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This year my own small mountain town had an upbeat well attended Women's March. I would like to share some of my photos. I will report on policy and science a little later. For now, it is simply important that you know the government is shut down until there can be an agreement on a budget.
I am holding the sign saying, "Make America kind again ". I think this by itself would help so much.
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 ?
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.
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:
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.
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.
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 :
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.
First in the no-surprises department:
Good News Department:
Stay tuned for more breaking news from the world of Obstetrics and Gynecology, next week, right here on Medical Monday.
Happy new year ! Hopefully this year we will benefit from the upheaval of 2017. Many of us became more political. The issues about which we care came into distinct focus. Perhaps we clarified our priorities. Hopefully health and quality time are high on your list.
In that spirit, I am going to try to streamline what I hope has already been a streamlined blogging format, and go to what could perhaps be called “ bullet blogging”. Perhaps you have heard of “ bullet Journalling” or “dot journalling”? I had been doing it for some time without realizing it. Instead of journaling in full sentences and paragraphs, I journal in bullet lists, small graphics and graphs. It is fun, fast, and lets me indulge my visual nature.
If you have been into any Michaels, Joannes or any other craft store lately, you may have seen prominent displays showing fancy little bound or three ring journals, sticker sets, small format markers, washi tape, and specialized fill pages - all for such enhanced journaling. There are also many cool online resources for bullet journalling.
I am an incredibly digital oriented person, and so it may seem a surprise that I would be interested in such analog things. I believe that for every person’s life or work management system, there is a particular optimal balance between digital and analog. Everyone one needs a little paper. In my office, I have suggested that my employees keep “ one notebook to rule them all”. Instead of a proliferation of sticky notes and other scraps to get mangled or lost, the one notebook, complete with dates and legible writing, held everything. I gave them some beautiful starter notebooks, and they took it from there. They seem to enjoy it. One co-worker in particular has made hers into what I would call an art form. That is the idea ! It is to take some joy and satisfaction in even the smallest things, like note taking and scratch calculations at work.
And so it has occurred to me to try “ bullet blogging”. It is my hope it will be faster, simpler and easier on the eyes. I’m going to give it a go.
Via CMS( Center for Medicaid Services) :
Employees of the CDC ( Centers for Disease Control) and other federally funded health and science organizations were “discouraged" from using seven words in budget reports:
Two separate letters have been issued from > 300 public health organizations urging the HHS ( Health and Human services) to ignore this. The second letter included signatures from
ACOG ( American College of Obstetricians and Gynecologists)
AAP (American Association of Pediatrics)
APHA ( American Public Health Association)
Blocking the blockers
Kick the can
GOP has kicked the real budget and real health care bill into January. Stay tuned.
ACOG President-Elect Lisa Hollier, MD MPH, Houston, Texas, brings a new clear focus: the rising maternal mortality in America.
Study: Breast pain is not a symptoms of breast cancer. Neither lack of pain nor lack or palpable lumps means lack of breast cancer. Upshot: Get your mammograms !
Study: Cervical Pessary may be of use in preventing preterm birth.
Study: at home STI ( sexually transmitted infection) test kits may increase detection rates.
Study: Post menopausal Estrogen therapy may protect against some forms of memory loss.
Study: Income and weight are inversely related for women. This is not true for men. Contemplate.
FDA (The Food and Drug Administration) plans to increase regulation of homeopathic remedies. Because there are no real studies on these. Contemplate.
Marijuana update
Male Contraceptives ?
NIH ( National Institute of Health) and the Population Council are sponsoring a clinical trial of a hormonal male contraceptive gel. Don’t expect it on the shelves for at least 5 years. I wonder how the GOP will attempt to regulate male methods of contraception.
It’s best if you follow up on these leads to put together your view of women’s health care in this country. What I have given you should contain enough key words so you can google your way to the source material. Remember to seek out reputable sources like the NIH, the CDC, ACOG, AAP, APHA, or major academic medical centers like Mayo Clinic or Stanford.
2018 is a new year, and a new approach is needed to ensure the best for women’s health care. Get involved.
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:
Democrat concerns at the beginning of the administration change:
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.
The big policy news this week is that we still have a government. Yes, Congress passed a stopgap measure to avert a government shutdown, but that will not even get us to Christmas. At issue is spending. By now you know that the budget of the nation is greatly influenced by the tax structure and also on major expenditures like health care. Major expenditures that must be resolved to attain a budget including the funding of ACA subsidies and thus stabilization of the ACA insurance market places. There is also a lot of pressure for CHIP or the children’s health program to be refunded. People across the board are NOT happy about that program being in jeopardy. Now if we can just show people that the health of women and the health of children are deeply intertwined, we will be even better off.
Did you know that health care spending is not first nor even second on the list of big Federal expenditures? It is third. I am lifting a great infographic from pewresearch.org and giving you the link to encourage you to read the whole article.
Now that you know the proportions, how about some actual dollar amounts ?
Health care spending reached it’s new max in the end of 2016 at $3.3 trillion dollars. It increased in 2016, but not as much as it increased the prior year in 2015. The share of the economy devoted to health care went up to 17.9% representing a gradual increase. This grew slightly faster than GDP ( gross domestic product). Expenditure on heath insurance grew to about $2500 per year, while OOP ( out of pockets) grew to about $350 bucks per person per year.
Is this amount of spending good or bad ? Is it appropriate to spend this percent of income on health? My health means a great deal to me. If you compare countries with health care that is equal to or better than ours, you will find they spend much less personally but generally pay considerably more in taxes. Their taxes are larger, but the distribution of good health care in their countries is wider. Their higher taxes buys them less income and health disparity as a a country, broader prosperity and better social stability. Do you think that is worth it ?
You may have noticed from the infographic that number one and two on the list of federal expenditures are Social security at 24% and Medicare at 15%. Do you feel like health care has taken all the budget scrutiny heat ? These other programs may now be in jeopardy too. After the immediate legislative sessions, the GOP is looking at cutting other parts of the social security “ safety net” which old folks have been paying into all this while… Social Security and Medicare. How do you feel about that ?
The States not the Fed are taking charge of key practical health care issues that need prompt attention. Instead of engaging in the philosophic, sociological or religious debates characteristic of Capitol Hill, they are taking care of business. For example, North Carolina has addressed its high risk pregnancy situation and has created a statewide initiative to identify and give special care to high risk pregnancies. They are doing this through multidisciplinary “ medical homes” where advanced Obstetrical care can be rendered. The District of Columbia has voted unanimously to mandate that insurers offer contraception, breast cancer screening, STI counseling, without raising copays or deductibles. As previously reported, other states such as Massachusetts have protected contraception.
In medical news, we have a great new data gathering resource, Pregsource. The NIH (National Institute of Health) has partnered with ACOG ( American College of Obstetricians and Gynecologists) to gather a wide variety of data from pregnant women. Research on pregnant women is hard to design and fund, since there are concerns about the fetus. But we need usable information on pregnant women just as much as on other people, and so there needs to be an acceptable way to move forward. The idea of including pregnant women in drug studies is rapidly becoming a hot topic, since to date they have mostly been excluded. But this is often without medical reason, and both caregivers and patients are starting to raise the alarm.
Here is Pregsource:
If you are pregnant, there is no reason not to join. Tell your caregiver so they can make their other patients aware. This is a fantastic example of citizen science in action. It is also a relatively low cost way to assemble a much needed research base of data on pregnant women.
In the mostly good news department, Sanofi has devoted what appears to be an effective Zika virus vaccine, It has shown good immunogenicity, and a 90% response. However it has been tabled due to “political pressure over pricing”. I think this is promising since it shows that such vaccines are possible. Apparently there are other similar vaccines in the works. I can’t help but connect the dots between the high drug prices we pay and the amazing things that drug companies are able to do with that money.
Ob/Gyns are becoming a dying breed. I can certainly understand why, what with coverage challenges, political upheaval and malpractice threats. Apparently a new study has shown that 50% of US counties lack an Obstetrician Gynecologist. Just so you know, high risk cases in either Gyn or OB can scarcely be handled by any other types of doctors, except for perhaps general surgeons, and they are generally overburdened to begin with. The number of Ob/Gyns is due to diminish further with a shortage of nearly 8000 by 2020 two years from now.
A new study on oral contraceptive pills is apt to be misconstrued by the media. It is a large Danish study which has shown a slight increased risk of breast cancer with oral contraceptive pill use of at least a year. They hastened to add the the overall all risk was low, and that it was considered safe. However a twenty percent increased risk on top of a very small number is still a very small number. This is the thing I think the press will miss. I hope the press does not fail to point out the very real DECREASE in risk of ovary, uterus and colon cancer that happens at the same time with oral contraceptive pills. And oh, by the way these prevent pregnancy the vast majority of the time, and pregnancy carries its own risks which are not inconsiderable.
In sobering news, research out of the CDC (Centers for Disease Control) has shown that black women in dies in childbirth 3-4 times as often as white women. This circumstance of childbirth highlights the worst case of health related racial disparity that we in the US know. We in the US are on a Perinatal Mortality par with Mexico and Uzbekistan.
If you ask me, now is not the time to be gutting the budget for women’s health.
Stay tuned for more breaking news from the World of Obstetrics and Gynecology.
So by now all of your know that the Republican Tax bill passed. Most of you also know the tax bill is not just about taxes. With it’s passage, the Individual Mandate of Obamacare has been repealed. Therefore it is now no longer incumbent upon people to hold any health insurance. So, like an uninsured driver in a bad accident, someone else will foot the big bill when fit hits the shan.
Those of us in medicine realize that in the short term this will save the Fed money. However in the medium and longer term, it will cost far more than was saved in both monetary, productivity and human terms. I only hope that this resultant data will be kept properly so that can see the true results of our lawmaking and course corrections in policy can be made accordingly. I am beginning to consider all such bills on taxes and health insurance as politically charged estimates, and how costs and benefits actually turn out are another matter. How costs and benefits are actually tallied and reported are yet a third concern, and I daresay I will view all reports with skepticism unless their methods are sources are clearly declared. Transparency in reckoning will be critical, and in this climate of alternative facts, something fundamental will have to change.
The Congressional Budget Office estimates that premiums will go up about 10% for all policies through Obamacare simply because of the loss of the Individual Mandate. The CBO also estimates about 4 million people will either lose or forgo health insurance because of the change.
