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Issues in Health Care Delivery - Insurance coverage

Based on your readings and research, answer the following:

-Discuss the process by which the patient in the case study is referred through the healthcare system from primary care to tertiary care and rehabilitation. What parts of this process works well and what can been improved?
-What is the significance of the patient's payer in determining her care?
-Do you feel that the patient's referral from primary care to specialty care is handled appropriately? If no, why not?

Case Study—Radical Mastectomy

It is Tuesday, June 14, 2005, 7:15 a.m. Mrs. Nancy Stritmatter is a thirty-nine-year-old professional chef in Cincinnati, Ohio. Nancy and her husband Roy own and operate a successful restaurant and catering service there. They have three sons of ages eleven, thirteen, and sixteen. For years now, Nancy has been performing a monthly breast exam as instructed by her nurse practitioner, Jana Cook, Advanced Registered Nurse Practitioner (ARNP) , at the Silverton Clinic near her home. Nancy is officially a patient of Dr. David Pederson at the clinic, but she has always been much more comfortable with Jana, especially for "female" matters. Nancy takes her monthly breast exam ritual seriously. Her mother and one of her aunts died of late-diagnosed metastasizing breast cancer. On conducting her breast self-exam, Nancy notices one small area in the upper, outer region of her right breast that seems a little different. She can't really call it a "lump," but something feels different there. She also notices a tiny amount of dimpling of the skin over that area. Nancy immediately places a call to Jana Cook at the clinic.

Primary Care

Jana wants Nancy to come to the clinic the same day, but Nancy has a large Rotary awards luncheon that day. As Nancy works all morning getting ready for the banquet, and then works all afternoon on the cleanup, she can think of nothing else. She also struggles back and forth with whether she should tell Roy anything about this just yet. She decides not to. Roy does notice that Nancy is a little quiet, but Nancy explains that she is just tired. Tuesday night is sleepless for Nancy. On Wednesday morning, Jana calls Nancy's home at 7:30 a.m. Dave, who takes the call, assumes it is about catering the Medical Staff Golf Tournament dinner which Jana organizes each year.

Physical Exam

At the clinic, Jana does a thorough physical exam, including a breast exam. She is looking for any of the characteristics of breast cancer, which include:
Lumps or thickening in or near the breast, or in the underarm area
Nipple discharge or inverted nipple
Redness or changes in the skin or contour of the breast, areola
Nipple ridges or pitting of the breast in which the skin looks like the skin of an orange
Jana finds the area, which Nancy describes, and she is concerned. There is a definable density, though very small, in the right breast, on the upper, outer quadrant. There is some pitting of the skin over this area. There is no enlargement of the lymph nodes in the right axilla.

Jana explains, "Nancy, the fact that we are noticing density in the outer, upper part of the breast means that we really need to work on this right away. Findings in this area of the breast are more likely to be more trouble than findings in some other areas. When I couple that with your family history it means that you need to get a mammogram done today." There is a mobile mammography unit that comes to the clinic once a month. But Jana doesn't want to wait till the next scheduled visit, which is on Friday. She recommends that Nancy go to the Cincinnati Breast Care Center because it is a provider for Nancy's insurer. Nancy has Blue Cross/Blue Shield "Blue Select" insurance through the small business association. A medical assistant at the clinic gets Nancy an appointment the same day at 5:45 p.m. Meanwhile, Jana quickly confers with Dr. David Pederson, her supervising physician, who concurs with her plan of care and signs off on the chart.

Diagnosing the Problem

Mammography

Nancy feels that Roy needs to know what is going on at this point. She calls him on his cell phone and explains. He responds simply, "Whatever this is Nancy, we will get through it together." He remembers the whole ordeal when Nancy's mom died, and he is secretly scared to death. In the Breast Care Center waiting room, Nancy and Roy notice two large certificates posted, one a certification from the Food and Drug Administration and the other an accreditation from the American College of Radiology. Both have current stickers in place showing that recent inspections have been completed. Jana had once told Nancy how important it was to get the mammogram done at a facility with these certifications. Nancy's wait is about 45 minutes, and she is greeted by Judy Lynch, radiologic technologist (RT). Judy is a registered radiographer with specialized training in mammography. Judy explains that in order to get the best possible images, it will be necessary to compress each breast during the mammogram. This also allows for the lowest dose of radiation to be used in the exam. Judy provides Nancy with 200 mg of Ibuprofen to reduce any discomfort she might experience during the exam. The procedure takes about 15 minutes. During the exam, Judy notices the area of concern and uses a technique called spot compression to better focus the image on this area. On reviewing Nancy's history, radiologist Jeff Woeller asks her to wait for a preliminary interpretation. The mammography report reveals a large amount of glandular tissue and an architectural distortion in the upper, outer quadrant of the right breast. An ultrasound follow-up exam is recommended to closely observe the area of abnormality in the right breast.

