Homebirth Midwives: Better Outcomes, Moving Toward Broader Acceptance

From John Weeks in the Huffington Post, positive news from out west:

“Midwives have a central focus in our strategic plan. We are hoping Washington State can double out-of-facility births in the next two or three years.”

The speaker was Jeff Thompson, M.D., MPH, chief medical officer of the state of Washington’s Medicaid program. He spoke in a taped interview for Symposium 2012 — Certified Professional Midwives and Midwifery Educators: Contributing to a New Era in Maternity Care. The gathering took place at Warrenton, Va.’s Airlie Center on March 18, 2012.

Thompson, a member of the National Advisory Council for Healthcare Research and Quality, works in the state with the most evidence-based exploration of the value and risks associated with direct-entry, licensed, non-nurse, midwives. His state’s heightened interest began with a state requirement in 1996 that health plans cover midwives. Washington, like 11 other states, presently also covers midwives via Medicaid.

If the certified professional midwives (CPMs) get their way in Congress, CPM services will be reimbursed by Medicaid in all 26 states where CPMs are licensed. Passage would significantly expand access to low-income women across the country. The Access to Certified Professional Midwives Act was introduced in the U.S. House of Representatives in 2011 by Congresswoman Chellie Pingree (D-ME). Passage would energize a slight bump in home births captured in recent data from the Centers for Disease Control.

Cancer v. the Constitution

A human tragedy, which could become much less common or much more common depending on what the Supreme Court decides.

She hadn’t gone to the doctor because she had no health insurance. The only kind of work she could get in a struggling rural community was without benefits. Her coat and shoes beside the gurney were worn and her purse from another decade. She could never afford to buy it on her own. She didn’t qualify for Medicaid, the local doctor only took insurance, and there was no Planned Parenthood or County Clinic nearby.

So nothing was done about the bleeding until she passed out at work and someone called an ambulance. She required a couple of units of blood at the local hospital before they sent her by ambulance to our emergency department.

I looked at the fungating mass on her cervix. Later the Intern wondered why she hadn’t picked up on the smell. Probably a combination of it being so gradual and denial. It’s amazing what people learn to tolerate when their options are limited.

“I’m very sorry to tell you this looks like a cancer of the cervix,” I said

She looked surprised. “Oh.” She paused in silence as she adjusted to the news. And then quietly she added, “But the doctor back home said you could fix me up. He said you can offer free care because you have the university.”

But we didn’t have free care at the university hospital.

h/t Meteor Blades

Study Confirms Weight Loss Surgery Benefit for Diabetics

This new research confirms what was strongly suggested by earlier studies — that bariatric surgery leads to major weight loss, and either directly or indirectly leads to major improvements in the diabetic status of these formerly obese individuals.

I’ve lectured on this topic in my clinical nutrition class and it generally stimulates fruitful class dicsussion. Essentially, we’re looking at a dangerous condition that is almost entirely preventable through diet and exercise. We then see tens of millions of people failing at prevention and then finding themselves in a terrible situation. Once they’ve reached that point, this surgery clearly leads to much improved outcomes. It’s a classic example of radical measures being offered at a late stage for something that should never have reached that point.

It concerns me that we are now seeing, for what to my knowledge is the first time, a serious suggestion that bariatric surgery be provided to diabetics who are even slightly overweight. Again, where is the prevention?

The following quotes are from the National Public Radio coverage of the story, which I’m citing because unlike the MedPage story cited above, this one mentions recommending this surgery for diabetics with a Body Mass Index as low as 26, which is just barely overweight. (Obesity starts at a BMI of 30, and morbid obesity, which is usually when bariatric surgery is provided, starts at a BMI of 40).

This research raises an important question: Should diabetics start getting this operation more often? Paul Zimmet of the International Diabetes Federation, who co-authored an editorial accompanying the studies, thinks they should.

“Diabetes coupled with obesity is probably the largest epidemic in human history. At the moment, bariatric surgery is seen as a last resort. And it should be offered earlier in management,” Zimmet said in a telephone interview.

But others aren’t so sure. The new studies followed only about 200 patients. And while the operations appear to be pretty safe, there can be complications. And the complications can be serious.

“I think we need longer-term follow-up than what was done in these studies to make sure you’re not trading one problem for another,” said Vivian Fonseca of the American Diabetes Association.