The current administration is also trying to roll back in the Contraceptive Mandate. This is the part of Obamacare which requires all health insurance to provide coverage for birth control without copay. The Democratic States Attorneys General have banded together to prevent this from happening. Their argument is that the planned rollback of the Contraceptive Mandate "for employers to include birth control in their health insurance plans is an unconstitutional endorsement of religion” and "violates the constitutional separation of church and state and encourages illegal discrimination against women.”
In science there is a phenomenon called a natural experiment. This occurs when happenstance set up a comparison between one set of circumstance and another, allowing a later comparison. For example, there have been instances of twins separated at birth and raised under different conditions. The resulting differences can then be studied.
What if there were a modern country where birth control was not readily available ? What might that be like ? While considering that Venezuela and the United States are very different, one can still view the situation in Venezuela a cautionary tale. Venezuela is experiencing a shortage of birth control. Women are using the “ counting method” otherwise known as rhythm, and using unproven folk remedies. Venezuelan health officials are noting spikes in unplanned pregnancies, sexually transmitted diseases, and unsafe abortions. Data in the United States while the contraceptive mandate was in place show abortion has hit an all time low.
In the nobody-saw-this-coming department, Ob/Gyn residency training programs in Wisconsin and perhaps across the nation might be at risk of de-accreditation. At present, the Accreditation Council for Graduate Medical Education requires that abortion training be part of residency in Obstetrics and Gynecology. Two Wisconsin state representatives have introduced legislation that would eliminate resident’s ability to complete this training, thereby putting the program out of compliance with the accrediting body. As it is, a national shortage of Obstetricians and Gynecologists is looming; it is already the case in rural areas, and will be so everywhere if trends continue.
CMS, the Center for Medicaid Services is floating a proposal to allow individual States to determine what constitutes “ essential benefits”. These are things which insurers MUST cover. As of right now, under Obamacare, things like annual exams, cancer screening, like paps mammograms and colonoscopies, and prenatal care are covered. Medically necessary surgery is covered. Emergency room visits are covered. However, with this proposal, this might change, and it might vary widely between individual states. Health care providers are worried this will leave many necessities uncovered, and insurers are worried States will want to keep insurers providing benefits, which will cost them more money.
The deadline to sign up for the ACA is December 15th. As of last week, about a million more people are signed up than at this time last year. That's what I call an endorsement.
On to the Medical News.
A new study has shown us something we have always suspected. We have known for some time that obesity is a risk factor for uterine, or more specifically endometrial cancer. (Endometrium is the lining of the uterus. ) The reality is even more stark. It turns out that fat cells drive the growth of endometrial cancer cells. In particular, a protein produced by fat cells “tells” endometrial cels to proliferate. It’s one more powerful reason to make sure your weight is optimized
In the we-already-knew-this department, robotic assisted laparoscopic hysterectomy is looking good. In particular, a recently published study compared robot hysterectomies with “open” hysterectomies, meaning the ones using a large incision similar to the incision used for Cesarean Sections. Guess what ? The robot cases with the tiny incisions, precise instrumentation and excellent visualization had better results than the open cases with large incisions, manual instrumentation, and variable visualization. In particular, this study shows they had fewer complications across the board and shorter hospital stays compared to the open cases. I should add that literature and the prevailing experience is that patients having robot cases also have less post op pain.
Stay tuned for more gripping news from the world of Obstetrics and Gynecology, here, next week, on Medical Monday.
Greetings on this Cyber Monday. I am happy to report that we had a great Thanksgiving Break and that I did not even go into town for Black Friday, the official start of the Christmas season. I may however, patronize Cyber Monday. Accordingly, politics has taken a bit of a back seat to commerce and the holiday, and I rather like it. Nonetheless there are a few things to report.
Massachusetts is bringing good cheer as Governor Charlie Baker, Republican (!) signs a law protecting free birth control without copay. The Baker administration has declared that women of Massachusetts right to contraception will be protected regardless of what goes on in Washington. All the while, the Trump administration is trying any way it can to demand the contraceptive protections set in place through the Affordable Care Act (ACA).
Contraception again made the news in that a group of states Attorney's General are filing suit against the Federal government over their weakening of the contraceptive mandate for corporations which hold religious or moral objections to it. I still think it is ridiculous to confer beliefs to corporations.
Meanwhile enrollment in the ACA is up for this stage compared to last year, despite the enrollment time being cut in half.
The funding of the proposed Trump tax cuts is really no mystery. They are to be funded by repealing the individual mandate, the insurance subsidies and the contraceptive mandate, saving the federal government money that would have been spent on health care. The Fed can then garner support from those people who need deductions, i.e. those who have taxable income. The greater the income, the greater the benefit. So yes, the tax plan is a case of robbing Peter to pay Paul where Peter is health care and Paul is people with substantial income. Again, I have have emphasized this so much: Investment into health care pays itself of many times over, in both human and economic terms. The trump Administrations simply does not seem to know or care about this. They are interested in keeping their campaign promise of cutting taxes. However there is no free lunch, and those that elected him should have realized the money for the tax cut would have to come from somewhere. Perhaps Trump supporters value the short term gain of lower taxes more than they value the long term gain brought by comprehensive, universal and affordable health care.
Math: The Trump administration quietly cut $200 million from Teen Pregnancy Prevention Programs only to greatly promote a $10 million dollar program of their own that they have recently unveiled. Their philosophy: abstinence only.
On the medical news. In the Fun and Clever Obstetrics category, there is a new study reporting on work by a Canadian charity to foster early prenatal care in African women. Bridge to Health Medical and Dental is bringing early Ultrasound to women of Africa, but more importantly they are bringing women to Ultrasound. How ? By advertising that “ you will see your baby”. They have shown that women are 9 times more likely to show up for early US if they hear this message.
More Zika data is filtering in. We know that Zika virus infection in pregnancy is associated with a high rate of fetal malformations. However, we now know it is also associated with a very high rate of miscarriage compared to controls. Among those who survive and are assessed at one year, 94 % appear grossly normal.
In the news that may impact you department, we have the revision in the definition of normal blood pressure. Formerly normal Bp was defined as anything less than 140/90. Now it is anything less than 130/80. What’s your blood pressure ? The best thing to do to answer this question is to get a BP cuff for home, ideally one that is smartphone connected. Take lots of readings under different circumstances, and see where you really live. Share your data with your doctor.
We used to recommend having a normal period or two before reattempting pregnancy after a miscarriage. However newer data suggests this may not be necessary.
New data suggests that Advanced Maternal Age patients 35 or older should be induced by 40 weeks. In the past we waited until 41-42 weeks, but this has proven to be associated with increased rate of complications.
Kratom. This is the newest herbal supplement to a.) become popular b.) cause serious health problems and even 36 deaths. It is Southeast Asian plant used to treat pain anxiety and depression. It produces euphoria. People in opioid withdrawal use it on the street to treat their symptoms. It is clearly dangerous and the word is not yet out.
In an interesting twist of research fate, a new study has identified risk associated with the discontinuation of hormone therapy. In particular, women under 60 who discontinue hormone treatment had a higher risk for cardiac death and stroke during the first year of discontinuation. The same was not true in those after 60. Clearly more research is needed to understand the reasons behind this.
Periodically, research comes out noting the association of lower rates of C sections and episiotomies in those who see midwives. Every time I look at this type of research I find it to be disingenuous to some degree. This means, it does not account for the factor of self selection to midwife care or provider veto of midwife care. I am the principal Obstetric backup for our local midwife practice. We work very closely with one another to see that midwife patients are low risk, and that those who become high risk transfer appropriately to a higher level of care. Additionally, Should point out the patients are generally insightful and understand when low risk care is appropriate, and risk themselves out of midwife care when they feel they are likely to have complications. See how all this would skew these studies ?
We know that obesity has many adverse health effects. Here is a new one: Breast cancers in obese women are larger at the time of diagnosis. They are harder to feel, and harder to image as a result of obesity. Another reason to attain a healthy weight.
We have a great entry for the we-already-knew -this-deparment. Americans are not eating enough fruit and vegetables ! Only 12% of Americans ate the recommended amount of fruit while only 9 % at the recommended amount of vegetables. Compliance with recommendations tracked with income but even the highest bracket did a poor job.
Finally, also in the we-already-knew -this-deparment, 71 % of American women would prefer an annual mammogram rather than every two years. Many groups, including ACOG and the American Cancer Society had to publicly disagree with the US Preventive Services Task Force over a controversial interpretation of data in 2009 saying annual mammograms conferred to benefit. Confusion still reigns in the media. In 2016 the USPTF still reaffirmed hat the harms of screening outweigh benefits. Benefits are early detection of cancer, but that is not addressed by their data. Harms they define include pain of mammograms, fear of mammograms, and indicated breast biopsies whose results return benign. I’d say this last one in particular is actually a blessing.
Stay tuned next week more more news from the world of Obstetrics and Gynecology.
The word must be out that the ACA (Affordable Care Act) is alive and well. In the first four days of enrollment, November 1st through 4th, over 600,000 Americans enrolled. That is to be compared to the 1 million who enrolled in the first 12 days last year. This year so far, 22% were new enrollees whereas last year approximately 24% were. These figures do not include enrollees in independent state exchanges created since last year. Insurance companies corroborate that, at this point, enrollment is up compared to last year.
The Congressional Budget Office has revised its estimate of how much the repeal of the individual mandate would it affect the national debt. Initially it was thought that removing the Individual Mandate (the requirement in the ACA that all people maintain some form of health insurance) will result certain number of people not buying insurance through the ACA. Savings would occur because the ACA would not have to spend money to cover these individuals. The initial estimate of these savings was $416 billion. The new estimate of the savings has been reduced $338 billion which still sounds like a lot of savings.
I wanted to know if these big sounding ”savings" included an economic analysis the savings or expenditures outside of the coffers of the IRS. They did not. The actual letter from the Congressional Budget Office to Richard Neal of the Committee on Ways and Means in the US House of Representatives is here:
https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1deficitsanddebt.pdf
It clearly states that while their calculation indicates a savings to the Federal Government by repealing the Individual mandate, it does "not include the macro economic effects of enacting the legislation”. What are “macroeconomic effects” ? These are the economic effects downstream resulting from poorer health and it’s consequences. Have these macroeconomic consequences been precisely defined ? No. But the general trends are clear and overwhelming. Losing health care coverage depresses individual and nationwide economic well being.
