Medical Monday: Breaking News from the World of Obstetrics and Gynecology

Maternal mortality is a big topic nationwide. The rates are unacceptable in the US, and particularly bad in the South. Arkansas, in a reasonable move to triage women for eligibility for home birth, have established a screening process. That screening process for women helps the State determine who may legally delivery at home. Heretofore, this screening did not require a vaginal exam. Now it does, and this has brought fire from patients and home birth midwives. It has always been our position that a patient may decline anything for any reason. However, to qualify for certain program certain requirements must be met. My position would be that women who do not want vaginal exams will have to forgo participation in that particular program. And, I must ask, what is the problem with vaginal exams ? Women are not fragile and information is power. This type of overly precious attitude toward the female body, even by women, is counter to the interests of maternal and fetal health. It is case of putting philosophy over responsibility. 

Texas OB/Gyns are starting to speak out about what they see are the causes of excessive maternal mortality rates. They are identifying system errors such as failing to recognize risk, as well as more subtle phenomena, such as unconscious bias. Race is of course a factor as black women are four times more likely to die than white women. A rally in Boston highlighted the same cause of maternal mortality. The centerpiece of the rally was a billion the US Senate which will promote the formation of state review committees for maternal mortality. 

Pennsylvania is also taking measures to try to curb maternal mortality and has established a committee through the State Health Department to scrutinize the problem. 

In an effort to get more pregnancy women into prenatal care, Connecticut has approved a bill to make pregnancy a “ qualifying life event”. This means that pregnant patients in the state my enroll in insurance plans anytime, and need not enroll within the confines of the enrollment period. 

With all this talk on maternal mortality, one might take a moment and discuss maternal morbidity. Morbidity means serious complications short of death. The CDC (Centers for Disease Control) has indicated that for every 1 mother who dies, 70 nearly die. That is an astonishing statistic and goes a long way in my mind toward explaining why Obstetricians have such burn out, and why their numbers are decreasing. Maternal morbidity comes from all the same things maternal mortality: worsening maternal health, worsening access to evidence based care. poorly funded health care systems, unconscious bias, race, etc. 

The Trump Administration is considering implementing the so called “gag rule”domestically. This would prohibit the dispensation of Title X funding to any clinics which even mentioned abortion. I wonder how this reconciles with freedom of speech ? Can you imagine trying to enforce this ? All patient consultation and exam rooms would need to have audio recording equipment and someone would have to review the recordings. Dystopian much ? 

The Trump administration is reappropriating about $15 billion in unspent funds from CHIP (Children Health Insurance Program) and certain part of the ACA ( Affordable Care Act). Democrats feel this is not the time to cap these budgets or reduce rainy day funds. However the Trump administration budget is ballooning and they are trying to cut costs anywhere they can even for vulnerable groups. 

Iowa has banned abortion once a fetal heartbeat is detected, which is at around 6 weeks. However, similar measures have passed in North Dakota and Arkansas but they have both been struck down as being unconstitutional and inconsistent with Roe V. Wade. 

Louisiana has seen a quadrupling of the rate of neonatal abstinence syndrome (NAS). NAS describes the condition of infants who are born to opioid addicted women. A recent feature in teh New You Times has reported that about 90% of pregnancies among addicted women are unintended. The reasonable inference here is that addicted women have a hard time using birth control effectively. 

ACOG (American College of Obstetricians and Gynecologists ) advises pregnant and breastfeeding women not to use marijuana for concerns about developmental delays. Nonetheless, a new study has shown that 69% of Colorado Dispensaries phoned do recommend it to pregnant women for nausea. Dumb and dumber. 

New data is coming out that induction at 39 weeks may be associate with fewer risks and lower C section rates. More research is needed. 

A new study on genetic testing for breast cancer has shown that those who do not meet the criteria for testing have harmful mutations AS OFTEN as those who do meet the screening criteria. Sounds like the screening criteria need broadening. 

In other genetics related news, we find that the number of genetics tests available is increasing. A new study has shown that only a small subset of physicians order genetic testing, and even fewer know how to interpret them. This appears to be a case of the technology moving faster than our understanding. 

