THE VIRGINIAN-PILOT
Copyright (c) 1997, Landmark Communications, Inc.
DATE: Monday, February 3, 1997 TAG: 9702030029
SECTION: FRONT PAGE: A1 EDITION: FINAL
SOURCE: BY DEBRA GORDON, STAFF WRITER
LENGTH: 174 lines
Insurance companies in Virginia are refusing to pay for some stages of breast reconstruction, infuriating women and doctors and prompting state legislation that would mandate coverage.
Across the nation, plastic surgeons report difficulties getting the initial reconstruction - performed after a woman loses her breast to cancer - covered by insurance companies. While that isn't a problem yet in Virginia, say local doctors, follow-up procedures like surgery to make both breasts look the same are rarely covered.
The goal of breast reconstruction is to enable a woman to look as normal as possible, say plastic surgeons. In about 25 percent of cases, that involves not only rebuilding the breast that was removed, but also lifting, reducing or enlarging the remaining, natural breast to match the reconstructed one.
But many insurance companies, including the state's largest, Trigon Blue Cross Blue Shield, often call surgery to restore symmetry``cosmetic'' and refuse to pay.
Some insurers also won't pay to correct complications, such as scarring, from the original surgery. Molding the nipple and darkening the skin around it to create an areola are other procedures that often are not covered.
A survey by the American Society of Plastic and Reconstructive Surgeons, which represents nearly all board-certified plastic surgeons in the country, found that 84 percent of its members had up to 10 patients denied insurance coverage for breast reconstruction in 1995.
Forty-three percent had been denied coverage for symmetry procedures and nearly 20 percent had been denied coverage for changes made after the initial surgery.
``Getting approval for the opposite breast surgery and the areola never was a problem five years ago,'' said Norfolk plastic surgeon Lawrence B. Colen. ``Now it's a routine problem.''
Even when the surgery is covered, reimbursement for the eight-hour procedure is so low, doctors say, many fear they won't be able to continue offering the surgery long-term.
Women who have had breast reconstruction say the entire procedure - including follow-up surgery - is necessary for their emotional well being, already devastated by the diagnosis of cancer.
``If you weren't symmetrical, it would be a kind of a shock,'' said Meg Graf, a 49-year-old Virginia Beach women who had breast reconstruction two years ago. Her insurance company, Trigon, wouldn't pay for the symmetry surgery, but her surgeon provided it for free. Without it, she said, ``it would almost be as disfiguring as the original disfigurement.''
Nationally, about 182,000 women will be diagnosed with breast cancer this year. About 4,500 of those cases will be in Virginia. Last year, 85,000 women nationally underwent mastectomies, with about 26,000 choosing reconstruction.
There are two main methods of reconstruction: man-made implants and autologous reconstruction, in which the woman's own tissue is used to rebuild the breast.
Implants are the simpler and less expensive procedure. They cost about $2,400 for the surgeon's fee and are done primarily on an outpatient basis. But they have several drawbacks, some Norfolk plastic surgeons say. Implants aren't recommended if the woman needs follow-up radiation; they need to be replaced after several years because they wear out; and some women don't tolerate them well.
Autologous reconstruction is commonly called a TRAM - transverse rectus abdominus myocutaneous. In it, fat from a woman's abdomen or back is used to shape a new breast, providing a more natural-looking breast, say doctors. But the six- to eight-hour operation, including follow-up care, costs about $6,400 for the surgeon's fee and requires an overnight stay in the intensive care unit, as well as several days in the hospital.
Age and severity of illness have nothing to do with a woman's desire for reconstruction, said plastic surgeon Christine Horner-Taylor, of Edgewood, Ky. Horner-Taylor is founder of the national Breast Reconstruction Advocacy Project. The grass-roots project is trying to get legislation passed to cover all aspects of reconstruction.
A woman's identity is connected with her breasts, she said.
``It's a feeling of wholeness, it's all about how a woman feels about her sexual identity.'' Fear of losing a breast, she said, is one reason women spurn early breast-cancer detection programs.
Horner-Taylor started her organization in 1995 after a Kentucky insurance company told her that a woman's breast was ``an organ with no function'' and refused to cover the initial reconstruction.
``That's when I went insane,'' Taylor said. ``I said, `You will pay and everyone will pay,' and started organizing the whole country.''