Repealing the Individual Mandate leaves more money in government coffers, yes. But so would something ludicrous like ending Medicaid and Medicare altogether. Data from multiple disciplines shows us that money spent on health care is well spent, and results in a saving in the long term. Yes there is a savings in human suffering, and that is paramount. But if you are the sort of person who only wants to speak in dollars and cents, you too will realize a monetary savings. We as a society will realize higher levels of educational and vocational attainment, less unemployment, and greater individual and national economic productivity if we pay now for health insurance. You’ve heard of pay now or pay later ? This is a perfect example of this adage. We pay for health insurance for all, covering prevention and health maintenance, OR we pay later, in more unemployment, more welfare recipients, and the unreimbursed cost of advanced diseases and disability. So do not get too exited about that $338 billion in savings. It is not going to jump right back into your pocket as lower taxes.
The state of Maine is currently a battleground between the people and the Governor's office. Despite a popular vote supporting the Medicaid expansion, the Governor plans to stop it based on his department's analysis of fiscal consequences. He estimates the cost of Medicaid expansion to be somewhere between 63 million and a hundred million dollars, whereas the nonpartisan budget office estimates that the expansion will cost 54 million and bring in an additional 525 million dollars of annual federal aid. I always find these large factual discrepancies disturbing because it seems clear that some of them are informed primarily by party politics. It seems to me that some sort of double-blind research could take place using a high degree of computational analysis. With this, a sound human-free estimate could be generated on pretty much any question. I doubt either side wants this though because it would take away their ability to play politics.
The Massachusetts House has voted 136 to 16 to approve legislation which would protect birth control coverage for women. The law will require health insurers operating in the state continue offering birth control coverage without copayments for prescription contraceptives regardless of changes in federal policy or repeal the Affordable Care Act. The bill also goes further and mandates coverage for over-the-counter emergency contraceptives without a doctor's prescription. The Governor of Massachusetts, Charlie Baker supports this bill. It will be taken up by the Senate this Tuesday. The Senate is expected to approve the measure.
A House bill under consideration would the eliminate medical expense deduction. About 9 million households or 6% in our country utilize this deduction. This is interesting because this deduction could apply to anyone who pays their deductible. I am embarrassed to say that when I was a new business owner in the 1990s I was not aware that my medical expenses not paid by insurance were tax deductible. I later learned this from my accountant. I still find that a lot of people are unaware of this deduction. My total family out of pocket currently sits at about $5000 and we seem to utilize it every year. I can easily document how much of it we utilize through my insurance company's website where I can access my EOBs (explanation of benefits). I simply submit this information to my accountant and it counts as a sizable deduction.
Why the federal government wants to tax expenditures related to health I do not know. You would think they would encourage responsible spending of this nature. You would also think that there are plenty of other things to tax. For example, we already tax vices like alcohol, and tobacco. But we could tax them more. I am a strong proponent of vice taxes because they work. Those intent on buying the substances are willing to pay more to get what they want, and those who are on the fence and want to use less say they appreciate the additional financial disincentive which ultimately results in them using less.
Americans are known for their consumerism. One could argue that we all have far more stuff than we need, and that we are not adequately responsible for repurposing, repairing, reusing, donating, giving, or recycling what we have before we buy something new. What if these such discretionary items were taxed ? What if we made sure that items like food, hygiene products, cleaning products and other necessities like over the counter medications, were not taxed, while so called luxury items, which we do not necessarily need, are taxed. Wait ! We have this already, and in some states it is called a sales tax. It applies to everyone, people can chose to pay it or not, and it does not disincentivize spending on health. Think about it. Government should incentivize individual spending on health and education. In my opinion, this could happen far more than it is.
Doulas. By now you’ve heard of them. They are people, usually women, who help pregnant women during labor. They are espoused by all levels of Obstetric care because of their association with better outcomes. However, they are now being utilized in the postpartum period. We are increasingly focused on postpartum depression and its risk factors. We are also focusing on supporting women as they initiate breastfeeding. Postpartum doulas can help with all of this. They can address some of the exhaustion and sleeplessness that new mother experience by helping with nighttime feedings and infant care. They can help with meals and housekeeping. The American College of Obstetricians and Gynecologists has recently formalized its support for such postpartum care in its recommendations.
For women, the association of moderate to vigorous physical activity and longevity persists even into old age. A recent study where the average age of participants was 72 has shown that those who log an average of 70 minutes of regular exercise a day had a 70% lower risk of death compared to the least active women who move just eight minutes a day. This research is important to me because I have many older women in my practice who feel certain that exercise consists of a leisurely walk. It is true that you cannot take such patients and insist that they suddenly start a program of moderate to vigorous exercise. But you can recommend that they start gradually with supervision, and work their way up to what is actually appropriate. Is high time to stop treating middle-age and older women as fragile.
In sobering news, new data indicates that women treated for early breast cancer still face a risk of recurrence to 20 years later. This data comes from a meta-analysis including 88 smaller clinical trials. The patients surveyed were believed to be disease free. These are patients who completed five years of post cancer therapy with tamoxifen or aromatase inhibitors as recommended. So this study result is an unhappy surprise, but one that should quickly prompt further research, and may even change therapy for such patients in the very near future.
It is interesting to think about this new data in light of the current findings published recently in the Journal Cancer Epidemiology, Biomarkers and Prevention. This study revealed that "many breast cancer patients skip recommended treatment after surgery because they lack faith in the healthcare system”. While these patients did not report distrust of their doctors, they reported a general distrust of medical institutions and insurers. These women were more likely to skip follow-up treatment such as chemotherapy, hormone therapy, or radiation, statistically worsening their outcomes.
Finally in the we-already-knew this department, the International Journal of Public Health has published a study concluding that sexual harassment whether verbal or physical, can “cause psychological harm”. While this seems entirely within the realm of common sense and conventional wisdom, readers should realize that it is critical that studies like this be performed and published. On the basis of studies like these, tangible harms can be demonstrated in a court of law, and justice can be pursued in a more definite way.
Stay tuned next week for more exciting news from the world of Obstetrics and Gynecology, right here on Medical Mondays.
The big policy news is the ACA (Affordable Care Act). It is still in force. Furthermore, As of November 1st, it is enrollment time again, the fifth so far. Apparently 76% of Americans did not know that enrollment started last Wednesday. This is year is different, with uncertainty and confusion abounding. The public needs to be aware that the ACA is still in force, and that those eligible should enroll. A recent poll indicates that 18% of Americans do not think the ACA is still in force. They must be aware they may not see much about it in the media, since the Trump administration slashed funds for advertising by 90%. Moreover, they should be aware that the time for enrollment has been was cut in half, to 6 weeks, with no service for 12 hours on Sundays. The bottom line is that many consumers MISTAKENLY BELIEVE they will not get insurance the next year.
Those that do sign up will find premiums have risen by 37 % on average. This is because of fears, loss of subsidies, and fewer insurers who are participating. All would do well to realize, though, that while there were 167 insurers in 2017 participating, there are still 132 this year. While the Trump administration has cited rising premiums as evidence that the ACA has failed, 80% of consumers can get a plan for less than $75 per month after tax credits.
The States have generally recognized the long term and short term value of the ACA. Accordingly Governors, as a rule, have objected to its weakening. There are, however 12 States, who have taken matters in to their own hands, and run their own marketplaces. These plans will advertise normally, and have appropriate infrastructure to help consumers enroll. They realize that more enrollees makes a more stable market, and one that will run at the least possible cost.
Preeclampsia has made the medical news this week. A new study has focused on the all too common disease process which pregnant women and their babies. An official at the CDC (Centers for Disease Control) has called it the most common severe problem for women in pregnancy. It leads to morbidity for both mother and baby. It has a price tag of over 2 billion dollars annually. And yet it’s exact cause remains unknown. We do know that it is more common in the very young and the very old who are pregnant, as well as the obese, the hypertensive, and those with certain autoimmune disorders. We do not that daily aspirin can help prevent recurrence, but that many patients are not receiving this simple, safe and inexpensive therapy. More research is needed.
Contraception is again in the news. Columnist Bryce Covert has rightly summarized a large body of scientific literature in his opinion piece about the relationship between the availability of contraception and the strength of the economy. He points out that the Trump administration’s curtailment of access to contraception is likely to be associated with a gradual slowing of the economy. If women are able to easily chose the size of their family, they are more likely to chose a size they can afford. If they can put off childbearing until they are finished with education, their educational and professional attainments will be higher before bearing children, should they chose to do so. The pool of workers will be larger, and it will be more skilled. Families will be more solvent and have bigger savings. All these things contribute to the strength of the economy in very real terms.
More good news for breastfeeding. Breastfeeding has numerous benefits to mother and baby. For mother, it helps slow post partum bleeding. It helps loss of pregnancy weight gain. It fosters bonding. It is convenient and hygienic. For babies, it enhances dental health, immunity, and growth of the newborn brain. It fosters bonding. New research also indicates that just two months of breastfeeding lowers the risk of SIDS, sudden infant death syndrome. The American Academy of Pediatrics recommends a minimum of one year of breastfeeding.
Preterm birth rates are creeping up in the US, disproportionately affecting minority women. Complicating matters, is that the one proven preventive, 17- hydroxy progesterone, brand name Makena, is expensive, and is greatly underutilized nationwide, especially in underserved area. And here, I’d like to speak to insurance companies: Think Makena is expensive ? Try comparing that with a long stay in the Newborn ICU !
Stay tuned for more amazing news from the world of Obstetrics and Gynecology, next week, here on Medical Mondays !
In policy news, President Trump has publicly declared the Opioid Crisis a “Public Health Emergency”. In concrete terms, this means that Medicaid money can be used to combat the problem. Trump also explained it also meant there would be money spent in an effort to develop non-addictive painkillers. Thirdly he indicated that there would be an advertising campaign to address the problem.
The idea about non-addictive pain killers is interesting to me. I do not view the opioid crisis as an issue of pain control. I view it as an issue of coping with life. Opioid use may start with need for pain control, but then abuse and addiction develop later from different factors. The FDA( Food and Drug Administration) Commissioner Scott Gottlieb as recommended MAT, or Medication assisted therapy, which combines medication treatment of addiction with counseling.
