Two random articles that TOTALLY resonated with me re: birth politics/health care reform

[EBeth0000]

Maybe I have been doing just FAR too much thinking lately about birth politics, our health care system (for those of us in the U.S.) and how we can get maternity care in this country to reflect EVIDENCE-BASED practices. . .

but it seems like everything I read lately touches on this in a roundabout way. Stick with me here, and check out this story on NPR: Are All Those Angioplasties Necessary?
by Richard Knox
http://www.npr.org/templates/story/s...oryId=95720324

What is really interesting to me here is a couple of things:
1) They talk about financial motives for providing inappropriate (i.e. too high-tech, high-interventionist care) before even trying less invasive techniques

2) The story addresses a myth that is usually lobbed at women--when confronted with the problem some Dr.'s say, "oh no, it's the patients' fault--they are DEMANDING angioplasty!" I guess this is the Dr. defense now. . .blame the patients

3) It also addresses HOW we could actually start to incentivise (sp?) evidence-based care. . .by setting up a fee structure that rewarded Dr.'s higher rates for resorting to angioplasty AFTER trying drugs and leaving them with a meager fee if they leapfrog over lower-tech treatments.

So what's REALLY crazy is the day after hearing this story I pick up our recent issue of Forbes (oct 13 2008) and on pg. 34 there is a story by George A. Diamond and Sanjay Kaul, two cardiologists at Cedars-Sinai Medical Center called "Pay for Proof: One way to bring medical costs way down; pay more for proved treatments, less for ones based on hunches."

I can't find it online but seriously, so much overlap! They describe a system in which Doctors would be reimbursed NOT for the providing of treatments but for improving patient outcomes. They address the treatment of coronary artery disease--drugs vs. stents. Drugs work, stents show they work less long term and at a higher cost. But Dr.'s overwhelmingly try stents before even trying drugs. So they suggest relaigning physician payment to medical outcomes and patient well-being by using evidence-based reimbursement starting with Medicare.

From the article "By discouraging inappropriate procedures and encouraging more appropriate alternatives, this evidence-based reimbursement strategy could save billions of dollars annually while simultaneously improving the overall quality of case."

Problems: Neither article mentions Obstetric care. . .big surprise (sarcasm)
Also, obviously the big fight then becomes what evidence is being looked at/used to provide reimbursement. . .there does become a war of data over these studies, but I think overall studies favor non-interventionist birth care. . .people just don't follow it!

Anyone want to geek out with me on health care policy discussion?

[EBeth0000]

found the link to the Forbes article:
http://www.forbes.com/opinions/forbe.../1013/034.html

[MegBoz]

Originally Posted by EBeth0000

Anyone want to geek out with me on health care policy discussion?

Bwaa ha! I love that phrase "Geek out."

I've been absolutely horrified at the thought that other medical specialities could be even close to as twisted as obstetrics. I'm disappointed to hear that anti-evidence practice is indeed alive & well in other areas. If any of my family members end up sick, I'm gonna have to quit my day job just to do research!

I agree with you though that pay for improving patient outcomes presents an ideal scenario. However, not everything is within the doctor's control. So if a patient does not heal and recover, the doctor may receive a lower fee - through no fault of their own. Is that fair as well?

In such a scenario, they are not paid based upon the work they perform.

For example, apparently there was an extra fee for the 2 stitches my MW put in my perinium for my 1st degree tear. The hospital was paid more money because she stitched me. Of course, a better outcome would be for me to not have torn at all in the first place. And, as we know, there ARE things a birth attendant can do to reduce or increase the risk of tears.

In the current system: Take preventative measures to prevent the tear= get paid less money (no suturing).

New system - get paid more for preventing the tear, but then not paid for the work of suturing.

Just some random sleepy thoughts as I'm about to go to bed.

[Turquesa]

Originally Posted by EBeth0000

They describe a system in which Doctors would be reimbursed NOT for the providing of treatments but for improving patient outcomes.

