For women to make informed surgical treatment decisions about their breast cancer, there is a critical need for patients and providers to discuss reconstructive surgery options. At the time of surgical decision-making, a large percentage of surgeons do not refer patients with breast cancer to plastic surgery, despite the 1988 Women’s Health and Cancer Rights Act’s requiring insurance companies to provide coverage for breast reconstruction.1,2
In a 2007 study, researchers reported that prior to surgery only 24% of surgeons referred more than 75% of their patients to plastic surgeons for mastectomy reconstruction. Extrapolating from their findings, they found that the providers most likely to have a “high referral propensity” were female physicians, those physicians who have a high clinical volume, and those who work in cancer centers. It has been suggested that factors other than insurance coverage are playing pivotal roles as drivers and barriers to receiving reconstructive surgery.1
The obstacles to breast reconstruction are multifactorial and involve patients’ lack of awareness of options as well as location, economic factors, poor reimbursement, and negative healthcare provider attitudes concerning reconstruction given specific patient and tumor characteristics. Without access to plastic surgery consultations, patients are not sufficiently informed of potential reconstructive choices, such as breast-conserving surgery and total breast reconstruction, that can be implemented immediately or later.
Telemedicine may play an important role by enabling remote healthcare delivery, which may reduce barriers to screening, chronic disease management, and postoperative care. As access to mobile technologies becomes more widespread, so do the many benefits of implementing this technology, including flexibility and decreased travel time and cost.3
Particularly in underserved and rural regions, telemedicine may play a critical role in the future by creating pathways to overcome persistent obstacles to healthcare access, particularly for breast cancer reconstruction.
A systematic review identified a range of obstacles to adopting telemedicine technology, including concerns about the availability of high-speed Internet bandwidth, confidentiality, medical licensure, and reimbursement.4 As a result of varying state laws and payer policies, telemedicine is reimbursed inconsistently.
Xue and colleagues describe in detail how integrating a telemedicine program into clinical practice using web-enabled video teleconferencing platforms such as Zoom can provide secure communication among providers and patients, while complying with the Health Information Portability and Accountability Act.
Medicolegal considerations must be recognized as the field of telemedicine advances. Interstate consultations are an area of concern, given that medical licensing requirements are not standardized. While there have been ongoing legislative efforts to reduce the impact of geography through the TELEmedicine for MEDicare Act, the Telehealth Promotion Act, and the Veterans E-Health and Telemedicine Support Act, the Interstate Medical Licensure Compact has had the most significant impact by offering an expedited route to licensure to practice medicine in multiple participating states for qualified physicians. At present, 29 states are implementing or beginning to adopt these measures. Precise state regulations still require clarification, and arrangements with medical licensure boards need to be made. Likewise, to ensure compliance, individual malpractice insurance carriers need to be synchronized for telemedicine consults and associated liability concerns. Legal counsel should be consulted to ensure that requisite consent and waivers are generated.
Source
Xue EY, Chu CK, Winocour S, Cen N, Reece E. Establishing a telemedicine program for breast reconstruction. Plast Reconstr Surg Glob Open. 2020;8:e2594.
References
- Alderman AK, Hawley ST, Waljee J, et al. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer. 2007;109:1715-1720.
- US Department of Health and Human Services. Women’s Health and Cancer Rights Act. www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/whcra_factsheet#:~:text=The%20Women's%20Health%20and%20Cancer,in%20connection%20with%20a%20mastectomy.&text=Surgery%20and%20reconstruction%20of%20the,produce%20a%20symmetrical%20appearance%3B%20and. Accessed February 26, 2021.
- Gardiner S, Hartzell TL. Telemedicine and plastic surgery: a review of its applications, limitations, and legal pitfalls. J Plast Reconstr Aesthet Surg. 2012;65:e47-e53.
- Scott Kruse C, Karem P, Shifflett K, et al. Evaluating barriers to adopting telemedicine worldwide: a systematic review. J Telemed Telecare. 2018;24:4-12.