Ultrasound Exam

Judy explains to Nancy, "In some patients the breast tissue is very dense, and our mammography equipment does not provide as clear a picture as we would like. So then we do an ultrasound exam. Dr. Woeller has asked us to get you examined tonight if that is all right with you." Nancy replies, "Sure, let's get this over all at once if we can." The ultrasound exam involves using sound waves to image the breast tissue and differentiate between areas that might be fluid-filled cysts instead of cancer. The ultrasound exam is performed by Kathy Decker, Registered Diagnostic Medical Sonographer (RDMS). The ultrasound exam reveals a small lesion in the right breast. A core needle biopsy of the lesion is recommended for further investigation

Telemedicine

When Jana gets to her office on Thursday morning, she receives an e-mail regarding the radiology reports for Nancy Stritmatter. Jana logs in to the Intellimed site and checks up both Nancy's reports and her images. The reports and the images reveal something serious. She calls Nancy at home and informs her that she needs to have a needle biopsy done at the center.

Ultrasound-Guided Core Needle Biopsy

Dr. Woeller, an expert in obtaining breast biopsy specimens, chooses ultrasound for Nancy to be sure that he is in exactly the right spot when he samples. He explains to Nancy, "I use a biopsy gun, which takes little samples of tissue from your breast. When you had your ears pierced, they might have used a gun, something similar to one I am using for the biopsy. I will warn you each time before I take a sample, and I will be numbing the tissue with lidocaine. Most patients tell me that this does not hurt very much. It is important for you to lie very still while I take the samples. The procedure should take about ten minutes, that's all." The procedure is not as bad as Nancy had feared. She is home by 6 p.m. and goes immediately to bed, exhausted.

Pathology Report

The following day, pathologist James Minkus, MD at the University of Cincinnati Hospitals receives Nancy's specimens. He examines the specimens microscopically and reports ductal carcinoma in situ.

The Options

The phone rings at the Stritmatter home on Friday morning, during breakfast. Nancy knows that it is Jana calling. She is scared to death as she answers the phone. Jana says, as quickly as possible, "It could be a lot worse, and we can treat it!" Nancy breathes. Later that afternoon they discuss the options, with Dr. Pederson in attendance. He explains, "Nancy we could go one of three ways here, and you will be a key player in the choice. What you have is ductal carcinoma in situ, which means that the cancer cells are only in the lining of the breast duct, and they have not spread outside the duct to other tissues. What you were feeling in your breast self-exam was the enlarged duct. Thankfully Jana had trained you very well on the importance of a careful monthly exam due to your family history. In short, this is a very early catch, and that is great news."

Dr. Pederson explains the options.

A breast conserving surgery in which only the cancerous tissue is removed, with or without hormone therapy
A simple mastectomy, with or without hormone therapy
A radiation therapy as an adjunct to either of the above options
Whichever procedure Nancy chooses, Dr. Pederson recommends Dr. Sampsel at University Hospital, who has done literally thousands of such operations. Luckily, he is a provider for Nancy's insurance. Dr. Underwood at Mercy Hospital is also outstanding, but he is not a provider for Blue Select. Dr. Pederson tells Nancy to think it through before deciding, but that she has to decide by the following week. With that Dr. Pederson leaves, heading for another exam room. Nancy likes him, as he seemed very knowledgeable and friendly, but always in such a hurry. She and Jana chat for another 20 minutes or so, explore the options, and decide that Roy should have a say in the decision.