An undocumented 17 year old at 16 weeks of gestation has succeeded in her appeal to obtain an abortion. Since September, this undocumented immigrant has been detained in a federally funded shelter and has been requesting an abortion. Her case has highlighted the fact that the Trump administration has quietly changed policy on the matter, and now denies abortions to minors in custody. The particular memo is in an email from E. Scott Lloyd, director of HHS (Health and Human Services) Office of Refugee Resettlement. It states “…government funded shelters… should not be supporting abortion services pre or post release; only pregnancy services and life affirming options counseling. “ The position of the Justice Department on the matter was that it did not dispute the Constitutional Right to abortion. However, it asserted that it was not obligated to facilitate abortion by releasing her from federal custody. In order to obtain an abortion, she could either leave the country or find a custodial sponsor. Some accused HHS "anti-abortion zealots" of “holding her hostage” to prevent her from obtaining an abortion. E. Scott Lloyd was an avowed and zealous anti-abortion activist before he was appointed by the Trump administration to the Department of Health and Human Services.
The lawsuit against the Trump administration over the plan to end insurance subsidies was denied by a US District Judge Vince Chhabria. At issue was whether the cessation of subsidies would cause immediate harm to consumer. Somewhat ironically, the Judge argued that since many States had, on an emergency basis, anticipated and provided for shortfalls, that no immediate harm would come to pass. This decision, of course, simply sanctions the transfer of insurance expenses from the Fed to the States, who are variably able to afford them. The Judge also wrote that it was a “close case” and that it was in an “early stage”.
In medical news, it is once again confirmed that the teen birth rate and the US abortion rate fell during the years of the ACA (Affordable Care Act). The US teen birth rate has fallen to its lowest rate since the 1940s. The abortion rate fell the fastest among American teens. Evidence points to contraceptive availability as the cause of the decreases.
At the same time, use of fertility treatments has doubled in the past decade. Twelve percent of reproductive aged women use these services.
Yet another case has been added to a list of cases of babies who have developed a life threatening infection after water birth. While ACOG ( American College of Obstetricians and Gynecologists) supports water labor, it does not support water birth where there is potential for babies to inhale not only water, but particulate matter such as non-sterile blood clot and fecal material, not to speak of whatever else in is the pool. Readers should remember that human lungs are not made to accommodate water, even sterile water or saline. Amniotic fluid may look like water, but its chemical composition and properties are far different.
In the troubling and should-be-easy-to-fix department, we consider US Maternal Morbidity and Mortality. The CDC (Centers for Disease Control) identifies maternal deaths through death certificates. Death certificates are very short documents and do not allow for elaboration. This limited source of information does not allow us to calculate the true rates of maternal mortality or late complications, much less to determine which deaths were preventable. Being simple and brief, these forms foster a gross under-reporting. Surely a more informative digital cloud based solution could be devised.
Texas continues to struggles with a crisis in maternal morbidity and mortality. In particular, African American women are dying or pregnancy and birth related complications at an alarming rate. These women account for 11.8% of Texas births, but 29% percent of Texas pregnancy and birth related deaths. Experts believe potential causes relate to obesity, poverty, diabetes, delayed prenatal care, higher C section rates which result form these other factors, drugs, hypertension and related cardiovascular problems.
In major scientific news, result of the OncoArray Consortium have been published. This is a global project wherein 550 researchers shared genetic data from 300 institutions and 275,000 women, 146,000 of whom have had breast cancer. The work, published in Nature and Nature Genetics, has identified many more previously unknown genetic mutations associated with breast cancer. We have long suspected and counseled patients that BRCA1 and BRCA 2 are probably not the only cancer mutations. Now we have specific confirmation on this. While these results may initially seem daunting, they are the kind of data that can lead to better “precision" methods of diagnosis, prevention and treatment in the not so distant future.
Reader should take note of the multilaterally of this OncoArray Project. The non-academic person understands that research studies take money, time and test subjects. They also understand that more money, subjects and time mean higher quality results. One might ask then why has it taken this long for researchers the world round to combine resources to get truly powerful results ? Indeed perverse incentives have, until recently, been in place to silo, hoard or hide data, one researcher from the next, or one institution to the next, in a climate of competition for research dollars and accolades. Even at present, the open date movement is not mainstream among researchers, nor is the idea of sharing medical record information including genetic information popular among patients. There are costs to sharing data, but the benefits may well prove to be greater.
Did you know that there are various sizes and types of IUDs ? There is most likely one that is suitable for everyone, including teens, women who have not had children, and women near menopause. Many misconceptions about IUDS arise among patients and caregivers. For example, we used to believe that IUDs prevent implantation of a fertilized egg. However, ACOG now recognizes that IUDs prevent fertilization. Many who oppose a method which fosters non-implantation of the fertilized egg will be comfortable using this method knowing its mechanism of action.
“Vaginal seeding” is the deliberate transfer of a mother’s vaginal flora to the infant’s nose mouth or skin. This procedure is under research investigation and should not be attempted at home. Women who undergo C section may have an interest in this as their newborns have not been exposed to vaginal flora like an infant born vaginally would have been. There are very real risks to vaginal seeding, because, as with many things, the devil is in the details. It turns out that vaginally born and cesarean born babies microbiota are slightly different, but that they equalize after about 6 months. It also turns out that breastfeeding provides the best and safest transfer of flora.
Stay tuned next week for more fascinating news from the world of Obstetrics an Gynecology.
Now here is something we haven't seen in a long time. Four days ago on Thursday Congress practiced bipartisanship. With the news the abrupt cessation of insurance subsidy payments by the federal government, those all over the healthcare sector were scrambling. Lawmakers had to cooperate against Trump’s decision or risk chaos. Senators Lamar Alexander, Republican from Tennessee and Patty Murray, a Democrat from Washington state have announced that they have a viable bill. This bill to reinstate subsidy payments has 12 sponsors divided evenly between Republicans and Democrats. These Congressmen are promoting a bill to resume federal subsidies to insurers that Trump has blocked. The Senate Majority Leader Chuck Schumer has confirmed that all 48 Senators would vote for the bill. They number 48 which, when combined with 12 sponsoring Senators who are already known to support the bill, would give 60 votes at least, enough to defeat a filibuster.
Good thing lawmakers have decided to try to cobble together a solution to this problem. It turns out that several powerful states have banded together to sue the Trump administration over the decision to end ACA subsidy payments. Lead by the attorneys general of both California and New York the states include California, Connecticut, Delaware, Kentucky, Illinois, Iowa, Maryland, Massachusetts, Minnesota, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia and Washington state. Additionally, the healthcare industry and the insurance industry have roundly condemned the interruption of subsidy payments, stating that this move will cost US economic and health harm.
A group of medical associations, the so-called"Group of six”, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association, has made a joint statement “ Our organizations strongly reject a marketplace that allows insurers to discriminate against any individual based on their health status age or gender allowing insurers to sell narrow, low cost health plans likely will cause significant economic harm to women and older sicker Americans who stand to face higher cost and fewer insurance options."
Concerns have already been raised that restoring subsidies paid from the federal government to insurance companies would benefit it insurers more than consumers. The authors of the bipartisan bill, Alexander and Laurie, and explicitly addressed concerns that"Restoring the payments to insurers could be viewed as… a bailout”. They indicated that the agreement would contain"The strongest possible language" to insure that the money provided for the subsidies would go to the benefit of consumers, not insurers. It is unclear at this time whether or not this bill, once enacted, would prevent some or all of the large rate hike that all of us can expect in our premiums this next year.
The fine details of women's reproductive health care are very much on the table in this political climate. As you are no doubt aware Trump has weakened the Affordable Care Act’s contraceptive mandate. Last week he created a loophole which will allow employers to stop providing birth control coverage in their corporate insurance plans if they have religious objections. This week the bill has been introduced to reverse this exception. The bill is called"Protect Access to Birth Control Act”. Unfortunately it does not yet have the bipartisan support that it needs.
A Denver school teacher, Jessica Campbell, has filed a federal lawsuit against the Trump administration for it's modification of the contraceptive mandate in the Affordable Care Act. The suit names the President and his Secretaries of Health and Human Services, Labor and the Treasury.The suit states that the exceptions “jeopardize women's health and economic success in order to promote certain religious and moral views by attempting to nullify the right equal access to preventive medical care, particularly contraceptive care and services, protected by the US Constitution set forth by Congress in the Women's Health Amendment to the affordable care act.” The suit seeks to prohibit enforcement enforcement of the changes.
The Omaha World Herald, has surveyed several large Nebraska and Iowa employers. They presented their informal findings in a recent article which explains that according to their survey, most Nebraska and Iowa employers will continue to offer insurance plans with contraceptive coverage.
IUDs (Intrauterine devices)are one of the best and one of the most expensive contraceptive methods. This is because they're extremely effective with very low failure and complication rates. It is also because they are able to be used by women who cannot tolerate hormones. Although the most popular IUDs contain hormones they contain only enough to treat the lining of the uterus and they do not produce systemic effects outside of the uterus. The their side effect rate is low. Some experts worry that because this method is particularly costly i.e. somewhere upwards of $1000, Women may lose effective access to it.
Dr. Haywood Brown, President of the American Congress of Obstetricians and Gynecologists has written an opinion piece indicating that he is opposed to the Trump administration’s ”…regulation that will threaten contraceptive access for women everywhere, particularly in underserved rural communities”. He argued that access to contraception” amounts to more than just dollars and cents. It can be life saving for women who already faced serious medical conditions such as heart disease, diabetes and high blood pressure."
Access to all forms of reproductive health care have been compromised in various ways under the Trump administration. An important methodology utilized by the Trump administration has been the political appointment of many antiabortion and anti-contraception activists to government positions despite lack of qualifications. It is ironic and disturbing that the restrictions placed on contraception, a benign medical treatment, will lead to a certain increased rate of abortion.
On to the medical news.
In the good news department, vaginal estrogen is safe for all postmenopausal women. This includes women who have had a hysterectomy, women who still have an intact uterus, women with history of cancer, those with cardiovascular disease, only those with thromboembolic history such as a deep vein thrombosis for a pulmonary embolism. The results of this study presented recently at the annual meeting of the North American Menopause Society also fall under the category of the we-already-knew-this department. This is because we have always known that estrogens given vaginally do not get into the systemic circulation, this research finding is worth reiterating because indicates that no post menopausal woman need suffer with a painful atrophic vagina.
Also in postmenopausal news, and in the we-already-new-this department, a new study confirms that oral estradiol and progesterone may improve menopause related quality of life. While this type of therapy reduces hot flashes and mood instability related to menopause, but it's use is constrained particularly in those who still have a uterus. This is because the administration of the combination of both estrogen and progesterone may only be given for about five years or the shortest amount of time at the lowest effective dose. After five years or so concerns begins to mount for increasing risk of breast cancer and cardiovascular disease.
There is an increasing number of women in South Carolina who are giving birth without any prenatal care whatsoever. It has been long established that lack of prenatal care is a contributor to for birth outcomes.
