that somehow those health professionals that provide these services warrant extra scrutiny for "daring to cost the system precious dollars".  There is also a growing use of the phrases "waste, fraud and abuse".  However, these phrases are more sound bite than sound reasoning and political machinations than a protection of the people.

Medical services, items and treatments are by their very nature individualized- prescribed by a physician and dispensed by health professionals for a specific health need.  Whether it is a DME/HME supply, orthotics and prosthetics, breast prosthetics or a major surgery, the decision for that treatment should be a conversation between an individual and their physician. And those directed to provide those services should not be singled out for absurd scrutiny or held "guilty" until they prove that they are not part of a "health care fraud scheme."

What does all of this have to do with the price of tea? 

Overzealous regulations and witch-hunt like tactics in an attempt to "find the money", cripple Medicare; contrary to current political claims for "quality health care for all." Time, resources and dollars are spent in sole accommodation of a new and ever changing regulatory environment.  Time resources and dollars that practitioners would prefer to spend on care for individuals.

Already in 2009, with the implementation of BIPPA 1997 et al, including Accreditation and required Surety Bonds, 20% of current small women-owned businesses, establish post mastectomy providers, have closed their doors or terminated from the Medicare program.  These are not fraudulent providers but businesswomen, forced to close by government policy. This is a 20% reduction nationwide, of providers of a critical health service to women and men who have survived breast cancer and can only be interpreted as a reduction in quality of care and access to care. 

Forcing providers out of business, the loss of jobs, city and state revenue is not a way to save taxpayer money or justify bad legislation.  Lukily good legislation has been introduced to limit or stop surety bonds, competitive bidding and other issues related to over regulation. As well as provide positive ways to ensure provider quality, and quality of care.

For more information, please visit www.aabcp.org

 

1 in 8

We have all heard the statistic.  One in eight women will be touched by Breast Cancer in their lifetime. 

But the more important statistic: there are over 2.2 million women in the United States,   LIVING with breast cancer.  These women beat it!  They are SURVIVORS. 

And they are now faced with another sometimes insurmountable task...finding post breast cancer services, usually known as "post-mastectomy" services AND getting their insurances to pay for these medically necessary products and services.

Many insurances limit or deny payment for post mastectomy services and even Medicare limits or denys as "medically un-necessary" some post-mastectomy services.

Survivng Cancer, being healthy, can not be quantifed in dollars nor is it defined by "only basic medical care".  Health and in this case SURVIVORSHIP demands the ability to pursue Quality throughout one's lifetime.

 

Next Time, More on the Current State and Federal Legislation and the people fighting for the right to maintain "quality of life".

As Always....Dr T.

Welcome!

Hello and welcome!

The American Association of Breast Care Professionals is truly excited to launch the "Politics of Breast Care" blog.  It will be a critical look at how daily Politics and Politicians influence cancer treatments, access to quality care, insurance issues and industry stakeholder relationships.

New laws, pending legislation and State and Federal initiatives will be highlighted and discussed in an ongoing attempt to identify issues, improve the post-mastectomy profession and expand the options available to the breast cancer survivor.