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

Policy News 

The Trump Administration will continue to use a bundled payment model for Medicare recipients. This means that the government will pay a certain lump some to cover all the inpatient and procedure related medical care given to Medicare patient rendered in a 90 day period of time. If the healthcare providers use less than that amount of money they can receive a bonus. This strikes me as a terribly perverse incentive. Hospitals and caregivers have every incentive to skimp on care so they can pocket the bonus. What if the amount of money allocated is not enough for all the care the patient needs within the 90 days? It is interesting to note that this bundled payment strategy was created under Obamacare (The Affordable Care Act or the ACA) and has been reincarnated in almost exactly the same form under the Trump administration.

Several women’s health organizations including the American College of Obstetricians and Gynecologists (ACOG), have instituted a program called"The Care Women Deserve”. Under this program, there will be an effort to educate all women regarding the health services to which, under the ACA which is current law, they are entitled, at little or no cost. Examples of these services include well woman visits, also known as annual exams, Pap smears, contraception, also known as birth control, HIV screening, mammograms and breast-feeding support. Not all women know that they are entitled to all these services.

The Trump administration has long tried to weaken the contraceptive mandate, the part of the Affordable Care Act which requires insurance companies to cover contraception without co-pay. They have received many legal challenges to these attempts. The Trump administration has paid out over 3 million dollars of taxpayer money to to settle these lawsuits.

For the first time in Medicaid's 50 year history certain states will be allowed to interpose work requirements on certain able bodied adult recipients. The National Health Law Center is preparing to challenge this in court.

Washington DC’s only pubic hospital has been closed due to quality concerns. 

The Wall Street Journal is reporting that the GOP is scaling back plans to reform the ACA and social security type programs. They are focusing on basic problems like funding the government. They are even talking about increasing the debt limit and reaching a compromise on immigration. Since when has the GOP been interested in increasing the debt limit ? 

Medical News 

Studies 

• Once again our own immune system is at the heart of a disease process. Evidence from a mice model suggests that the damage caused from Zika virus infection is actually from the mother’s immune response against the virus in the baby. This was published in Science Immunology. 
• A large retrospective study has indicated that pregnant women who take methylphenidate for ADHD have a higher likelihood of having a baby with a heart defect. 
•  A new study published in the Journal Birth looks again at Texas maternal mortality rates. Between 2011 and 2015, there has been an 87% spoke in maternal mortality. The worst has been in mothers over, 40 with that group having a mortality rate 27 times that of women under 40. This is felt to be related to increasing rates on chronic and under treated disease including obesity, lack of insurance and lack of health care. 
• A 172 woman study published in Menopause made the we-already-knew-this-department. They have shown that one year of postmenopausal hormone therapy prevented depressive symptoms more effectively than placebo. Postmenopausal hormone therapy is FDA approved for hot flashes and vaginal dryness, but not for mood disturbance. Maybe it should be. 
• The Journal of Asthma has published a study linking prenatal exposure to PCBs ( polychlorinated biphenyls) to asthma and upper respiratory infections and eczema in children. 
• A new study has indicated that women who work night shifts have a (gasp) 19% higher chance of getting cancer than those who do not work at night. This meta-analysis has shown that the risk is proportional to time worked at night, and that the risks  go up differently for different cancers. The most surprising is skin cancer with a 41% increase in risk. Next is a 32% increase in breast cancer, and an 18% increased risk in digestive cancers. Yikes ! I hope the exact reasons for this get figured out and dealt with ! 

We have a new department ! It is called the stupid and irresponsible department. Our inaugural feature is devoted to the TV show Black Mirror, whose writers decided to depict emergency contraction, aka “ Plan B” or “ the morning after pill” quite incorrectly. In particular, they portrayed a teen who took it as having nausea, which is not typical. A nurse in the show informs her she had taken it “ to terminate a pregnancy”. Basically the show confused the morning after pill with the abortion pill. The morning after pill is progesterone only, thus should not cause nausea. Plan B does not cause abortion of an established pregnancy. It prevents pregnancy. Thanks so much, TV,  thanks. 

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

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

As expected, the Trump administration is planning to roll back the contraceptive mandate. The contraceptive mandate requires that insurers cover costs for contraception without copay. The proposed change in regulation would allow employers to refuse to cover contraception because of religious or moral objections. This change will not go unchallenged, Numerous lawsuits will likely be initiated if this change takes place. 