Tanning addiction is real, and it increases risk of skin cancer. A new study published online any October 11 edition of Cancer, Epidemiology, Biomarkers and Prevention, Young white women with a history of depression were found become prone to tanning addiction. Indeed, over 20% of young white women who have frequented at tanning salon do become addicted to tanning. The study noted that these young women "depend on tending to feel attractive often show symptoms of depression.”
Oral HPV and the disease that it produces are increasing. HPV stands for human papilloma virus and it is the virus responsible for general warts, cervical cancer and cancer of the mouth and throat. Girls and boys between the ages of 926 should be completely vaccinated against the virus. The vaccine remains underutilized and many do not realize it must be given to males as well as females. I'm going data on the vaccine continue to confirm its safety.
At the present 7% of women with breast cancer are younger than 40 years of age. It Is noteworthy that this percent has been increasing since the mid-1990s. With all the debate about mammogram testing frequency and age at first mammogram, I wonder how we can be expected to screen for these cases among young women. At present, the debate is between whether to start mammograms at age 40 or age 50. With increasing cases in women under 40 this provides a good argument for the breast self exam and also to tailor mammogram screening to risk factors.
In related news, the percentage of women who opt for breast reconstruction surgery right after mastectomy for cancer is increasing rapidly. Over the past five years the proportion of breast cancer patients opting for reconstruction grew by about two thirds. In 2009 only about a quarter of women opted for reconstruction whereas more recently in 2014 and 14 the number rose to 40%.
Obstetric history stays important long after your last baby is born. Preeclampsia may indicate a tendency towards high blood pressure later in life. Similarly, pregnancy associated or gestational diabetes can signal a risk for diabetes and even heart disease later in life. Recent study published online in JAMA internal medicine has shown that patients with a history of gestational diabetes can mitigate their risk for cardiovascular disease by healthy lifestyle. In particular, gestational diabetes was not significantly associated with cardiovascular disease risk elevation among women he maintained a healthy diet, were physically active, never smoked, and maintained normal weight.
A rather fascinating new bit of research indicates that lack of sleep could raise a pregnant woman's risk for gestational diabetes. In particular, women he slept less than 6.25 hours and I were almost 3 times likely this study tells us nothing about which where the causes and which were the effects. Still it is an interesting relationship and one which deserves more scrutiny perhaps even outside of pregnancy.
The CDC(Centers for Disease Control) has released a new data indicating that obesity rates among US adults is steadily increasing with the current rate of about 40%. This is not near overweight where the body mass index is between 25 and 30. This is obesity, with body mass indices in excess of 30. Approximately 30% of people where obis in the year 2000 15+ years later that is increased by 10% to 40% of all people. Of course there's significant state-by-state variation but the numbers are formidable across the board. For every state where the percentage is lower than that there is a state whose percentage is higher. Obesity sits with mental health and addiction as the three topmost priorities the Department of Health Services.
These days, when a patient asks to have her tubes tied, we may suggest that she have her tubes altogether removed. This is because of the relatively new Revelation that many if not most of all ovarian cancers actually come from the tubes. Thus we can get some theoretical and hopefully real cancer reduction by removing the temps instead of merely tying them for cutting them. This interesting conclusion about the origins of "ovarian" cancer have come from the nascent field of molecular genomics.
Stay tuned next week for more news from the breaking world of Obstetrics and Gynecology.
Policy News this week is monumental. President Trump signed an “ executive order” which allows small businesses and individuals to buy cheaper less comprehensive policies which do not met the minimum ACA (Affordable Care Act) requirements. Critics have several issues with this legislation. First, it decreases money in the collective pot used to cover anyone with a catastrophic illness for which a large payout is required. Second, it will drive prices up disproportionately, hurting mostly older Americans.
Perhaps more impactful is the Administration’s decision to stop making federal subsidy payments to insurers. It is effective immediately. The President has further said that it may continue subsidy payments if a bipartisan agreement is made on health care. This last bit may illuminate the whole issue. When I first heard this announcement about cutting of subsidies, I ascribed it to wholesale lunacy. However now I view it more as blackmail. Without subsidies, the insurers will either bail or fail. Then the economy will follow, according to many analysts. No administration wants this. A bipartisan agreement has been impossible to craft, thus far. However, opposition to this move, and even opposition to the President himself may cause a high degree of motivation to compromise. Leading Republicans have called for continuing payments to insurers. As you read this on Monday, I wager you will be hearing fierce objection from both sides of the aisle.
Hot off the press is an announcement that the current Administration will allow health insurance sales across State lines. Many of us did not realize that health insurance is sold within a given state. Insurers and their plans must be approved within that State and must answer to that State's Insurance Commissioner. Trump and many other Republicans have endorsed this before. They have asserted that, through increased competition, premium prices will drop across the board. However, the National Association of Insurance Commissioners has called this a "myth". They have warned that this will start a " race to the bottom" wherein Insurance Companies will choose more lenient State regulators. Such regulators would require less and less coverage to consumers in order to maximize profits. This would result in healthier people getting cheap policies that cover little, and everyone else needing standard coverage getting steep rate hikes to compensate for the insurance company's loss in revenue.
Unbeknown to most of us, the insurance industry was the Wild West before the ACA came along. Most of us only knew about insurance in their own State. But, it turns out there were different levels of what was covered, different caps on out of pocket, and different limits to premium prices. That all got more standardized with the ACA. That standardization is now being deconstructed bit by bit by changes like this plan of selling across State lines.
The Department of Health and Human Services has put forth a couple of deeply controversial issuances. They have issued new rules on contraception. Without data or authority they have stated that “ Imposing a coverage mandate on objecting entities whose plans cover many enrollee families who may share objections to contraception, among some populations, affect risky sexual behavior in a negative way.” Importantly, this sentence uses confusing syntax. The subject of the sentence is “ a coverage mandate”. The verb phrase is “would…affect” the object is “risky sexual behaviors”. Thus the gist of the sentence it, a coverage mandate would affect risky sexual behaviors. Perhaps they meant to say the following: contraception WHICH could, among some populations, affect risky sexual behavior in a negative way. I suggest this because they have taken this position before: that contraception promotes sexual activity, particularly teen sex activity. A mass of available up to date and well derived data indicate otherwise. For example, no-cost contraception is associated with a decrease in the number of partners. Additionally, contraception is NOT associated in a rise in sexually transmitted infections. Available research data clearly show too that rates of abortion and pregnancy fell among teens, when no-cost birth control was provided. ACOG (American College and Obstetricians and Gynecologists) has voiced it’s objections to the weakening of the contraceptive mandate. They have shed light on the patently false claims of the Administration about contraception. Many States have sued the Administration over the weakening of the contraceptive mandate.
The second controversial issuance by the Department of HHS, Health and Human Services, has been to define life as “beginning at conception”. It has done so through a strategic plan document. This draft reads “HHS accomplishes its mission through programs and initiative that cover a wide spectrum of activities serving and protecting Americans at every stage of life, beginning at conception.”. Defining life at conception is not arguable in scientific terms. That is because it is a belief. In fact, it is a religious belief. As such, one might ask whether including this language in the strategic plan document of the HHS violates the separation of church and state. Clearly this language was advanced by those whose religious beliefs preclude abortion.
I do not believe there has ever been a time in history when government has been so intimately involved in matters pertaining to Obstetrics and Gynecology.
Pap smear frequency is again becoming controversial. As usual, the minimalist and government funded USPTF ( US Preventive Services Task Force) has interpreted the available data to mean the need for less frequent screening. They seem to consistently overemphasize the harms of screening (extra false positives, extra office biopsies) and consistently underweight the harms, i.e. more cancer cases. ACOG, various other cancer organizations, and patient advocacy organizations, give less weight to extra false positives and biopsies, with more concern focus on catching cancer early. ACOG still states that paps and HPV testing should go together from 30 to at least 65 years of age, and that for an average risk patient. Smokers, for example, would be screened, even more often.
In the we-already-knew-this department, a new study shows that epidurals do NOT prolong second stage (the pushing part) of labor. The study, published in Obstetrics and Gynecology, also show no adverse effects of epidural on mother or fetus.
Also in the we-already-knew-this department, a new study shows that women who have their fibroids embolized may need additional procedures. In particular, they have a fair chance of still needing a hysterectomy later. These women who go from embolization to subsequent hysterectomy were still better off in terms of complications than those getting myomectomies (removal of the fibroids from the uterus) to begin with.
Finally for a trifecta in we-already-knew-this department, we feature a new study which indicates that “intensive exercise may attenuate excessive gestational weight gain for obese pregnancy women”. Excessive weight gain in pregnancy increases the odds of gestational diabetes, large for gestational age babies, and need for C sections. Research elsewhere also indicates that exercise in pregnancy also produces many other good effects, such as increased likelihood of vaginal delivery.
Somewhere between politics and medicine we find people and society, and society has a lot to do with health. This week those in the entertainment industry have been reeling from all the revelations of sexual abuse and misogynistic workplace bullying by Harvey Weinstein. It has been sickening and yet illuminating to read the accounts of the women involved. The victims were abused in various ways. Those that escaped unscathed, had career setbacks by failing to acquiesce. They all suffered the shame and anger associated with such encounters, and even now are having to answer for why they did not disclose sooner, why they acquiesced, why they did not have more sense to begin with, etc. etc.
see:
http://www.vulture.com/2017/10/the-harvey-weinstein-sexual-harassment-assault-accusations.html
It is widely believed that Harvey Weinstein is not the only such perpetrator in Hollywood. It is also well known that Hollywood is not the only industry where this occurs. Although Weinstein's victims were generally celebrities, most victims are not. Yet even these celebrity women were caught off guard and were made to feel powerless and vulnerable. How much more so must the average woman feel, working a standard paying job on which they depend.
Harvey Weinstein’s methods were outrageous. The vaster number of abuses in the workplace today are far more subtle. They are microaggressions. They are just enough to make you uncomfortable, but not enough make you realize it is abuse, much less move forward to report it. All of this adds up over time, and it takes a toll professionally and personally, and on stress levels, which eventually impacts health. I had one patient who developed certain medical problems. In taking care of her and getting to know her better, it turned out she had an extremely hostile workplace environment. We encouraged her to speak to people at the local department of labor. After a lot of effort and gumption on her part, the case went to the courts, where she prevailed. She emerged empowered and eventually healthy. But it had been years that she had suffered before she understood what she had actually been dealing with and where it fit on the spectrum of normal social interactions.