This would certainly be a step in the right direction, but as PP indicated, it has its loopholes. How many doctors could keep up (and even increase) the 30% cesarean rate with speculative comments like, "It's a good thing I did this, or the baby would be dead. See? The outcome was good. Healthy mom, healthy baby."

BTW, I heard the angioplasty story on NPR, and my brain went to the same place that yours did! f you don't mind my contributing to your "geek out" session, I'd like to throw a couple more articles into the mix.

This commentary from Consumer Reports makes the argument that our hyper-interventionist health care delivery isn't improving outcomes and driving up our health care costs. Technocratic Model of Birth, anyone?

Another related issue is the controversy over self-exams for breast cancer prevention. Now breast cancer runs in my family and is something that I take extremely seriously. Yet I did find it interesting when research indicated that they were doing more harm than good. It isn't the exam in and of itself; rather, it's the response of a trigger-happy health care delivery system that leaps into countless tests and interventions, many of which turn out to be unnecessary and dangerously inaccurate.

Of course, this issue is so entrenched in ideology that critics were outraged.

nak--During my pregnancy, I wasn't worried so much about the many screenings as how the hcp's would respond to them.

I think that the trouble begins when you combine a Culture of Fear with a Culture of Profiteering.

random thoughts while i'm nak.

[EBeth0000]

[QUOTE=MegBoz;12405002]For example, apparently there was an extra fee for the 2 stitches my MW put in my perinium for my 1st degree tear. The hospital was paid more money because she stitched me. Of course, a better outcome would be for me to not have torn at all in the first place. And, as we know, there ARE things a birth attendant can do to reduce or increase the risk of tears.

In the current system: Take preventative measures to prevent the tear= get paid less money (no suturing).

New system - get paid more for preventing the tear, but then not paid for the work of suturing.
QUOTE]

I had 2 stitches after a completely supported natural birth, so I know what you mean!

I think, at least in the Forbes article, what they are actually proposing is something like this:
old system: get paid $500 for providing drug therapy, get paid $15000 for providing stent

new system: Dr.s get paid MORE (say $1000) for providing drug therapy WITHOUT leapfrogging directly to stents. Dr.s who try stents WITHOUT trying drug therapy FIRST get paid much less than $15000, say, $8000 or something. Dr.s who try drugs first THEN try stents get the full amount of $15000 for providing the stent. Make sense?

So in your example of birth. . .if they don't provide evidence-based practices to prevent tear and then you require sutures, they would simply get paid less (like 1/2 the fee) than for stitching sutures after a birth in which they did everything according to the best standard of care, in which case they would get paid the full amount because they had shown they had done more to prevent the costly fix. Also, they would be compensated for providing the services that are indeed evidence based so perhaps there would be more pay for that as well.

I could see this being extended to, say, Dr.'s who do AROM getting paid less for an eventual cesarean birth than Dr.s who refrain from it, since there is no evidence to show it helps, and in fact, evidence to show it is harmful.

[EBeth0000]

Originally Posted by Turquesa

This commentary from Consumer Reports makes the argument that our hyper-interventionist health care delivery isn't improving outcomes and driving up our health care costs. Technocratic Model of Birth, anyone?

Another related issue is the controversy over self-exams for breast cancer prevention. Now breast cancer runs in my family and is something that I take extremely seriously. Yet I did find it interesting when research indicated that they were doing more harm than good. It isn't the exam in and of itself; rather, it's the response of a trigger-happy health care delivery system that leaps into countless tests and interventions, many of which turn out to be unnecessary and dangerously inaccurate.

Of course, this issue is so entrenched in ideology that critics were outraged.

nak--During my pregnancy, I wasn't worried so much about the many screenings as how the hcp's would respond to them.

I think that the trouble begins when you combine a Culture of Fear with a Culture of Profiteering.

random thoughts while i'm nak.

