Tuesday, December 23, 2008


This story is bizarre beyond being believable, but here we go anyway. Someone has to tell it and I was present and accounted for.

I received an email recently from an agent of the Massachusetts Executive Office of Health and Human Services. It read, "Mr. King, We understand you are familiar with events occurring in Dorchester that may not be followed by the usual news media or government agencies. We request a meeting to discuss some unusual, medical occurrences that have taken place in Dorchester and would like to learn your insight on developments concerning a demonstrable uptick in back alley surgical procedures. [italics mine]." This certainly seemed like my bread and butter so I agreed to an interview on the eleventh floor of One Ashburton Place downtown.

The agent and I sat at an empty conference table while nibbling catered sandwiches delivered from rebecca's cafe (lower case for proper nouns dictated by rebecca's corporate HQ). The agent asked me what I knew about illicit, unlicensed surgeries being performed in Dorchester. I admitted that this development hasn't registered on my radar.

A little back story: Over the past few years Mass Medicaid has been approving and paying for gastric bypass surgery for beneficiaries whose overall health is threatened by morbid obesity. As one would expect, rerouting a person's esophagus more directly to the small intestine is an expensive affair, even at government rates. The surgery is generally successful in alleviating the condition it is supposed to cure. Patients on average lose between 65% to 80% of excess body fat very quickly. This rapid weight loss often results in the patient acquiring a pannus about the patient's midsection.

Pannus is the Latin word for cloth though in this case it may be more properly translated as 'apron.' The patient's skin cannot contract as quickly as the excess fat being lost and hence an apron of empty skin develops that, in some cases without the underlying support, can hang almost to the knees. The Health and Human Services agent informed me that rumor on the street is that Mass Medicaid considers removal of this pannus after gastric bypass surgery isn't covered by the program since it is considered cosmetic surgery rather than therapeutic. I could see the reasoning. After all, I don't see any supermodels with an apron of excess belly skin strutting the catwalk, not even at Boston fashion shows.

The agent explained that some panniculectomies, as the surgical removal of this apron is called, are medically necessary. The underside of the pannus is often subject to dermatitis either of the fungal kind because of difficulties in keeping these deep folds clean and dry, or of the mechanical kind due to excessive rubbing against other surfaces. She emphasized that when medically justified the surgical removal of excess belly skin is a covered service under Mass Medicaid guidelines. This sounded reasonable to me.

The agent leaned in so close that her hair was in my egg salad, "Do you know, Mr. King, that we have seen a twenty-seven patients at Boston hospitals who are suffering complications from panniculectomies performed for private payment in unlicensed operating theaters in the Dorchester area?" I admitted that didn't know that. She continued, "Most of these beneficiaries are eligible for coverage under Mass Medicaid rules from contracted providers but they don't go there because they've been told the Commonwealth is cutting back on reimbursement for this procedure. They are going to unlicensed surgeons to correct their deformity and paying out of pocket. Granted, it's a reasonable fee considering the work being done, but it often much more than what Mass Medicaid has determined to be the proper reimbursement rate. Naturally, providers not certified by the Commonwealth don't always adhere to the standards we here at the Executive Office of Health and Human Services beleive to be in people's best interest. The system is starting to see the consequences in post-operative infections and sponges being left in the wounds." It was all news to me.

She said, "Do you know where most of these operations are performed?" I knew the answer already before she said it, "Mattapan."

Of course, Mattapan, that neighborhood where all sorts of trickery hatches without breaking egg shells. Mattapan...Where truth and falsehood exchange hats and every passing face is an enigma that asks. "How do you do?" Mattapan... Where fake IDs are passports. Mattapan... Where every shyster and accountant and hedge fund manager proudly hangs a store-bought diploma behind his desk. Mattapan... Where the best hot dogs are served, where best suits are tailored, and where the most well-attended churches make room to shelter their congregations. Mattapan.... Sweet, trusty, shady, sparkling, sparking Mattapan, the part of Boston that is most a'glow with unbridled opportunity. Mattapan...

The agent asked me if I could shed any light on the department's statistics. I said no and I thanked her for the sandwich. Exiting onto Ashburton Place, I looked at Boston's skyline looming and stretching to the south. I was only a few miles from Mattapan but I was a world away, slender and stylishly dressed in a bespoke suit and a shirt sporting folded-over cuffs. I get my tailoring done in Mattapan by an unlicensed tailor. If I needed a panniculectomy, I might consider the unlicensed neighborhood surgeons headquartered in that part of Boston. It is a place known as much for its bargain quality as for skirting around regulations. The two go hand in hand. Let the buyer beware and do due diligence. Any sawbones with a paring knife and a bottle of rubbing alcohol can hang his or her shingle in Mattapan but so can any respectable surgeon. You roll the dice for relief and the chance to improve your condition. You take your chances but there are worse places than Mattapan. There aren't any statistics for all the successful operations.

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