The Human Genome Research Institute is developing “ preconceptual screening” for couples. Right now screening is piecemeal, meaning only for a selection of known genes. However, they are developing  a whole genome sequencing program, which has been made possible by NGS, or next generation screening. 3.5 % of participants had a medically actionable finding. As of yet, the majority of the information acquired does not have a clinical application. 

Yet more data has come out of a large study on the HPV (human papilloma virus). In a study of 73,000, it has been shown not only to prevent cervical cancer, it also prevents precancerous lesion of the cervix. Additionally it did not show any increased risk of side effects compared to control. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology next week, here on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

MEDICAL POLICY NEWS 

The new budget has blown the top off the old budget, and this, from conservative lawmakers. It exceed prior spending caps, and suspended the debt limit for a year. As part of the package it did refund CHIP (Children’s Health Insurance Program) for four years. 

CMS is the Center for Medicaid Services. According to their actuaries, health spending in the nation will increase by about 5.5%per year to $ 5.5 trillion dollars, nearly a fifth of the economy. The fastest growing sector of health spending is prescription drugs, estimated to grow by over 6% per year in the next decade. Due to the Affordable Care Act, (ACA) personal spending for health care has been at historic lows, though it is projected to increase, even under the ACA, at over 2.2% per year, which is over the cost of inflation which is 1.9%. Whether or not this is good, bad or indifferent, I cannot say. As a mother and as a physician, I feel we undervalue our health care and its costs. We spend on electronics, vehicles and vacations, which are important, but forget that health is at the foundation of it all. 

The Trump Administration is disinclined to regulate drug prices. However, they propose “easing government regulations (read: protections) to “spur innovation” to “lower drug prices”. They also proposed expanding drug coverage and  placing a cap on out of pocket spending for Medicare recipients. While the federal government will not regulate drug prices, it will allow up to five states to band together to negotiate drug prices. 

The ACA has a dependent provision saying that children up through the age of 26 may stay on their parent’s health insurance policies. A study recently published in JAMA, the Journal of the American Medical Association, has revealed that this provision resulted in increased rates of prenatal care, early prenatal care, and reductions in preterm birth. As an Ob/Gyn I can tell you that one of our holy grails is finding a successful approach to preterm birth. Looks like having health insurance might help. 

Maternal Mortality is four times higher for black women than white women in our country. Access to prenatal care is believed to be part of this. A recent New York Times editorial  featured a free Obstetrics clinic in Florida who accepted clients regardless of ability to pay. They were able to document a 40% reduction in preterm labor and low birth weight in this group. 

I reported earlier on the Utah bill which will provide for the use of Medicaid funds to provide family planing services to low income women. Part of the genius of this is that these are not just any poor women. These are women who are below the poverty level, but who are not so poor that they qualify for Medicaid. They are the so called women in the gap. Lawmakers would save everyone money if they gathered data about the lowest income at which one can reasonably afford private insurance, and made that the same level at which one qualifies for the Affordable Care Act. From there, the ACA should cover straight down to incomes which qualify for Medicaid. Then there would be no gaps. Rocket Science. 

Health care is a case of pay now or pay later. By now, everyone including consumers and lawmakers should understand that attending to health and paying for it up front saves both money, productivity and suffering in the long run. This is the single most important message I can tell you. 

Planned Parenthood has been under scrutiny, defunded in parts, and under continuing threat of more defunding. Planned parenthood provides many primary health care services at very low cost, not just family planning services. Their services disproportionately benefit women. Many associate their defunding in certain states like Texas, with increased rates of Maternal Morbidity and Mortality. This last week, leadership of Planned Parenthood announced they will begin a campaign of legislative action in key states. 

West Virginia is attempting to supercede Federal Law. Their Senate has passed the “no constitutional right to abortion” amendment, and it now heads to their House. All this is despite the federal law Roe Versus Wade which guaruntees the right to abortion within various age parameters. One opposing Democratic senator, a physician, simply read ACOG’s (American College of Obstetricians and Gynecologists) statement of opposition to the measure as his response. 

The Trump Administration has developed a “Conscience and Freedom” division of the Department of Health and Human Services. Since when did a Government office dealing with health care need a “ Conscience and Freedom” division ? It sounds very "morality police" to me. Encompassed in this type of approach would be protections for physicians who withheld certain treatments, and punishments for physicians who administered them. This move has also raised concerns in the hallowed halls of academic medicine. Professors from the Bixby Center for Global Reproductive Health and the Department of Obstetrics and Gynecology at UCSF (University of California San Francisco) have written an op ed against the formation of this committee and its enforcers. They have asked the Administration “to stop politicizing medicine and interfering in the judgement of medical professionals.” 