I saw both of these, too! The consumer reports was so mainstream I sent it to all my friends who haven't had kids yet! The breast cancer research was in keeping with a lot of new findings about screenings of all types (here's a NYT article about inaccuracy of MRI and the costs of pursuing treatments based on inaccurate results), but like you said, it is such a sensitive issue and it's hard to address it in a rational way.

What you said about a Culture of Fear really resonated with me. It's like people are so overwhelmed with media information, while at the same time our population in general is less well-equipped to sift through it, whether it's not understanding statistics or even general ignorance of the scientific method, and also a lack of source criticism.

I think Susan Jacoby's "The Age of American Unreason" really got to me, but I am seriously worried about our culture. Because I feel like this trend on the "establishment's" part of pursuing profit at the expense of the general citizenry's tendency to react out of generalized fear is very threatening to our democracy. Wow. I sound like such a liberal reactionary

I should say I'm trained as a historian with a deep interest in American intellectual and medical history so I tend to get a little nuts about this stuff!

[Turquesa]

Originally Posted by EBeth0000

I saw both of these, too! The consumer reports was so mainstream I sent it to all my friends who haven't had kids yet! The breast cancer research was in keeping with a lot of new findings about screenings of all types (here's a NYT article about inaccuracy of MRI and the costs of pursuing treatments based on inaccurate results), but like you said, it is such a sensitive issue and it's hard to address it in a rational way.

Consider it bookmarked! I love collecting research and articles like this. Is there a geek among our Smiley choices? This guy * : * technically, but I need something nerdier to convey it fully!

What you said about a Culture of Fear really resonated with me. It's like people are so overwhelmed with media information, while at the same time our population in general is less well-equipped to sift through it, whether it's not understanding statistics or even general ignorance of the scientific method, and also a lack of source criticism.

When I commented about the Culture of Fear in my previous post, I had patients, i.e. health care consumers, in mind. But the more I think about it, I truly believe that the Culture of Fear has subsumed the practice of medicine so that doctors, too, are a part of it.

First, with so many professions, a sort of myopia can develop. My icky, horrible confession is that when I did social work with domestic violence victims, I had to fight the urge to view every male stranger as a potential wife beater. So why should it surprise us that so many female obstetricians would rather give birth by voluntary, scheduled cesarean? If you see so much risk in your profession, why wouldn't you see the world through risk-colored glasses? Why wouldn't that one, anomalous horrible birth color your entire perception of childbirth at large? Why wouldn't that one hospital transfer from a midwife make you think that the midwife was negligent and home birth was unfathomably dangerous?

The other factor is the mythical Litigation Nation. Fear of getting sued may be a major contributor to the high cesarean rate. It may even be a major contributor to the other phenomena that we've discussed in this thread. In fact, this article elucidates the subject well.

The Culture of Fear creates this climate of defensive medicine. Do you remember the infamous case in the 1990s of a woman who spilled hot McDonald's coffee in her lap and successfully sued the company? She became a poster baby for the tort reform movement. Suddenly, everybody who had a malpractice case was painted like this woman--vengeful, greedy, and irrationally frivolous. The way the AMA and ACOG talk, you would think that doctors were victims and incapable of wrongdoing. Of course, you and I both know the real elephant in the room: Doctors can and do make mistakes. But from much of the physician lobby, I infer more fear of getting sued than I do of genuinely causing harm to a patient.

I think Susan Jacoby's "The Age of American Unreason" really got to me, but I am seriously worried about our culture. Because I feel like this trend on the "establishment's" part of pursuing profit at the expense of the general citizenry's tendency to react out of generalized fear is very threatening to our democracy. Wow. I sound like such a liberal reactionary

How does her book link to this discussion? (Keeping in mind that I haven't yet read it . . .)

I should say I'm trained as a historian with a deep interest in American intellectual and medical history so I tend to get a little nuts about this stuff!

Sweet! I actually started out in that field until realizing that academia wasn't my schtick. It won't stop me from going nuts with you, though.