Thirteen states currently have laws mandating coverage of breast reconstruction, although not all cover symmetry surgery and other follow-up procedures. The Virginia bill, which would require payment for symmetry procedures, has been referred to a committee that studies mandated benefits. No action will be taken on it until next year's General Assembly session.
But federal legislation may be passed in the meantime. Two bills introduced in January - one by Rep. Anna Eshoo, D-Calif., and one by a bipartisan coalition of House and Senate members, including Sen. Alfonse D'Amato, R-N.Y. - would require coverage of all aspects of breast reconstruction. Sen. Ted Kennedy, D-Mass., is expected to introduce a third bill.
Health Insurance Industry of America, an insurance trade group, opposes mandates.
``They tend to drive up the cost of health coverage,'' said spokesman Richard Coorsh. He said most plans in his organization cover breast reconstruction, although he didn't know if that included follow-up procedures.
Reconstruction helps women avoid the depression that often comes with a cancer diagnosis, said Dr. Ronald Iverson, president of the American Society of Plastic and Reconstructive Surgeons.
Symmetry is important, Iverson said, because ``the fact that (the breasts) don't match, means they still have the stigma of having breast cancer surgery.''
Lynette Brown, 45, of Virginia Beach, understands that feeling. Brown, who had her right breast reconstructed last summer, still won't undress in front of her husband because she's embarrassed by her uneven breasts. Her insurance company, OPTIMA Health Plan, wouldn't cover surgery on her left breast, calling it ``cosmetic.''
``Now, one side is up and one side is down,'' she said. ``That's a part of your body and it kind of hurts when you look at yourself and you're two different sizes.''
In cases where symmetry isn't covered, some women won't even have the initial reconstruction, said Mary Jo Ellis Kahn, of the Virginia Breast Cancer Foundation.
While he couldn't comment on individual patients, Sentara Health System medical director Randy Axelrod says he makes such decisions on a case-by-case basis. The initial reconstruction, including nipple and areola creation, he said, is always covered.
He examines photographs of a woman's breasts, reads letters and medical records from the surgeon, and often talks with the doctor before making his decision.
``I don't know of any other way to do it properly,'' he said. ``At what point do you say that's pretty good, and getting it any better is really more of a challenge for the plastic surgeon than a benefit?''
Women dealing with the issue say the decision should be left to them and their doctor.
``I was just livid,'' said Gail Smith, of Martinsville, whose symmetry reconstruction was denied insurance coverage last spring. ``I didn't choose for this to happen. Everything I've read said that symmetry is an important part of the surgery.''
She complained to state Sen. W. Roscoe Reynolds, D-Martinsville, who introduced the Virginia bill.
Such legislation is necessary, say local doctors, because even though they are not currently seeing denials for the initial reconstruction, ``it will get here,'' Colen said.
But legislation won't solve the ever-increasing problem of declining reimbursements, say local doctors.
Some insurance companies, including Medicare, pay them about $1,000 for the eight-hour procedure, which includes all pre- and post-surgical counseling, office and hospital visits.
The day is coming when plastic surgeons will no longer be able to afford to do the procedure, said Dr. John B. McCraw, a Virginia Beach plastic surgeon.
McCraw, like most of the other plastic surgeons in Hampton Roads, is capitated by OPTIMA Health Plan. He receives a set amount each month - in his case, about $600 - to provide all necessary plastic surgery procedures to OPTIMA patients.
Two years ago, about 70 percent of McCraw's surgeries were breast reconstruction. Now, he estimates, it's about 20 percent. He does the surgery ``as a hobby,'' trying to make up the revenue loss with cosmetic surgeries, which patients pay for themselves.
But that can only continue so long, he and other doctors said.
Colen, who is also capitated by OPTIMA at about $1,800 a month, said he sees the day coming when doctors may try to steer women to less expensive reconstructions like implants, whether or not they are most beneficial.
``If I can put a breast implant in a patient and it takes two hours and get paid the same as if I do a six-hour flap reconstruction, even though the patient may not look as good, or may not really want an implant, or may be at risk for developing implant complications, why should I do the (flap) reconstruction?
``More than the denial of the reconstructive surgery, the issues we're going to face are going to be whether or not the plastic surgeon can afford to do what's right for the patient based on their office overhead and their collections.'' ILLUSTRATION: [Color Photo]
CHARLIE MEADS
The Virginian-Pilot
Meg Graf, of Virginia Beach, had reconstructive breast surgery, but
her insurance covered only part of the work.
KEYWORDS: BREAST RECONSTRUCTION SURGERY INSURANCE