Think all this sounds implausible ? Think again. The Iowa Senate has approved a bill to ban abortion after a heartbeat is detected. We routinely detect heartbeats at 5.5 to 6 weeks after the last menstrual period. The bill includes a provision to charge physicians who do such procedures non-emergently with a Class D felony. Opponents of the measure are many. The University of Iowa would lose it’s accreditation of it’s residency program in Obstetrics and Gynecology if this were to be the case. This is because,to comply with the state law, the Program's policies have to comply with medical science and recommendations. This would worsen the problem of the shortage of Obstetricians and Gynecologists. 

MEDICAL NEWS 

In the recent past, Betamethasone steroids were only given to women expected to deliver before 34 weeks. More recently, the recommendation is to expand the use up through just before 37 weeks., the so-called late preterm period. Steroid given in this way decreases pulmonary (Lung) problems in the premature newborn. New research presented at the Society for Maternal Fetal Medicine has concluded that up to $200 million in savings could be realized by following this new recommendation. 

Increasing evidence shows that ovary cancer starts in the tubes rather than the ovaries. You might know this already if you have recently been counseled about a tubal sterilization procedure. In the past, we performed sterilization by tying, clipping, or cauterizing the tubes. However now we offer patients removal of the tubes to confer additional cancer prevention. 

American “fertility rates” are falling. This could be misconstrued as meaning more American women are infertile. However, this is not what it means. It does mean our birth rate is decreasing. Researchers believe this is explained by later marriage, smaller families, better adoption of birth control and fewer births among the unmarried. Their are varying assessments of this trend. Some people believe economic prosperity is dependent upon ever increasing birth rate, but this is an outdated and flawed analysis. Some believe that decreased birth rate alone will rescue the environment. I wish it were that simple. Data shows that income, educational attainment, and savings all increase with smaller families. 

HPV vaccine rates are still low. They are rising, but are still low. It is effective and has nothing to do with the choice to become sexually active. It prevents cervical cancer and genital warts. The side effects are limited to the side effects of an injection. What’s not to like ? 

Juice is out. Juice has been out for some time but many people seemed to have missed the memo. Many people still think that drinking 100% pure (even organic) fruit juice is a healthy thing to do. It is not. It is too much fruit sugar, in too broken down a form, for people to metabolize without spiking their blood sugar and risking fat deposition. A calorie is not a calorie. The RATE at which sugar enters your bloodstream is key. The rate with juice is just higher than our physiology can handle. It is far better to eat the whole fruit itself. The fruit has structure, even once chewed or blended in a smoothie, and it will enter the bloodstream in a slow release fashion. New research has shown that postmenopausal women who have a single 6 ounce serving of fruit juice per day persistently gain weight over the years. Of course many factors probably go into this, but the juice drinking may be a marker for misconceptions they have about nutrition. 

New research shows that who who meet criteria for and get MRI for breast cancer screening get more “invasive” (meaning with a needle or some other sharp object) biopsies. They say it like its a bad thing. Of course they get more biopsies. We see more detail and raise more concerns. The research goes on… fewer of these biopsies result in a cancer diagnosis”. AGAIN they say this like its a bad thing ! It is good to have no cancer diagnosis. What we are seeing here is a natural expectation of increased sensitivity and decreased specificity in the testing. There are more false positives, which we as a society have decided to accept as the “cost” of earlier diagnosis and better cures. So we as a group trade more pokes with a big needle for many women in exchange for greater years of life for a few. Sounds like a bargain to me ! Read these sensational headlines with care people, and don’t be afraid of needles. Sharp objects are your friend. And by the way, they talk about “invasive biopsies” like there is even such a thing as non-invasive biopsies. Spin the headlines much ? 

It is still meaningful to get your flu vaccine. If it does not prevent flu, it still will decrease the severity. If you don’t want to do it for yourself, do it for the unwell, elderly, children or pregnant women about whom you care. They are especially vulnerable and the death toll nationwide is appalling. Anti-vaxxers, take notice. There is cost to what you say. 