Sometimes we do not realize that what we live with may not be normative. Our standard for what is acceptable behavior may be skewed due to a rough upbringing, or a innate tendency to think that we ourselves are the problem. If you think you may be living or working in some kind of an abusive environment, reach out to a trusted physician, attorney, local social services agency, community health center or mental health professional. Life is too short to let your quality of life or health suffer.
Stay tuned for more news from the work of Obstetrics and Gynecology her, next week, on Medical Monday.
Please remember to contact your elected officials to tell them what you think about all of this.
As I step back and look through my last year of posts I am astonished to the extent to which politicians are getting deeply involved in the particulars of my profession, Obstetrics and Gynecology. This week's post underscores this in no uncertain terms. Is this really where we want government and politicians, right in the middle of a very specialized medical field, and right in the middle of the doctor patient relationship ?
The New York Times has reported the the Trump administration plans to expand exemptions to the so called “ contraceptive mandate”. They are not abolishing the contraceptive mandate at this time. However, they are allowing employers to chose plans that do not cover birth control. These employers or insurers must be exempted on basis of “sincerely held religious beliefs”.
It is my assumption that it is employers’ assumption that such plans which do not cover contraception are less expensive. However I feel entirely comfortable asserting that insurance companies know precisely where their dollars go, and they will not, for one minute, pass the savings on to the employer. That is because in about nine months after institution of this policy, there will be no savings. Seriously, do people really think that pregnancies and miscarriages will cost less than contraceptives ?
As far as religious objections go, there are ostensibly several considerations. First, social conservatives have argued that the use of contraception encourages what they view as illicit or teen sex. This has been proven not to be the case. Moreover, they may object saying that contraception causes abortion. IUDs do act in part by preventing implantation of fertilized eggs, but they also act by causing cervical mucous to become viscous and block the cervical canal, preventing fertilization in the first place. So in this sense, a few fertilizations may take place which cannot implant. However, and critically, without any IUD or other birth control in place, as many as 25 % of fertilizations which do occur simply do not implant naturally, or they implant and naturally fail. Thus, with an IUD, a very small percent of fertilizations occur and do not implant. Without an IUD or other birth control method, 25 % of fertilizations fail and are lost, most before the period is even missed. In the end, there are many more natural abortions that there are IUD related abortions. If an abortion is an abortion, and one wants to minimize their numbers, one would certainly want to provide as much contraception as possible. A true anti-abortion advocate should espouse both IUDS and other forms of birth control, especially pills which prevent ovulation.
But it seems those who are anti-abortion are interested in more than just preventing abortion. They are interested in legislating a world view and lifestyle. They see a world where there is only one right way to live, and that those who live this way should have power over those who don't. I can only conclude this because of the “don’t bother me with the details” approach of much of the GOP on numerous scientific and medical issues such as contraception. If the GOP really cared about strengthening families, preventing abortion, and the health of infants and children, they would choose policies scientifically proven to meet these goals. ACOG ( The American College of Obstetricians and Gynecologists) has already come out against the bill since it is at odds with those goals.
It becomes somewhat misleading to write so much about abortion policy since there are so many other pressing medical policy issue of the day. However, so much is happening in this area that it behooves me to report on it. For example, the ACLU (American Civil Liberties Union) has sued in Federal court in Hawaii challenging restrictions on the use of Mifiprex, the so-called abortion pill. They have argued that it should be available by prescription in a pharmacy. At present, a clinic or hospital visit is necessary. Particularly in the Hawaiian islands, access to clinics is variable. Mifeprex has been determined safe and legal, so ACOG has supported this suit. My concerns with pharmacy dispensing is that patients with positive pregnancy tests should have a reasonable idea of their gestational age before they take the medication, and that ectopic or tubal pregnancy not be missed.
The House just approved the “Pain Capable Unborn Child Protection Act” which bans all abortions after 20 weeks. ACOG’s position is that a fetus cannot feel pain until 24 weeks. You just have to continue asking yourself, how do organizations and people formulate their opinions ? What data do they use ? Do they use data ? Would they know bad data from good data ?
Forget alt facts. This next report shows us how far certain members of the GOP are wiling to go in their separation of politics from reality. Former Congressman Tim Murphy, a Republican from Pennsylvania, was a staunch anti-choice politician. However, he was recently caught telling his mistress to get an abortion. Think this is this height of hypocrisy ? Think again. Mr. Murphy promptly recused himself and resigned. Not Scott Dejarlais. This physician and Republican Representative from Tennessee circa late 1990s, called himself “pro-life”. However, he had multiple affairs with 3 co-workers, a “drug rep” and at least 2 patients ! At his divorce, he testified that he had supported his then girlfriend and now ex-wife to get two abortions. You would have thought he too would leave politics. However he has since been re-elected twice. The people have spoken and will get what they deserve.
Finally, in a surprising turn of events, the Republican Governor of Illinois, Bruce Rauner, has signed a bill allowing Medicaid to cover abortions. He has stated that he does not feel women of different means should face different options. He has gone on record as a pro-choice Republican.
Meanwhile the entire hurricane belt suffers under a burden of destruction and disease. There is a shortage of just about everything, from basic needs, to power, to medicine, doctors, and means of transportation to get all of it where it needs to go. Shortages of pharmaceuticals in particular may be felt all through the US based on the increased need in the South.
In medical news, we shift our attention to yet another case where beliefs seem to supersede science. Witness the practice of certain women of a more "natural" bent taking their placenta home to consume. It’s meat, right ? It’s even your own tissue, so what’s the big deal ? Most mammals do it. Modern women can have it various ways, but the most refined way is to have it “ encapsulated”. It turns out that “placentophagy" can make you and even your baby infected and sick, through pathogens (bacteria) that would have been killed by your own immune system, but aren't since they are separated from it and encapsulated into little gelatin capsules for swallowing. Moreover, the hormones in the placenta are NOT what you want after birth. The whole mechanism of uterine involution (contracting to prevent bleeding) and nursing is triggered by the expulsion of the placenta and it’s hormones. It is the expulsion of the placenta that changes you from pregnant to non pregnant. If you had complications in pregnancy like hypertension, you won’t get better until all your placenta and it’s hormones are gone.
A new study has shown that those who drink four cups of coffee per day have a 64% lower risk of early death. I would like very much to see that stratified by sex and age. Men do not have to worry about osteoporosis ( bone thinning) as much as women. Caffeine does thin the bones, and bone fractures in old age are a tremendous source of morbidity in older women. Women who are pregnant certainly should not drink that much caffeine. We ask our pregnant patients to limit their caffeine intake to 200 mg per day which is alot less than four cups. More than 200 mg per day of caffeine is associated with poor fetal growth. Whenever hearing results of a research study, ask yourself several questions. To whom does it apply ? Did they include women in the study ? What does this mean for women, or for a person like me ?
Once again we have new evidence linking obesity with more than just diabetes and heart disease. A new report from the CDC (Centers for Disease Control) has indicated that “excess body fat accounts for at least 13 different kinds of cancer. This study looked at over 600,000 people in the US in 2014. Obesity rates have increased even more since then. Results like this should change the way we think and teach about obesity.
We have already mentioned the Southern United States in this post - the Hurricane belt. That same area is also know as the fat belt, also the bible belt. New data also shows that those in the deep south and midwest have higher smoking rates than the national average. In that area 22% of adults smoke, compared with 15% in the rest of the US. Could there be cultural reasons for the smoking and obesity ?
A few years ago there was a bit of a scandal pertaining to a drug to treat preterm labor. Sold as a name brand, it was exorbitantly expensive. Generic, or even compounded, it was very cheap. It came down to FDA approval as to whether it could be sold as generic. First it couldn’t, then it could due to public and medical outcry, then it couldn’t again due to concerns about safety efficacy. However, now a new study published in JAMA Internal Medicine has indicated that the two preparations are equivalent. It will be interesting to see how long this data takes to get translated into policy, and we can once again buy cheap generic and have it be covered by insurance.
In the good news department, breast cancer rates are declining. The American Cancer Society reported that breast cancer deaths increased through 1989. Thereafter, they have been on a steady decreased, altogether down 40 % since 1989. This attributed to better treatments and medications.
Stay tuned for more fascinating news from the world of Obstetrics and Gynecology, next week, on Medical Monday.
Policy has marched on, despite my delay. Last week, the Graham Cassidy Bill to replace the Medicaid Expansion with State Block grants fell with a thud without even being brought to a vote. This is because it did not even have enough Republican support.
Early in the week, the Secretary of the Department of Health and Human Services resigned amidst constroversy. He was criticized for his extensive use of taxpayer funded charter flights. He was, by those in the medical community, not considered to be a friend of health care. He was viewed as a political appointee there to tow the party line.
Most recently, Senator Bernie Sanders has revealed that this administration has been giving consideration to cutting Medicare as well as Medicaid. Medicare is the Federal Health Insurance Program for the elderly and the disabled, which Medicaid is the health insurance program for the poorest sector. Democrats allege these cuts in health care for vulnerable populations would be used to finance tax cuts “for the rich”.
Premium prices for those purchasing health insurance through the ACA will most assuredly increase. Some increases will be more than 50%. This increase in cost of insurance premiums is NOT based on any definite information of federal subsidies reductions. Instead it is based on the THREAT of reduced or eliminated subsidy payments. Uncertainty and instability from the Federal government is causing insurers to raise prices, and is causing in insurance commissioners to allow them to do so. All premiums for all insurance plans are likely to rise.
Prescription drug prices are likely to rise. The FDA (Food and Drug Administration) Commissioner Dr. Scott Gottleib, has declared that these high prices are a public health concern. In response, he has indicated a commitment to “more efficient generic drug development, review and approval”.
Such uncertainty means hospitals and insurers will be unable to predict their income. This is causing them to take conservative positions across the board. This has also resulted in the closure of many rural hospitals, and the closure of maternity units within otherwise operational hospitals. More than half of all rural counties to not have a a prenatal clinic or Ob care facility.
As discussed previously, several states have taken matters into their own hands. A red state, Utah, is fielding a proposal to expand access to birth control for low income women. Utah State Representative Ward has cited patient autonomy and cost savings as the driving benefits behind the bill.
The morning after pill, widely considered in medical circles to be utterly safe, is now being dispensed from vending machines on certain college campuses.
Massachusetts is considering a bill ensuring the provision of free birth control. This bill required the input of the third party payers, the insurance companies, as well as reproductive health advocates. It is expected to pass.