Those objecting to the contraceptive mandate often cite their objection to certain birth control methods which prevent implantation. However, mainstream authorities focus on the fact that increased contraceptive availability is associated with plummeting incidence of abortion and unplanned pregnacy. 

In other policy news Texas plans to continue funding their task force to determine the causes of their alarming rate of maternal mortality. It is really a shame that Texan’s don’t just save their money and acknowledge the obvious: that increased maternal mortality is directly related to their gutting of health care services to women. At this time, one quarter of Texas women lack health insurance. Data from many quarters tells us that this is a sure fire way to ensure poverty and high maternal mortality for many generations to come. 

Arkansas is racing to the bottom as well. A Federal Appellate court in St. Louis has ruled that Arkansas can block Medicaid funding to Planned Parenthood. 

Winning the race to the bottom, is of course the the Trump administration, who has resolved to cut Teen Pregnancy Prevention program funding. The American College of Obstetricians and Gynecologists (ACOG) came out with a swift condemnation of this plan. The current administration supports abstinence only programs, and yet asserts they favor “ evidence based” programs. Sling that medical jargon. 

Lawmakers have prevailed upon the Trump administration to make the Federal Government insurance subsidy payment for August. In fact, it is Republican members of Congress together with Democrats who have convinced the administration to continue payments, fearing a collapse of insurance markets. They believe this will buy time for a bipartisan solution to stabilize the markets. The CBO (Congressional Budget Office ) continues to warn that ending subsidies with cause premiums to rise by 20% by 2018. 

In encouraging news, Oregon has passed law budgeting half a million dollars to expand comprehensive reproductive health care coverage for all its citizens. The law also requires insurers to cover such services with no out of pocket cost. Available evidence tells us that, as a direct result, they should expect decreased rates of unplanned pregnancy and abortion, with increased levels of educational attainment among women, decreasing unemployment statewide, and increased standards of living. 

https://www.cdc.gov/obesity/data/prevalence-maps.html

On to the medical news. 

It is time for us to start thinking about obesity in more sophisticated ways. Obesity is a devastating and widespread medical problem. It is also very personal and for that reason it is challenging to discuss and treat. We are now beginning to understand that the causes of obesity include but are not limited to individual habits. For example, poverty and its many causes factor in strongly. We can graph the incidence of obesity on maps and thus understand obesity is part of culture as culture spreads across geography. New research out of the National Institute of Health has revealed that the “ origins of obesity lie as much in early childhood - even prenatally and intergenerational- as it does in an individual’s current behavior. “ Obesity is closely tied to many forms of human suffering and disease, from heart disease and diabetes, hypertension and cancer, to poor self esteem and depression. Further research is necessary, by all means. However to effectively address this serious problem, both patients and physicians are going to have to do better at mustering their courage and talk about obesity in frank and accurate terms. 

You might have noticed my mention of obesity as having a role in increasing cancer risk. Maybe you were not aware of this, since there is not an obvious connection. However, we have always know that obesity is associated with many types of cancers. However, new research from the Journal of the Academy of Nutrition and Dietetics sheds more light on the subject. It turns out that “ women who eat a lot of high calorie foods may face a slightly higher risk of obesity related cancers - even if they remain thin” The study went on to elaborate that “ women who favored low nutrient high calorie foods had a 10% higher risk of cancer linked to obesity. “ Cancers related to obesity include cancer of breast, colon, ovary, kidney, and endometrium (uterine lining). 

A new study from the Canadian Medical Association has shown that oral cancers related to the HPV are on the rise. Between 2000 and 2012 it is believed that the incidence of such cancers has risen by 50 %. 

Smoking in pregnancy is still a big problem. It turns out that depression in pregnancy makes smoking more likely. This tendency of smoking during depression in pregnancy is on the rise, according to new research published online in the October issue of Drug and Alcohol Dependence. 

HPV and smoking are a bad combination. Did you know smoking greatly accelerates the progress of HPV related disease ? 

HPV has an effective vaccine against it. However, new research indicates that less than half of girls and a quarter of boys are vaccinated. HPV ( Human papilloma virus ) has a vaccine. Humans papilloma virus causes genital warts, precancerous and cancerous lesions of the genitalia and mouth. Vaccines are available for young people from the ages of 9-26 years of age. They have little in the way of known side effects. 