Stay tuned next week for more intense news from the world of Obstetrics and Gynecology. 

Medical Monday: Belated Bullet Version

Policy News 

In the name of choice, the Trump administration is proposing new rules to allow small businesses to circumvent the stipulations of the ACA and create cheap/incomplete heath insurance plans exempt from covering various "essential benefits” like: 

• mental health care 
• emergency services 
• maternity care 
• newborn care 
• prescription drugs

How is this even classifiable as insurance ? How many will be duped into buying this ? It will be just like the old days and those that cannot afford to pay for what their insurance does not cover will leave the rest of us and the medical system to foot the bill. Their cheap incomplete insurance will put little into the collective pot, cover little, and leave much unpaid. 

Deja vu: 

To repair or replace the ACA ( Affordable Care Act), that is the question. That is the question the GOP is asking itself. And it was the same exact question this time last year. GOP moderates say repair, GOP conservatives say replace. Nobody can say what to replace it with.  

Forget about the ACA ? Here's FAQs:

• Requires every consumer to hold health insurance of some kind or face penalty fee. (The Individual mandate) 
• The Fed supplies subsidies to insurance companies to enable them to charge consumers lower premiums and to provide comprehensive coverage. 
• There are no lifetime limits on health insurance benefits. 
• Essential health benefits ( see above) must be covered by all new plans. 
• Contraception should be covered through the “ contraceptive mandate”. 
• A consumer cannot be dropped by health insurance except through committing fraud. 
• Covers preventive services and immunizations. 
• Covers dependents until 26. 
• Creates a cap on insurance company administrative expenditures. 

The law had many more provisions but these are arguably the main ones of consumer interest. 

Since the Trump administration came to power, the following have been rescinded, weakened, or questioned : 

• The individual mandate
• Federal subsidies 
• The contraceptive mandate 
• Essential services 

Now that the holidays are over, Congress must find a way to save CHIP, the Children’s Health Insurance Program. Prior to Christmas, Republicans stole from Peter ( preventive health care under the ACA) to pay Paul (CHIP). That stopgap fund will run out in another couple months. 

Medical News 

First in the no-surprises department: 

• Smoking during pregnancy is associated with increased rates of ADHD. 
• Puerto Rico is facing an ongoing public health crisis without power, water and food. 
• Influenza is widespread in the US, especially the South. 
• Pregnant women in polluted areas have higher risks of birth defects. 
• Pregnancy weight continue to rise in the US, and with them pregnancy complications. 
• Maternal mortality is increased yet again in Texas. 

Good News Department: 

• A brand new programs on reducing Maternal Mortality, the Alliance for Innovation in Maternal Health, has already reduced maternal death rates in four states by 20%. 
• Estrogen cream may go generic soon, thereby reducing the very high cost of comfort. 
• Prescription of multivitamins and/or folic acid during prenatal care is associated with lower risk of autism in offspring. This was a 12 year study on over 40,000 children .
• The cancer death rate in the US has declined 1.7% just since 2015. Could this be related to the affordability of cancer screening covered through Obamacare ? 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology, next week, right here on Medical Monday. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

How stable are the ACA Affordable Care Act, aka Obamacare)  insurance plans? That remains to be seen. At present there is a bipartisan effort to shore up the so called ACA “marketplaces” . This means that certain lawmakers are trying to find a way to create a realistic budget to fund them. The Affordable Care Act was affordable since the Federal government supplied money to insurance companies to subsidize or pay for part of people’s premiums. 

Let’s roll back a second. Let’s make sure all this terminology is clear. 

Bipartisan= involving both Democrats and Republicans 

Marketplace = the system of insurance companies from which consumers buy health insurance 

Premium= the monthly amount consumers have to pay the insurance company to have insurance and to ensure that their insurance is in force 

Subsidies, aka insurance subsidies = payments from the Fed ( your tax dollars) to the insurance companies to defray (reduce) what consumers pay for their premiums. 

