Medical Monday : Two Week Catch Up

Happy Easter and Happy Passover. We have two weeks to cover. Thanks for reading ! 

Policy News

Much of the National Health Policy News this week deals with contraception and reproductive health. Can anyone remember any time in this or any other country when these private matters were ever so much on the national stage ? The politically conservative aspects of my nature questions why this degree of government intervention in private lives is necessary. My medical qualifications and medico-legal experience cause me to classify some of this meddling as practicing medicine without a license. 

Title X is a federal grant program whose purpose it is to promote positive birth outcomes and healthy families. It provides grants for family planning and health services. So here’s my first question: Why is it not run by health care professionals ? Trump administration officials are now contemplating new wording which would add additional criteria for clinics to receive Title X funding, namely the provision of primary preventive services. Sounds good right ? Well many clinics offer only reproductive health services. These clinics would have to expand or close. This measure seems like just another way of closing family planning clinics.  Now whether pap smears would qualify as preventive health is unclear, or whether paps would be classified as reproductive health, I don’t know. 

Texas is challenging the federal government’s withholding of funds for its family planning programs. They were withheld several years ago based on the fact that these providers, many of them through Planned Parenthood, also provided abortions.

Planned Parenthood itself is challenging the Federal Government on its withdraws of funds from the teen pregnancy program. Between this and two other plaintiffs, the Department of Health and Human Services has partially and temporarily restored some of the funding until litigation can be completed. 

Idaho has failed to solve the problem of insurance for those whose income falls between Medicaid and the Affordable Care Act coverage criteria. A proposal called Plan First Idaho would have funded family planing services for women in the gap. My question is, what rocket scientist designed the State’s the two programs such that their income qualifying criteria do not meet seamlessly ? This is a problem of their own making and it needs solving. Republicans in the Idaho House stalled this measure. 

Idaho Governor “ Butch” Otter has approved a measure by which prospective abortion patients must a told about “ abortion reversal” a procedure that does not exist. Additionally, he has signed legislation which will require abortion providers to collect personal and demographic information which, in de-identified form they intend to make public. I don't know what they think this will accomplish, but I have a feeling it may backfire, since they will be able to see how many and how diverse a group of women utilize the procedure.

The Supreme Court is hearing a case between the State of California and a group of "crisis pregnancy centers”, an actual chain of 130 outlets run by “ The National Institute of Family and Life Advocates”. These centers are anti-abortion counseling facilities, however they are licensed as family planning providers. California has a law requiring that all licensed family planning facilities to post notices of the availability of free or low cost birth control and abortion services and they are challenging it. They are arguing that this posting requirement violates their free speech.  So far the Court has expressed concern that these clinics not be singled out from other clinics. California has argued that their staff, many of whom are not medically qualified, present medical misinformation as truth, all to the end of dissuading patients from abortion. Apparently theses non-credentialed counselors actually wear white coats. 

Along with the opioid epidemic has come a hepatitis C epidemic. Kentucky, having seen a surge of the disease, has passed a law now requiring all pregnant women to be tested for it. Hepatitis C used to be very hard to treat. However, patients have much more hope nowadays due to the availability of effective therapy. 

Missouri has expanded Medicaid for pregnant women in drug abuse treatment. Their continued coverage will be contingent upon them staying in treatment, and could under those conditions, be continued up to 12 months.  

And now for more of a purple to blue state review:

Florida is considering a bill requiring HPV (human papilloma virus) vaccination to be required as part of the vaccinations required of children attending public school. Human papilloma virus causes multiple illnesses most notably cervical cancer and genital warts, and the vaccine has not demonstrated any conclusive evidence of harm.

It is interesting to note that physicians are not prescribing HPV vaccine equally for female and male children. Doctors recommend the vaccine twice as often for girls as they do for boys. This puts the boys at increased risk for HPV disease, and puts all their future partners at increased risk too. 

Mississippi passed a law banning abortion after 15 weeks Of course this is unconstitutional based on Roe V. Wade which is still on the books. A Federal Judge over turned Idaho's ban. 

New Hampshire has passed a bill which will allow pharmacist to prescribe birth control. No doctors visit will be necessary. The medical establishment has concluded that vast majority of the birth control methods are safe for the vast majority of women. They certainly are when compared to pregnancy for those same women. Authorities believe this will eliminate yet one more barrier to contraception. Utah signed a similar law into place earlier in the week. 