Researchers are now testing whether the surgery works on diabetics who aren’t even obese — people with BMIs as low as 26. And doctors and patients are waiting to see if insurance companies will pay for the operations just to treat diabetes.

Earlier this year, I attended (and spoke) at a U.S. Department of Health and Human Services listening session here in Kansas City that focused on what services should be included in an essential benefits package under health reform. For me, the most unexpected part of the event was that of perhaps 30 presenters, four were bariatric surgeons. I was surprised, in part, because I was aware of the research supporting bariatric surgery and had assumed they were in no danger of being excluded.

Now, in light of this new research that was certainly in the pipeline at the time of the hearing, it occurs to me that their presence (which I assume will be duplicated in many other venues), may have been part of a concerted push for a major expansion of their services into the non-obese market.

… in the Real World

This Washington Monthly blog post, “The Affordable Care Act in the Real World,” frames the question in ways that should matter most, in terms of how people’s lives are actually affected by the health reform law.

A priest I knew many years ago once said to me, “Turning real human suffering into an abstraction is among the greatest sins.” .

My children now have health coverage through mine, and our family’s health will now sustain itself through my children’s 26th birthdays. A mouth full of cavities was treated, and vision has been a godsend, and my daughters have the ability to go to the doctor at $20 a pop, instead of the $150 a pop uninsured rate, and they don’t have to go willy-nilly to a clinic setting!

A dear friend of mine skirted death with a ruptured colon, had surgery to the tune of over $80,000 because they were uninsured. and worried about preexisting conditions when it came to reversing the colostomy, qualified for insurance so he doesn’t have to carry around a bag for the rest of his life.

Amen.

 

What Will Change if the Supreme Court Overturns Obamacare’s Individual Mandate?

Ezekiel Emmanuel’s op-ed in the New York Times addresses some of the changes that will and will not be affected, if the individual mandate to buy health insurance is overturned as unconstitutional.

The very substantial downside is that 16 million people who would have been insured will not be. This number will rise to 32 million if Medicaid expansion is also deemed unconstitutional. According to Emmanuel, this would also trigger a downward spiral threatening to substantially increase insurance premiums for everyone.

On the other hand, changes such as bundling of payments, which have already begun, lead to better coordinated care and lower costs. These changes will continue apace regardless of what the Supreme Court’s decides.

Tens of thousands of Americans die because of hospital-acquired infections every year, and far more are harmed by medical errors. Last year, authorized by the Affordable Care Act, the Obama administration announced a $500 million program called Partnership for Patients aimed at reducing hospital-acquired infections, errors and other preventable complications. The act also requires Medicare to begin posting online each hospital’s rate of certain medical errors and infections, and to cut payments to hospitals with the highest rates.

Consequently, hospitals across the country are working to reduce preventable hospital errors. Once it’s clear that this is a major priority, significant progress can be made. A few years before the health care reform act was passed, the Hospital of the University of Pennsylvania, where I work, started paying attention to reducing preventable errors, and it managed to reduce infections from intravenous lines to 1 or fewer per month from 30 to 40 per month. All it took was removing intravenous lines whenever they weren’t necessary, changing them regularly and using a more vigorous sterilizing technique when inserting them. Many other institutions are making similar progress now. All of this has nothing to do with the constitutionality of the individual mandate and will continue no matter what the Supreme Court rules.

The same goes for the problem of hospital readmissions. Right now, nearly 20 percent of Medicare patients who are discharged from a hospital are readmitted within 30 days. Some are scheduled readmissions; others occur for completely unrelated health problems, like falls and accidents. But many could be prevented by paying more attention to the coordination of care between physicians and hospitals and by better follow-up after patients are discharged. Beginning this year, the health care reform act will penalize hospitals that have high readmission rates for three conditions: pneumonia, heart failure and heart attacks. This list will later be expanded. As a result, all hospitals are now scrambling to figure out how to create “the perfect patient discharge” so patients don’t become hospital “frequent fliers.”

If the Supreme Court rules that the individual mandate is unconstitutional — in my opinion, an improbable and legally indefensible decision — it will not end health care reform. Hospitals and doctors will continue to work to improve care and control costs. But tens of millions of Americans will continue to be excluded from the health care system, which is hardly an optimal outcome.

