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The Medical Professionalism Blog

Open or Closed? That is the Question

A study in the American Journal of Surgery found that 30% of breast biopsies done in Florida from 2003-2008 used surgical open biopsies. This number greatly exceeds the current medical guidelines that recommend open biopsies for 10% or less of cases.  The study extrapolates that 300,000 women a year in the U.S. are having unnecessary surgery at the cost of millions of dollars.

In their study, Stephen Grobmyer, MD et al. report that needle biopsies are safer, carry less risk, are less invasive and less costly. I’ve outlined their findings in the chart below:

Needle Biopsy Open Surgical Biopsy
Hospital Cost $5,000 – $6,000 $10,000 – $12,000
Doctor Fees $750 – $1,500 $1,500 – $2,500
Total Cost $5,750 – $7,500

$11,500 – $14,500

So why are open biopsies so overused?

Grobmyer et al. lay some of the responsibility on doctors not keeping up with medical advances and guidelines, and others who don’t want to lose biopsy fees by sending patients to a radiologist. Surgeons in the study said patients often wanted open biopsies, although the authors cited the surgeons having an inherent bias in determining patient preferences.

Another cause could be that a referring physician has a long-standing relationship with a surgeon and lacks the same with the radiologist needed to do a needle biopsy.

Quite possibly, the hospital is putting pressure on surgeons to perform more surgeries to increase revenue.

Maybe the real culprit is a toxic fee-for-service system that does not reward outcomes of care and their related costs. By “toxic” I mean a volume-based reimbursement system versus a payment system based on outcomes, patient satisfaction with their experiences and the cost of care.

Perhaps, it’s all of the above.

But do these factors abdicate the physician’s responsibility? It is not about blame, it’s about leadership and courage to lead change in the health care system.

It’s about the profession being in partnership with their patients and other stakeholders to find ways to improve care for patients.

It’s about adherence to evidence.

It’s about honest conversations with hospital executives about mission and with patients about their preferences, fears and misconceptions.

It’s about developing new relationships with the Medicare program that will alter the payment system (i.e., Accountable Healthcare Organizations and Patient Centered Medical Homes) to reduce the dependence on fee-for-service reimbursement and instead reward for quality, patient experience and costs.  (See Michael Chernow et al.’s Health Affairs piece on Private-Payer Innovation in Massachusetts. )

A new day is awakening in health care as result of health care reform legislation. There is an imperative to build high-performing systems of care that remove waste from the system and produce better outcomes and experiences for patients. These systems of care will motivate physicians to provide the right care, in the right place, in the right way… all of the time.

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