On the other coastline, the state of Washington now has a bill that will require insurance to cover contraception, abortion and maternity care. Additionally, after the first of the year, all contraception has to be co-pay and deductible free. This includes voluntary sterilization. 

The new budget has failed to shore up the ACA ( Affordable care Act) marketplaces. States will have to tighten their belts and work on their budgets one by one. 

ProPublica has reported that the “US is the most dangerous country in which to give birth”. States all over the US are creating programs to quantify and address the problem of maternal morbidity and mortality, even as the Federal government under Trump is dismantling reproductive and maternal health care piece by piece. 

Do you ever get the feeling that the various States in America are becoming like the countries of the European Union with different values, cultures budgets and laws ? 

Medical News: 

Obstetrics: 

Striking research findings presented at Lancet Global Health conference have shown that the death risk is double among pregnant women who are anemic compared with those who are not. The lead study author also found the correcting anemia is not a sufficiently high enough priority among physicians. 

Research presented at Diabetes UK conference has shown that excess weight gain incurred during pregnancy by  gestational diabetics is associated with greater risk of cesarean section.

Women who exercise in pregnancy have shorter labors. This interesting news was published in the May issue of European Journal of Obstetrics and Gynecology and Reproductive Biology. The study group attended a professionally led session of moderate exercise three days per week. Labor was shortened about one hour, mostly in the first stage, or dilating phase. ACTIONABLE ! 

Children who were breastfed exclusively for at least 6 mores were less likely to become overweight to obese than their counterparts. The conclusions were drawn by analyzing over 38,000 records from children South Korea. The finding were presented at the Endocrine Society Annual Meeting. 

Gynecology/General Medical News: 

There may be a male birth control pill on the horizon. Research at the Endocrine Society's annual conference has presented information on a new male birth control pill called DMAU. It contains androgen and progestin,  which is analogous to the contents of the female birth control pill, estrogen and progestin. Once daily tablets appear to be safe and effective. No period required. 

Menopause and aging in general is characterized by a loss of muscle mass and bone density as well as the deposition of fat. As suspected, the Mediterranean diet may have a positive impact on bone mineral density and muscle mass in postmenopausal women. The Mediterranean diet emphasizes the eating of high quality protein, large volumes of fruit and vegetables, healthy fats such as olive oil and a modest amount of complex carbohydrates such as whole grains. As a whole, the diet is lower in simple carbohydrates than the typical American diet and is also higher in protein and antioxidants.

There are now over 400 cases of a rare lymphoma which are linked, epidemiologically, to breast implants. Breast implants are not new. Lymphoma is not new. However our ability to collect and parse data is better than it has ever been. The FDA it's taken this ability and created a meaningful database for this type of information. While an association between breast implants and this rare lymphoma is being established through data collection, a causality between the two is not necessary implied. That said, nothing is more likely to lead us to understand the causes of this problem than amassing quality data about it. 

Federal funding support for cancers is disproportionately low for gynecologic cancers if you rank them by lethality. Cancer of the ovary and the uterus ranked near the bottom of the funding list. Contact your elected officials ! 

A new modification of the current device used for pap smears can identify cells from endometrial (uterine lining) and ovarian cancer. The investigational PapSEEK uses an analysis of 18 genes and analysis similar to that used in prenatal screening for Down’s syndrome to identical the genetically abnormal cancer cells. THIS IS SO COOL ! 

A new study on postmenopausal hormone therapy has shown that it does help maintain thinking and memory skills. This is the case IF it is initiated shortly after the onset of natural menopause. This study was presented in the Journal Neurology and was a high quality randomized controlled trial of 75 women between the ages of  42 and 56. 

In my mountain state, there is not a great deal of sunlight or seafood. As a result we have a high prevalence of vitamin D deficiency. New research indicates that vitamin D deficiency increases a post menopausal women’s risk of metabolic syndrome. Metabolic syndrome includes the unholy triad of diabetes, high blood pressure, and abnormal serum lipids ( cholesterol and triglycerides) which together increase cardiovascular risk. Vitamin D levels are checked by a simple blood test. Ask your doctor about this ! 

Stay tuned for more news from the exciting world of Obstetrics an 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.