 

Lead Plaintiff in Anti-Reform Case Declares Bankruptcy, Partly Due to Medical Bills

File under irony, along with genuine sympathy for this family’s plight.

Mary Brown, a 56-year-old Florida woman who owned a small auto repair shop but had no health insurance, became the lead plaintiff challenging President Obama‘s healthcare law because she was passionate about the issue.

Brown “doesn’t have insurance. She doesn’t want to pay for it. And she doesn’t want the government to tell her she has to have it,” said Karen Harned, a lawyer for the National Federation of Independent Business. Brown is a plaintiff in the federation’s case, which the Supreme Court plans to hear later this month.

But court records reveal that Brown and her husband filed for bankruptcy last fall with $4,500 in unpaid medical bills. Those bills could change Brown from a symbol of proud independence into an example of exactly the problem the healthcare law was intended to address.

The central issue before the Supreme Court is whether the government can require people to buy health insurance. Under the law, those who fail to buy insurance after 2014 could face a fine of up to $700.

The business federation, along with other critics of the law, calls the insurance mandate a “threat to individual liberty” that violates the Constitution.

Obama administration lawyers argue that the requirement is justified because everyone, sooner or later, needs healthcare. Those who fail to have insurance are at high risk of running up bills they cannot pay, sticking the rest of society with the cost, they argue. Brown’s situation, they say, is a perfect example of exactly that kind of “uncompensated care that will ultimately be paid by others.”

Blunt-Rubio “Contraception” Amendment: A Stealth Attack on Essential Health Services?

Press coverage this week on the Blunt-Rubio amendment to a Senate highway spending bill focused to a large extent on its sponsors’ stated goal of allowing employers to deny contraceptive coverage in health plans offered to their employees, based on religious or moral objections. Republicans sought to frame the issue as freedom of religion while for Democrats, it was primarily an attack on contraception and, more broadly, on women’s rights.

It is important to realize that impact of Blunt-Rubio, were it to be enacted into law, extends far beyond contraceptives, sex, and religion, taking aim squarely (if quietly) at the entire idea of requiring insurance plans to cover what are deemed “essential services.” It is no exaggeration to say that this proposal has the potential to thoroughly undermine the long-established process of requiring insurers to cover a defined set of health services.

This amendment, which only failed by a 51-48 vote, would allow all employers to determine whether or not to deny coverage for contraceptive services, regardless of whether the Institute of Medicine, Department of Health and Human Services, or state insurance regulators judged these to provide substantial health benefits. But more signifcantly, what it would also do is to allow any employer to eliminate coverage for any health care service, based on the religious or moral beliefs of the CEO or other decision makers.

How do we define moral beliefs? Our morals may be based on religious teachings (Catholic, Protestant, Jewish, Hindu, Buddhist, Muslim, Scientologist, Wiccan, etc.). Or, they may be based on anything else we choose to believe. Morals are quite personal and American society is exceptionally diverse in the range of moral beliefs professed by its citizens. Your moral beliefs may be based on deep philosophical inquiry and meditation, or they may be based on the last thing you heard on your favorite talk radio station.

If you are a CEO who strongly believes that vaccination is immoral because it violates the sanctity of the body as a temple, or any other reason), should you be able to eliminate that coverage from your employees’ list of covered services? How about a CEO who has joined the Church of Scientology and decides as a result to eliminate psychiatric benefits from his employees’ coverage? Should a corporate leader who considers sex outside of marriage to be immoral be permitted to eliminate not only coverage for abortion or contraception but also prenatal care for those who transgress his moral code?

Where does this stop? Blunt-Rubio is silent on that question, with its advocates preferring to limit the discussion to contraception. Did they not think it through? Or is this a stealth attack on government’s ability to define essential services and require insurance policies to cover them?

The implications are truly breathtaking in their comprehensiveness. Any employer can deny any health service for any reason, as long as he or she states that their objection is “moral.”  This is philosophically consistent with the conservative philosophy of governance that judges democratically elected officials to be the worst imaginable source to depend on for health care policy, choosing instead to vest that power in the hands of the private sector, specifically corporate CEOs or those to whom they delegate their power.

Is that the kind of health policy you favor?