Republican concerns at the beginning of the administration change:

1. Obamacare cost the Fed too much and made taxes too high (via the payment of subsidies to insurance companies) 
2. Obamacare funded programs that powerful special interest groups opposed, i.e. birth control (via the Contraceptive Mandate) 
3. Obamacare took away the choice of not having to get health insurance at all. ( Via the Individual Mandate) In other words, Obamacare law via the Individual Mandate required everyone to hold health insurance. 

Democrat concerns at the beginning of the administration change:

1. Obamacare was not adequately funded and could run out of money if not addressed.
2. Obamacare needed to continue to fund birth control as a human right and for the social and fiscal improvements it confers, ie. increased education, job productivity, individual savings, better health, fewer teen and unplanned pregnancies, fewer abortions. 
3. Obamacare needed to continue to fund preventive care and cancer screening since in the long run it prevents serious disease and saves money 
4. Obamacare need to continue to retain the Individual Mandate since

• Each person is obligated to contribute to the insurance fund to make it stronger for everyone. The American Academy of Actuaries has gone on record saying that repeal of the Individual Mandate “... would lead to premium increases” and reduce the "incentive for healthy people to enroll and balance out the costs of the sick.”
• Each person is responsible for covering their own care even if their health takes a downward and expensive turn, and they can only realistically cover it with insurance.
• Persons who do not hold insurance and who end up getting emergency or unanticipated health care get care whether they can pay for it or not, and their bill is absorbed by everyone else. They are cheating the system. 
• The ethic of the greater good should inform the Individual Mandate since health coverage enables health care and health care enables broad social benefits of all kinds. 

The deadline to enroll for Obamacare this year has passed. The site for enrollment, healthcare.gov, was getting crushed right through until the end, and at one point, customers were instructed to simply leave contact information with the expectation of a call back. Many did not know the time frame for enrollment since the Trump administration cut funds for promotion of the program by 50%. Numbers on enrollment are not yet in. 

There is bad news and good news for CHIP, the children’s health insurance program. The bad new is that it will run out of money by the end of January. The good news is that there seems to be broad bipartisan support for refunding it. A bipartisan group of Governors has also come forwards and requested that the government renew finding for CHIP. The question is, what with all that lawmakers have left undone, and still need to do, will they get to it in time ? Remember, the Federal Government only has a budget through December 22nd, which is fast approaching. 

In medical news, we find a convergence of holistic medicine and technology. A new study published in the American Journal of Obstetrics and Gynecology uses app-guided acupressure to relieve menstrual cramps. The results compared this technique with medical therapy of oral contraceptive pills or typical analgesics and the results were significant. 

Sugar and inflammation. I do not know the exact relationship. Let’s talk about excessive sugar. In particular, a new study reveals that pregnant women who consume excess sugar in pregnancy are statistically more likely to bear babies who have asthma later in life. Asthma is an condition of the airways and is believed to be mediated by inflammation. Excess sugar in pregnancy is associated with many more problems, like excess weight gain, and gestational diabetes. 

It is well know that pregnant poorly controlled diabetics have increase risks of serious malformations including spina bifida and congenital heart defects.  In new research, pregnant women with high glucose levels in early pregnancy - even those who are not diabetic, are more likely to have babies with heart defects. The relationship is linear. 

Got your flu virus yet ? I hope so. There are TWICE as many cases of flu this year compared to last. Bottom line: the flu shot is safe and effective in and out of pregnancy. Talk to your doctor. It is particularly risky to skip it in pregnancy since influenza is much more dangerous in pregnant women. 

There is some expected fall out after last weeks publication about a small increase in breast cancer risk with long use of oral birth control pills. Authorities are hastening to point out that while this finding about breast cancer risk was noted, it has also been confirmed that oral birth control pills decrease the risk of uterus, ovary and colon cancer, stabilize bone density and obviously, prevent pregnancy and all of its potential complications. Risks need to be weighed with benefits. 

Stay tuned for more breaking news from the world of Obstetrics and Gynecology on the next episode of Medical Monday. I will have to decide what to do for Christmas week, most likely depending on the news at hand. Let's hope the researchers take a nice break for the holidays. The politicians, well, they can just keep working right on through as far as I am concerned. 

Happy Holidays. 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

I spent this week at Stanford MedX Conference. This conference covers some of my fondest professional interests. In particular, we covered various themes of technology in medicine, such as the use of devices and apps for patients to use to follow chronic disease conditions like diabetes. We covered the increasingly important role of apps in research. 