In other virus news, there have been no locally transmitted cases of Zika viruses in Florida yet this year. The same encouraging trend has also been seen in Latin America and the Caribbean. Authorities now believe that those infected develop immunity to reinfection. However, authorities are also concerned that Zika may now be getting transmitted sexually. Work on a Zika vaccine is underway. 

Again, I encourage you all to contact your elected officials about your views on women’s health. Tell them the American people are willing to shoulder their collective responsibility for people's health care and the good of the future. 

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

Forty prominent groups concerned with women’s health have written a letter of complaint to the new administration. The recipients include President Trump, the Secretary of the Department of Health and Human Services Tom Price, White House aide Ivanka Trump. The letter has criticized each of the major changes that the present administration has either enacted or proposed, for example replacing Obamacare, cutting funds to Medicaid, reducing access to women's healthcare by shutting down Planned Parenthood as well as the "global gag rule”, also known as the “ Mexico City policy”  which prevents international organizations who offer abortion as part of their services from receiving any US funds. The letter further alleges that women's healthcare needs have been traded for political benefit. The letter went out during Women's Health Week to call attention to the issues. In order to begin addressing these concerns, Ivanka Trump has begun meeting with various groups concerned with women’s health, including female Democratic leaders. 

Imposition of the global gag rule may cut off millions in funding to combat other conditions like HIV/AIDS and malaria, leading to a global health crisis. 

In a move long opposed by Republicans, the Trump administration’s budget proposal will include 6 weeks of paid family leave for both mothers and fathers. 

Texas is still trying deal with having shot itself in the foot. Texas took a stand against abortion and removed Planned Parenthood from their Federal Funding recipients. By doing so under the Obama administration, they lost their Federal funding for the Texas Medicaid Women’s Health Program. Texas has the highest maternal mortality rate of all the States, and a very high percentage of uninsured people. They want their Federal funds back. 

Health insurance is not just about a single subscriber, or even a single family. It is a funding pool that we agree to make together, that lets us all have predictable manageable health expenses, even if something really bad and expensive should happen. It also is a way for everyone in society to help safeguard the future, by contributing to the care of the next generation. This is done by contributing to a pool that pays for the care of women and children. This elementary and beneficial concept behind health insurance seems to have escaped Republican Rod Blum from Iowa who believes men do not need to contribute to an insurance pool which covers pregnancy. He was jeered off the stage in a town hall meeting. 

And now for a piece of news that cinches the connection between policy and health care. Research presented at the annual meeting of ACOG (The American College of Obstetricians and Gynecologists) has shown that the Affordable Care Act (ACA) under Obama led many pregnant women to get prenatal care earlier and that led to better perinatal outcomes. Of course this is in jeopardy now. 

Researchers with the American Cancer Society have presenting new findings indicating that increased access to care under the ACA led to early detection of some cancers. These included breast, colon and lung cancers. Early diagnosis leads to more cures and longer survival. The biggest changes occurred in states with significant Medicaid expansions. These gains too are in jeopardy. 

A recent study has shown that women under fifty doubled their survival time in recent years. I suspect mammograms played a role in this. There is controversy on when mammograms should start: 40 versus 50. ACOG recommends 40. So do breast cancer survivors under 50. Cancer patients over 50 also saw increased survivals, but not quite so dramatic. 

The World Heath Organization has presented the shocking news that pregnancy complications are the leading cause of death for teenage girls worldwide. The biggest causes were hemorrhage, complications  from abortion, and obstructed labor. 

Lancet, one of the world’s premier medical journals produced research on “ Amenable Mortality”. “Amenable Mortality means deaths that could’ve been avoided through timely or effective medical care. American scores 80 on the heal care quality index (HAQ) and that is at the bottom on the second decile, on a par with Estonia and Montenegro. 

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

In policy news, things are moving at a slower, more measured pace. Moreover, the policy pendulum is swinging back to a more moderate place. In a move striking many as too little too late, the House GOP has proposed adding $15 billion to their now failed ACHA (American Health Care Act) making it more palatable to centrist republicans. This money would be pad to reimbursing health insurance companies for high cost patients. The intention is that this would help states reduce health insurance premiums for clients starting in 2018. The Kaiser Family Foundation has estimated that health insurance premiums will go up for the average ACA (Affordable Care Act) client by 19% if federal subsidies are withdrawn. Even with this 15 billion dollar amendment, the GOP did not have enough votes to pass their bill, and now Congress has adjourned for spring break recess. 