In medical news, I am happy to announce the official eradication of infant and maternal tetanus. This infection once killed 10,000 newborns per year in the Western hemisphere. This has been at least in part due to the successful vaccination program using DPT in the past, and TDAP more recently.
TDAP stands for tetanus, diphtheria, and acellular pertussis. Pertussis, also known as whooping cough, is a bad nuisance for healthy adults. However, it can be fatal in infants. All pregnant women are encouraged to get a TDAP booster in the third trimester. This turns out to confer 90% pertussis protection to the newborn. However, only half of all pregnant women got the vaccine.
Confirmed: hormone containing IUDs do not adversely impact breastfeeding. A new study confirms what we would already expect. We expect this because hormone containing IUDs do not send hormone into the greater circulation; only to the lining of the uterus itself. This is also the reason why they do not confer systemic side effects.
In the bad news department, the CDC (Centers for Disease Control) report that sexually transmitted diseases are at record highs, for a second year in a row. This includes Chlamydia, gonorrhea, and syphilis. This is attributed to budget cuts impacting screening and treatment clinics but also to better testing methods. Chladmydia is soaring in women, while syphilis is most prominently increasing in gay and bisexual men.
Much needed increased attention is being paid to post partum depression. I attended a conference today where it was highlighted that depression in this case is really a misnomer. The most common presentation of postpartum depression is anger or anxiety. A new study highlights that post partum depression is 27-47 times more likely to recur in a patient who has had it once. Postpartum depression has good treatments. More awareness and aggressive screening in the early post partum period is our best defense.
Now we are up to date ! Stay tuned for more exciting news from the world of Obstetrics and Gynecology , here, next week, on Medical Monday.
The Graham-Cassidy Bill leads the policy news this week. This is the GOP's last ditch attempt to repeal the ACA (Affordable Care Act). It has been simplified down to one key point : redistributing Federal funds for Medicaid expansion and insurance subsidies as State block grants. The bill was introduced by two GOP Senators, Lindsey Graham of South Carolina, and Bill Cassidy of Louisiana, and with support from others.
During the week that the Graham Cassidy bill has been around, it has been scrutinized. The Kaiser Foundation has determined that the redistribution of funds in those plan would be quite unequal between States. Consider that different States expanded Medicaid more than others, and some did not expand it at all. What States would stand to have taken away would therefore vary. Overall Federal spending on health care would drop by more than 100 billion dollars between 2020-2026 under this plan. Many physician groups have also criticized the plan. Most notably, ACOG (the American College of Obstetricians and Gynecologists). Eleven Governors including some from the GOP have come out against the bill as well.
It is unclear if there will be enough votes to pass this bill. More than 50 are needed. Toward the end of the week Senator John McCain has stated he will not support it, and that alone may doom it. Remember that Senator McCain was recently diagnosed with brain cancer this last year, and is therefore deeply involved in the health care world.
The deadline to pass this bill is September 30th. But it will only be brought to the floor if it is determined beforehand that it will pass. This deadline is needed in part because insurance companies and insurance commissioners need to settle on rates which the commissioners will approve and that will keep the insurers solvent.
The Iowa legislature voted to forego Federal Funding just so they could deny funding to Planned Parenthood. Now the Iowa Department of Health and Human Services is beginning a collection of data about the effects that this is having. They are trying to determine if defunding Planned Parenthood has reduced access to reproductive health services for Iowans. Seems bass ackward to me.
In a interesting and positive turn, State Senator Ray Ward, a Republican out of Bountiful, Utah has proposed a bill that would allow Utah Medicaid recipients to have a postpartum IUD placed while they are still at the hospital. This would bring the red state in line with all but 6 other states which lack this law.
On to the medical news.
How bad is the opioid crisis ? It is so bad that death from opioid overdoses is skewing our life expectancy gains statistics.
Women and opioids are a special case. It turns out opioid addiction and sexual violence are closely linked. In these cases, police are seldom called due to the presence of the drugs and fear or retaliation.
Speaking of drugs, ACOG has come out with a new Committee Opinion. In this latest document, they have stated clearly that pregnant and breastfeeding women should not use marijuana.
In the this-makes-perfect-sense department, a new study out of Harvard has shown that adequate sleep and adequate support protect against postpartum depression. That said, even those with high levels of support can get postpartum depression. For example, Ivanka Trump has recently shared her story of postpartum depression.
An insulin pump may give better control to pregnant diabetics than conventional prick and inject methods.We currently use insulin pumps in non-pregnant diabetics, but have not until now, seen evidence about their use in pregnancy.
There was a recent Apple event with new product announcements. In it, mention was made of the Apple watch, and the app called Health Kit, and their potential for ultimately helping patients like diabetics. Fast forward only a few days later when I attended Stanford MedX conference. We heard from a young diabetic woman who solved her own problem. Using small cheap components and a little home built computer set up called raspberry pi, she combined a blood glucose sensor with some dosing software and an insulin pump to create her own “ artificial pancreas”. We heard her presentation as an example of what an empowered patient could do. Empowerment plays a huge role in healing.
The opposite of empowerment is psychological trauma, with resultant PTSD. It turns out that this sort of thing significantly increases one’s risk of being diagnosed with lupus. Lupus is a serious autoimmune disorder characterized by inflammation of the joints and many other tissues. According to a study published in the Journal Arthritis and Rheumatology, trauma even without PTSD are than doubles the risk of getting the disease. Those with PTSD are three times more likely than their peers to get lupus. Nearly 55,000 women’s questionnaires were examined over a 24 year period. This news reinforces the already widespread advice that stress management is important.
Stay tuned for more exciting news from the world of Obstetrics and Gynecology, next week, on Medical Monday.
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.
I have lived through two hurricanes, Camille, and Agnes. I was a child, and when I lived for time in St. Petersburg, Florida, hurricanes were nothing but fun and games. We skipped school, had no power, and ate snacks. When it cleared, we rowed, paddled and boated all over the streets and the bayous which had become one. Harvey and Irma are another matter entirely.
I encourage everyone everywhere to explore the internet or other news media to understand the gravity and breadth of the situation. See the radar, see the satellite video, see the webcams, news and personal videos, the photos, and hear the personal accounts.
Put yourself in these people’s shoes. And then consider the ramifications of all of this on health. I will present some data and recommendations gathered by the CDC (Centers for Disease Control) in the wake of Hurricane Katrina. It is hard to say exactly how much of this could be generalized to other areas such as Houston or the Florida area, but I would suppose it is a reasonable starting place.
Here are some key points from the CDC:
Here is a key recommendation:
Consider that structures and infrastructure are damaged. This means not only homes and public buildings, but power plants, power lines, sewage treatment plants, and water lines. It means chemical plants and damaged. It also means that people in shelter are in close quarters with out adequate food or sanitation. Telecommunications are disrupted. Finally it means that hospitals, clinics and the movement of medical personnel are all disrupted.
What illnesses are to be expected ? In the above described setting, infectious rashes are common, with near universal exposure to polluted floodwaters. Respiratory infections come next, followed by Gastrointestinal illness. Vibrio cholera played a large role in GI illness, and other forms of the waterborne vibrio bacteria accounted for the serious skin infections.
Viruses also entered the picture, particularly the mosquito borne type. Remember that mosquitos reproduce in standing water. Human West Nile Virus had an uptake, but this year, officials anticipate Zika virus will be the major player.
Trauma of all kinds counts for most presentations to hospitals. Cardiovascular causes are a far second, with medication refills being a third. These three accounted for the vast majority of presentations to hospitals in the wake of Katrina.
Evacuees in the aftermath of hurricanes are at the most risk. Vaccinations are a key aspect of care for evacuees. For those evacuees in a group setting, the following are recommended: Influenza, varicella, MMR and Hepatitis A.
Emergency responders are another special group requiring care. Vaccination recommendations for this group include Tetanus if not up to date, Hepatitis B, and the same vaccinations as are given to evacuees if responders are working in large group settings.
reference :
https://depts.washington.edu/einet/symposium/USA031210.pdf
For critical additional reading :
https://www.cdc.gov/disasters/hurricanes/index.html
Please familiarize yourself with what is going on. Figure out how you can help.
I have lived through two hurricanes, Camille, and Agnes. I was a child, and when I lived for time in St. Petersburg, Florida, hurricanes were nothing but fun and games. We skipped school, had no power, and ate snacks. When it cleared, we rowed, paddled and boated all over the streets and the bayous which had become one. Harvey and Irma are another matter entirely.
I encourage everyone everywhere to explore the internet or other news media to understand the gravity and breadth of the situation. See the radar, see the satellite video, see the webcams, news and personal videos, the photos, and hear the personal accounts.
Put yourself in these people’s shoes. And then consider the ramifications of all of this on health. I will present some data and recommendations gathered by the CDC (Centers for Disease Control) in the wake of Hurricane Katrina. It is hard to say exactly how much of this could be generalized to other areas such as Houston or the Florida area, but I would suppose it is a reasonable starting place.
Here are some key points:
Here is a key recommendation:
A brief search on the Apple App store reveals several useful apps. Check out the ones from the Red Cross, FEMA, and the National Weather Service. As of yet there is no comprehensive evacuee app.
Consider that structures and infrastructure are damaged. This means not only homes and public buildings, but power plants, power lines, sewage treatment plants, and water lines. It means chemical plants and damaged. It also means that people in shelter are in close quarters with out adequate food or sanitation. Telecommunications are disrupted. Finally it means that hospitals, clinics and the movement of medical personnel are all disrupted.
What illnesses are to be expected ? In the above described setting, infectious rashes are common, with near universal exposure to polluted floodwaters. Respiratory infections come next, followed by Gastrointestinal illness. Vibrio cholera played a large role in GI illness, and other forms of the waterborne vibrio bacteria accounted for the serious skin infections.
Viruses also enter the picture, particularly the mosquito borne type. Human West Nile Virus had an uptick in Katrina, but this year, officials anticipate Zika virus will be the major player.
Trauma of all kinds counts for most presentations to hospitals. Cardiovascular causes are a far second, with medication refills being a third. These three accounted for the vast majority of presentations to hospitals in the wake of Katrina.
Evacuees in the aftermath of hurricanes are at the most risk. Vaccinations are a key aspect of care for evacuees. For those evacuees in a group setting, the following are recommended: Influenza, varicella, MMR and Hepatitis A.