The weekend at the Stritmatter house is tough to say the least. Roy makes Nancy repeat the options over and over again. He wishes that he had been at the appointment and heard it all firsthand himself, but somebody has to keep the business going. Nancy really feels, having watched what her mom and her aunt went through, that she should have a mastectomy. However, she is worried about how she would look, how she would feel about herself, and how Roy would feel. The weekend passes without a decision being made.

Surgical Consult

On Tuesday, June 21, at 3 p.m., Roy and Nancy are in Dr. Sampsel's office, waiting in the exam room for nearly two hours. He enters the room and says, "I am so sorry that you had to wait. I had a colleague who really needed a second set of hands in surgery, and I am way behind my own schedule. Well, Dr. Pederson made excellent notes for me, and I need to know which direction you would like to go. I can work with you on any of the options." Roy: "Can I ask what you would recommend doctor?" Dr. Sampsel: "If it were my wife, with this family history, we would be doing a mastectomy. Not a doubt in my mind." Roy: "But that's a hard call for anyone to make." Dr. Sampsel: "I'm sure that it is. What I can tell you, from twenty-seven years in this field, is that if we do the breast conserving surgery now, you folks will very likely be back in a few years with another lesion in this breast. The family pattern in this disease is just that strong. Sorry to have to tell you that, but you need to know." Nancy: "Yes, that is exactly what I thought, and I don't want to go through what happened with mom and subject my family to the suffering." Dr. Sampsel: "One advantage we have these days is Synthetic Hormone Therapy to block your body's natural hormones and prevent or slow the growth of breast cancer cells. It works, but I would still recommend the mastectomy."

Decision

The decision is made. It is very emotional for Nancy and Roy, but they have a feeling that this is the right thing to do. Above all, they want to avoid a repeat of what they lived through with Nancy's mom some years before. Before she is taken to surgery, Nancy has one more question for Dr. Sampsel, a question, which he has heard many times before: "Dr. Sampsel, should we really just be removing both breasts now so that none of this has to happen again?" He responds, "No, we shouldn't Nancy. We will have you on hormone therapy, which may very well prevent this from happening in the other breast, and you will be getting regular exams and mammograms to detect anything before trouble starts. Today's procedure is the right thing for you Nancy." That is what Nancy needs to hear. The procedure would be a simple mastectomy with sentinel node biopsy. This is the removal of the breast, with its skin and nipple. A sentinel node biopsy is then performed to remove only the first three auxiliary lymph nodes. These nodes are biopsied to be certain of no cancerous spread. Dr. Sampsel performs the surgery on Friday, June 24. He has done too many of these to count, and everything goes smoothly. Nancy is in surgery for about 45 minutes, recovers nicely, and is home on Sunday afternoon.

Back to Primary Care

Nancy has a follow-up appointment with Jana on June 28, and she gets some good news. The pathology reports on the lymph nodes that were removed are all negative. Jana comments, "Dr. Sampsel says no chemotherapy and no radiation, Nancy, and I am very happy for you about that. It's because you caught this thing so early. You will be taking synthetic hormone therapy, likely for the rest of your life, and there will be no missed doses. Got it?" Jana refers Nancy to a breast care website for information on the options about a breast prosthesis or reconstructive surgery. Nancy has no interest in surgery at this time, but she does want to obtain prosthesis as quickly as possible. Nancy is thrilled that things are getting back to normal. Within a week, she has her prosthesis and begins to use it. She decides to do her breast exams weekly from now on, and chooses Sunday mornings before church as her weekly time.

Solution Preview

Basically, when Nancy noticed a "lump" on her breast, she went straight to her primary care provider Jana. Her primary care provider Jana did a good job of examining Nancy for sign of breast cancer. Then after noticing the density in the "outer, upper part of the breast", she recommend Nancy to get the mammogram. She refer Nancy to another place, called the "Cinnatic Breast Care Center to get the mammogram. I think this is inconvenience and troublesome for Nancy because she had to go there because it is under her insurance. She has Blue Cross/Blue Shield which is not covered by her primary care provider. She has to go to the Breast Cancer Center for her mammogram because her primary care provider did not accept her insurance. Her only regret is ...

Solution Summary

Health benefit plans can played a key role in what type of specialist or primary care you will receive. Some medical benefits are not accepted by certain health care providers, and this can determine what type of care you will receive. It is important to carry the best health insurance so that you will get the best care for your conditions.

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