According to the Gallup poll, the majority of Americans now support the ACA. This is now the case for the first time since the ACA became law seven years ago. Though 55% of Americans now support it, many feel it could be improved. Centrist Democrats, calling themselves the “ New democrats”  and moderate Republicans,  “the Tuesday group”, are beginning to work with one another on small feasible improvements to the ACA which could benefit everyone.

Senator Bernie Sanders has promised to propose a bill for a single payor system, the so-called “ public option”, also known as “Medicare for all”  in 2018. 

Sixteen State’s Attorneys General have filed an Amicus brief against a new Ohio law which prevents health care providers who offer abortions from receiving any federal funds for any services. A US District Judge in Missouri has reversed a similar law in Missouri. 

In other abortion news, the 2013 Texas House Bill 2 required doctors to have admitting privileges in order to provide abortions. It also required them to do so in ambulatory surgical centers. Finally, it decreased the limit from 24 weeks to 20 weeks. The first two requirements put many midlevel providers in office settings out of business. About half of all abortion providers were put out of business. 

A new study in JAMA, the Journal of the American Medical Association, looked at the changes in practice since this law has taken effect. It turns out there were 20 % fewer abortions performed in that time frame. It also turns out that the abortions performed were done at a later gestational age. The researchers also calculated that an increased umber of abortions were performed illicitly. 

In medical news, the WHO (World Health Organization) has data indicating that fully 10% of all deaths worldwide are due to smoking. The number is believed to be underestimated since the effects of second hand smoke have not been accounted for. 

Death rates from the main types of cancer for all types of people have declined between 2010 and 2014. The decrease washout 2 %. 

In other good news, TDAP vaccine given in pregnancy is associated with lower rates of pertussis in babies later. (surprise ! ) 

Looking back at Zika, new data has shown us that 10% of women with Zika infection in pregnancy had a baby with a serious birth defect. The number may be higher since not all babies born to mothers with Zika have been given neuroimaging. Also in Zika news, a vaccine under development is progressing to phase two testing.  

In other vaccine news, according to the CDC, as of 2014, about 42% of all people carry the virus. A large new Scottish study of 20,000 women has shown that the HPV vaccine has been associated with a 90% fall in the prevalence of the virus.

Stay tuned for more breaking news from the exciting world of Ob/Gyn here, next week on Medical Monday. 

Thanks for your patience with my delay during Passover ! 

Here is may first ever angel food cake, made gluten free from scratch. It is served with a dairy free chocolate ganache, lemon curd, and cherry berry sauce. 

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

On last Monday , President Trump signed an executive order “ granting relief” from the stipulations of the ACA (Affordable Care Act). Among other things, this means the Department of Health and Human Services (DHHS) may reduce what insurers are obligated to cover for patient’s care. 

Planned Parenthood reports that the number of women trying to get IUDs in their clinics has gone up 900% since early November, i.e. the election. IUDs are a very reliable long acting contraceptive.  They are obtaining these IUDs under the contraceptive benefit under the ACA, which they fear will be repealed under the current administration. 

The Democratic Governor’s Association has urged Congress not to overturn the Medicaid Expansion or to convert to block grants. They stand to lose a great deal of coverage and funding for their constituents. 

Two moderate Republicans, Senator Susan Collins of Massachusetts, and Senator Bill Cassidy of Louisiana, a physician, have indicated a partial replacement for the ACA, which would allow states to continue to operate under it if they chose. Under this proposal, states who opted out of the ACA could get a block payment to administer on their own. The authors have emphasized that the bill is a work in progress. 

At the recent GOP policy repeat, a plan was made to have a replacement for the ACA  to the House floor by the end of March. The House Speaker, Paul Ryan indicated that they intend to get these replacement laws made in 2017. 

The US has frozen funding to health care providers in poor countries who discuss abortion as an option. This policy is called “ The Mexico City Policy” and it is been enforced and revoked back and forth through the administrations of Clinton, Bush, Obama, and now Trump. 

The CDC (Centers for Disease Control) reports that consumption of sugar drinks is still “ well above” the recommended limit. Consumption of these drinks has decreased steadily for the last ten years but now seems to have plateaued. 

The South has higher cancer mortality rates that the rest of the country. These are areas of the country where poverty, smoking and obesity are more prevalent, and these factors are believed to be the reasons. Overall, the US health rate from cancer has decreased 20% in the last ten years. 

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