Emergency responders are another special group requiring care. Vaccination recommendations for this group include Tetanus if not up to date, Hepatitis B, and the same vaccinations as are given to evacuees if responders are working in large group settings.
reference :
https://depts.washington.edu/einet/symposium/USA031210.pdf
For critical additional reading :
https://www.cdc.gov/disasters/hurricanes/index.html
Please familiarize yourself with what is going on. Figure out how you can help. Click on the up to date radar image below to help.
https://radar.weather.gov/Conus/full.php
The current administration continues to try to whittle away at the ACA (Affordable Care Act). This week, funding for the "advertising” for the ACA was cut. In particular, programs for health care enrollment were cut from 100 million to 10 million.
At the same time, a bipartisan group of Governors has stepped up to craft and submit a proposal to stabilize existing insurance markets under the ACA. Their plan maintains several original ACA features, including the individual mandate, guaranteed subsidies payments, and funding to promote ACA enrollment. New features would include a 15 billion dollar fund to supplement the subsidies, as well as tax credits for insurance companies willing to enter markets with only one insurer. The bill also favors more State flexibility in the spending of their respective subsidies.
The most interesting news in policy is the Love Ernst Bill, also known as the “Allowing Greater Access to Safe and Effective Contraception Act” . It has been introduced by two Senators and two Representatives, all Republican, and all women. They are Congresswomen Barbara Comstock (R-VA) and Mia Love (R-UT), U.S. House of Representatives to Senators Joni Ernst (R-IA) and Cory Gardner's (R-CO), in case you want to give them a shout out.
This represents great progress in the national conversation, and I applaud these forward thinking brave Republican lawmakers. At the same time, I fully understand the position of ACOG, the American College of Obstetricians and Gynecologists, of which I am a card carrying member. ACOG does not support the Love Ernst Bill. That is not because it is wrong, but rather because it does not go far enough.
ACOG has stated that the available evidence shows that cost is a significant barrier to contraception. They state that the ACA’s strategy of birth control without copay is therefore the best strategy. ACOG also objects to the artificial age restriction of 18, and rightly points to the need to continue to curb the teen pregnancy rate, especially among those under the age of 18. Finally ACOG supports the provision of all forms of birth control, not just the birth control pill.
At the present time, the use of IUDs ( intrauterine devices) is on the upswing. The developers of IUDs have come out with more brands and more sizes to meet the current demand and the particular needs of those who have not yet borne children. Nonetheless IUD use in the US lags behind our cohorts globally at 8% prevalence, while Belgium,for example is at 20% and South Korea at 70%.
Egypt’s government is taking steps which show understanding of the relationship of contraception to prosperity. The government would like to employ contraception to control overpopulation, which they consider a threat to national development. They are deploying 12,000 family planning advocates to 18 rural provinces to address conservative beliefs on the matter. Perhaps they can also visit the United States as well.
It is once again time to highlight the significant prevalence of post partum mood disorders. Time with a new baby is hard. Moreover, immense hormone changes are not always well tolerated. A new study published in the Maternal and Child Health Journal has shown that 21% of new mothers who have post partum mood disorders do NOT tell their physician.
It should not be surprising then that a 14 year study out of Ontario has revealed that suicide is one of the leading causes of death in the pregnant and recently pregnant women. The study revealed that 5 % of deaths in pregnancy or the first year of motherhood were due to suicide. The study shows a clear need for comprehensive prenatal and post natal care with assessment for mood disorders and suicide prevention included.
Let us not forget that Houston after Hurricane Harvey is a medical disaster. Several hospitals were just lost, and many had to be evacuated for repairs. Beyond that, ambulances could scarcely travel, and caregivers had trouble getting to work at all. Much of the floodwater is polluted and the water supply is unsafe. All this spells a second wave of potential disaster from the threat of infectious disease.
Polycystic Ovarian syndrome (PCOS) is a actually a cluster of conditions that involve problem with ovulation (egg production) and with carbohydrate metabolism. It turns out that those with PCOS not only have trouble getting pregnant, they have a higher complication rates in pregnancy, especially for gestational diabetes.
A new global study has shown that perhaps we should all be eating fewer carbohydrates. The PURE study, which was published in the Lancet and presented at the European Society of Cardiology, showed that people who eat a high quantity of carbohydrates have a 30% higher change of dying compared to those eating a low carb diet.
And in the truly awesome department, we look to the FDA approval of Kymriah, a new therapy for childhood leukemia. This is not actually a drug, per se. It is a technique, whereby the patient’s own white cells are extracted, genetically modified to kill cancer cells, then re-injected to do their job. It is being called a “living drug”. It produces remission in 83 % of cases.
Gentle readers, you have work to do. Keep giving feedback to your elected officials, and even to those exceptional ones outside your district.
And consider doing what you can for the those affected by Hurricane Harvey. Click on the satellite photo of the hurricane to donate via the Red Cross.
Actual patient care through the weekend prevented a timely publication of Medical Monday. Thanks for your patience !
The health care sector’s initial responses to the Trump administration’s approach to health care policy ranged from shock to anger. Now people and corporations are starting to take action, especially in the face of the administration’s disarray and impotence.
The Trump administration through the Department of Health and Human Services slashed $200 million from the Teen Pregnancy and Prevention Program. (Can anybody tell me the process that made this possible, or does the President just decide like a dictator ? ) The spokesperson of the National Campaign to Prevent Teen and Unplanned Pregnancy has spoken out and disputed the administration’s position which stated that there is “ very weak evidence of positive impact of these programs. “ Experts everywhere are dismayed since the programs are believed to have produced a 41% drop in the teen pregnancy rate since 2010. The CDC (Centers for Disease Control) and ACOG ( American College of Obstetricians and Gynecologists) both credit the declining teen birth rate to these programs.
The Trump administration is bit by bit, trying to dismantle the ACA’s protections on reproductive health care. Most recently, the contraceptive mandate for employer sponsored programs is on the chopping block. ACOG has stated that the contraceptive mandate has driven the unintended pregnancy rate to a 30 year low, and eliminating this feature would be a threat to public health.
The Trump administration has indicated its support for abstinence only sex education, which has no evidence to support its efficacy. However, the CDC has produced two meta-analyses which indicate that comprehensive sex education results in reduced overall levels of sexual activity and increased levels of protection among those that are sexually active.
Indiana law classified the use of aborted fetal tissue as a felony. A group of Indiana researchers has challenged this legislation with a federal lawsuit. The group bringing the suit is from the National Institute of Health funded Alzheimers Disease Center where they do study brain tissue from aborted fetuses.
A recent article in the Dallas Morning News has highlighted the new voice of corporate American in social policy. Corporate America needs a diverse and inclusive workforce, and it understand that inclusiveness is good for business. Accordingly, it has begun to stand up for diversity. From various quarters, highly placed business leaders have spoken out and defied the current administration’s divisive policies. Recent examples of these divisive policies and positions include the President’s reaction to the Charlottesville violence, as well as recent controversy regarding LGBT rights, i.e. the so-called bathroom bill.
The writer of the Dallas Morning News editorial, Dr. Daniel Grossman of the Department of Obstetrics and Gynecology University of California, San Francisco, has called upon the business community to begin speaking out on women’s reproductive rights as well. He cites the fact that fully 70% of Americans support women’s access to full reproductive services including abortion, and this is also the position of the American College of Obstetrics and Gynecology and the American Medical Association. A broad based field of research has shown time and again that access to comprehensive and affordable reproductive health care for women leads to better health, higher levels of educational attainment, and improved economic stability for women, families and society at large. To learn more see https://www.ansirh.org, Advancing New Standards in Reproductive Heath, a division of the UCSF Bixby Center for Global Reproductive Health, http://bixbycenter.ucsf.edu.
As mentioned in several past posts, States are starting to take matters into their own hands. They are, on their own State legislative calendars, enacting various bills that safeguard the requirements for insurance to cover various benefits such as birth control or prenatal care. The latest is Arkansas, which has passed a law which will require insurers in the State to cover indicated mammograms.
In the good news department, we have word that there are bipartisan meetings planned in the first part of September, which will include Governors as well as State Insurance Commissioners. The goal of the meetings will be to stabilize existing insurance markets under the ACA. Things may actually start to get real.
In medical news, the truth is starting to come out, as truth eventually does. New data published in a recent study shows that yearly mammograms starting at 40 (rather than every other year at 50) would prevent the most deaths due to breast cancer. According to this study out of Cornell and New York Presbyterian, for those aged 40-80, screening at 40 reduces breast cancer deaths by 40 % beyond current protocols. Those who read this column regularly already know that a whole segment of the health care world including ACOG, the American Cancer Society and the American College of Breast Surgeons among others, have always taken this view. They have taken serious issue with the short sighted recommendations of the US Preventive Services Task Force (USPTF) which has taken the position that mammograms in the 40s confer no benefit.
All parties concerned recognize that this earlier and more frequent approach mammograms produces a higher number of false positives. However, actual clinicians ( doctors, nurses and nurse practitioners who see patients) do not take the position of the USPSTF(statisticians and epidemiologists largely) that fear of mammograms, pain of mammograms, breast biopsies with benign results constituting a false positive, or even infected or bruised breast biopsies compare with a breast cancer death as a harm. In fact no number of these types of “harms” could ever add up to even one breast cancer death.
The next item is in both the good news department and the we-already-knew-this department. A recent analysis published in the journal Menopause has indicated that vaginal estrogen does NOT confer increased cardiovascular risk. Vaginal estrogen does not appreciably enter systemic circulation. It stays local to the vagina, and does its job to relieve postmenopausal vaginal dryness. Vaginal estrogen was found to NOT increase risk for breast cancer or for any of these: colon cancer, uterus cancer, stroke, clots in the lung (pulmonary embolus) or deep vein thrombosis. Sheepish gynecologists should prescribe with confidence.
A concerning new report published in the journal Pediatrics has brought to light that less than half of new moms are consistently putting their babies on their backs to sleep. Not doing so raises the risk of SIDS (sudden infant death syndrome). Three quarters state they “ usually" do so. Current guidelines clearly state that babies should be in their parents room, in their own bed, and on their back to sleep for the first six months of their life.
Breast and ovarian cancer patients are not getting genetic testing at adequate rates. Genetic testing for these patients informs the care of their children. Moreover, it can also provide insight into their own treatment. Finally, it may ultimately provide information that could help us screen for and treat cancer in new and better ways. I look forward to the day when disease is understood and treated at a genetic level. To get there, we must as a society, contribute our personal genetic information in a meaningful way.
That’s it for this week; Stay tuned next week for more news from the exciting world of Obstetrics and Gynecology.