We explored the phenomenon of peer to peer connections among patients and discussed how it is especially helpful with rare or undiagnosed conditions. 

Another prominent theme at the conference was design in health care. We heard lectures and  participated in workshops in human centered design, or more particularly patient centered design. We used design thinking to create maps of the patient experience, then took that information forward to inform features as disparate as language used in phone notifications, seating in exam rooms, and interior decor. 

One theme of the conference was “everyone included”. I already knew this meant the voices of all genders. I also learned it meant all those in health care, not just patients and caregivers. Namely, it also included family members, medical researchers, device makers and all those who design and evaluate the health care experience. 

The genius of the conference in my mind was that it brought together those who were traditionally separate. In my two years of attending the conference it became readily apparent that fantastic synergies were possible by bringing together people from these varied  backgrounds. Patients, physicians, scientists, designers and computer scientists, sat around around common tables to learn methods to solve vexing problems in health care. And yes, we were given large sheets of paper, colored markers and sticky notes. 

But... the people ! This was the best part of all. I am here to report that there are plenty of good and brilliant people in the world with the ability to conceive of solutions to serious problems. At this conference, they came in all shape, sizes, ages, nationalities and genders. You could not pick them out at a grocery store. But if they had a conversation at your dinner table, you would quickly learn how special they were.  

On to policy. The Congressional Budget Office (CBO) continues to predict a 15 percent rise in premiums for policies under the Affordable Care Act (ACA). They have reported that this will likely be the case due to uncertainty over the Federal government’s willingness to pay subsidies to defray the cost of health care. Also likely contributing might be reduced  number of enrollees now that the individual mandate is not being enforced. 

GOP Senators have pared their efforts down to a one point bill. This final attempt to repeal and replace Obamacare basically takes Medicaid expansion money and shifts it to block grants administered by States. 

At the same time, Senator Bernie Sanders has proposed a near opposite. He has proposed retooling Medicare in the image of Obamacare and providing it to everyone. This is the so called “Medicare for all” proposal. While this has no likelihood of passing this Congress, it is espoused by most of the potential upcoming Democratic candidates for President. The rationale here is that such a plan would save money in the long run. The reasons for this being conceivable have been discussed before and elsewhere. In a nutshell, it has to do with people’s willingness to keep up on their prevention, screening, contraception and prenatal care, thus avoiding costlier more severe phenomena. 

The Senate Finance Committee has obtained an easy bipartisan agreement to refund CHIP, the children's health insurance program,

In another strikingly bipartisan move, Congress has rejected deep cuts to the National Institute of Health. Indeed lawmakers on both sides of the aisle have defied the Commander in Chief and increased spending on biomedical research. 

In medical news, HPV vaccination rates continue to be sub par. However new data shows that vaccinations that have been given may be conferring a herd immunity as HPV infections have decreased 32% between 2009 and 2014. 

Vaping is viewed as a safe alternative to smoking in pregnancy. There is NO data to support this. In fact, newer data show an association between maternal vaping and asthma in the offspring.

Marijuana is viewed as safe in pregnancy. However, it is associated with learning difficulties in grade school  offspring. The State of Nevada is beginning a program to educate about this. 

In concerning but unsurprising News, pregnant women’s exposure to pesticides appears to be associated with premature delivery and low birth weight. 

 A recent study shows a faint correlation between two flu shots in row and miscarriage. Ever hear of signal to noise ratio ? This is probably noise. ACOG continues to reiterate the real demonstrated need for flu vaccine in pregnancy. 

Belly fat; it’s always the last weight to come off. However, it is well worth the effort. We’ve known for some time that belly fat was associated with increased rates of cardiovascular disease. However, new research indicates that central obesity is associated with increased rates of several cancers. Moreover, in the case of breast cancer, it is more closely associated with higher risk forms of hormone receptor negative cancer. 

As data science improves, so do our results. New research published in JAMA, the Journal of the American Medical  Association, constitutes the largest longest and best designed trials on the safety of postmenopausl a hormone replacement therapy. Happily, it does not increase the risk of premature death. This is medicine’s way of saying that the therapy is safe. 

Thanks for reading. Stay tuned next week for more exciting news from the world of Obstetrics and Gynecology.