DIY Baby! Your Essential Pregnancy Handbook...Pub Date: April 4, 2008
Let's Fix Health Care in 4 Easy Steps!...Pub Date: 5/1/2008
Get a Grip! On Your Hormones...pub date July 1, 2008
Omit Needless Worry: Awakening Your Power to Manage Anxiety...pub date October 1, 2008
Sunday, February 17, 2008
DIY Baby! Back Cover Copy
DIY Baby! Do It Yourself Baby:
Your Essential Pregnancy Handbook
Your Life Will Never Be the Same!
Your Life Will Never Be the Same!
Imagine being a parent...
Your baby will bring you unconditional love and unleash emotional capacity you didn’t know you possessed. Prepare yourself for an onslaught of dreams, responsibility and power. Parenthood defines adulthood. Pregnancy is the gateway.
You will:
Master the essentials of pregnancy and birth with the mentoring of a double insider’s view — an obstetrician and mother.
Understand how human life develops and how to maximize your baby’s potential through the power of information, preparation, and healthy living.
Explore new delivery options including home birth. Take charge of your baby’s beginnings and make the most of your delivery — Use the tools within to adopt a
NEW WELLNESS PARADIGM.
"This book is perfectfor those looking for pertinent information in a concise, yet entertaining vehicle. Dr. Binkley, who has seen pregnancy from both sides, comes at the subject from the standpoint that pregnancy is a natural process and not a ‘condition’ where providers are supporters and advisors, rather than meddlers."
— John C. Hobbins, M.D., Professor of Obstetrics and Gynecology University of Colorado School of Medicine, Aurora, Colorado
Avail yourself of this trusted doctor in your pocket. Enhance your own common sense and instincts by taking advantage of this physician’s dual perspective, knowledge, and experience.
Know your pregnancy inside and out — what are you waiting for?
Fixing Health Care
How to Fix the United States Health Care System
We Must Do It Ourselves
“Problems cannot be solved at the same level of awareness that created them.”
--Albert Einstein
Identify the Components: Ones That Work and Ones That Don’t
We must understand the components of what isn’t working in order to develop a system that will serve everyone to the best extent possible.
The first step to solving any seemingly daunting problems is to break it down into component parts, identify what works about the existing status; and what doesn’t. It’s crucial to learn from the past.
As a physician and owner of a solo practice (small business) I’ve experienced the health care system from all sides. I’m intimately familiar with how Medicaid, Medicare, and for-profit insurance companies such as Blue Cross, United Healthcare, Aetna, and others work. I am also a consumer of health care services. I’ve had babies, knee surgeries, and other personal interactions with the American medical system. I have witnessed first-hand the extent to which non-citizens are receiving benefits paid for by working Americans. I am a small business owner so I’ve had to decide whether and how to offer health insurance to my employees. I, and others like me, am among the most qualified people in America to help fix the health care system because we have experienced health care from all angles: health care providers, patients, business owners, and tax payers.
In this chapter we’ll explore what works and what does not work about the existing U.S. health care system. We’ll also address how to fix what doesn’t work and improve upon what does work.
Entitlement programs separate the payers of health care from the consumers of health care.
What Does Not Work
Big Government Entitlement Programs
Big Government does not work. Entitlement programs such as Medicare and Medicaid have spiraled out of control, increased our debt, and are a huge burden to existing and as-yet unborn taxpayers. Many people have figured out how to “game” the system and receive benefits they don’t deserve.
In my county the office that determines Medicaid benefits is populated by some former illegal migrants who are now citizens. Through knowing people who work in that office and are dismayed by current practices, I am aware some staff members are dispensing Medicaid benefits to those who don’t deserve them. We all pay for this. I don’t want my children bearing the cost of the ballooning U.S. entitlement programs, as it will impact their and their children’s standard of living.
Medicaid “Emergency Services Only” is a perfect of example of an entitlement program gone woefully wrong. Don’t misunderstand me – some of the recipients of this entitlement program truly deserve it. However, this benefit is dispensed to some citizens and non-citizens alike who drive brand new large SUV’s, and reside in single family homes – I’ve literally seen them deliver a baby at the taxpayer’s expense and drive away in a shiny brand new Cadillac SUV. They pay through these luxuries with cash earned “under the table,” not subject to income tax.
The Medicare Part D prescription drug program is another example of an entitlement program which benefits pharmaceutical companies and wealthy Americans at the expense of middle class and younger Americans. Most beneficiaries of Part D are retired older Americans who did not pay enough into the system to cover this benefit during their working years. As a consequence working Americans and future working Americans as yet unborn will pay for this program. Pharmaceutical companies are guaranteed a “permanent” revenue stream through Part D unless the system is revoked or revamped. As drug costs increase, which they inevitably will, Part D will balloon out of control as has the rest of Medicare and Medicaid and be another source of national debt and excess tax burden.
Big government does not work because it’s too expensive to administer and it is too easy to take advantage of “the system”.Big government does not work because it’s too costly to administer and it is too easy to take advantage of.
For the first time in U.S. history we are seeing new generations’ standard of living decline compared to the generations that preceded them. This should be a wake-up call to all of us. If you live in the moment and have the attitude, “It won’t affect me,” think again. Your children or your friends’ children, or mother Earth will bear the brunt of our existing behaviors.
Examine your motives. Be honest. Do you feel like you need more money or more stuff? Do you really need these things? Or do you need a healthy earth in which you and your children can live sustainably? Now that you’re making a baby it’s up to you to create the best world possible for them.
Inequities in Wealth Distribution Harm Everyone
As a species we have not solved the problems engendered by unequal distribution of wealth. The rich getting richer and the poor getting poorer is not simply an economic problem. It’s an environmental and moral one: It’s hard to care about the pollution you create as an individual when you’re worried about how you’re going to feed your family from day-to-day.
Ostentatious displays of wealth accentuate inequities and engender jealousy. This sentiment leads to the emotion of rage and ultimately to behaviors of radical and violent extremism, terrorism being just one example.
Dramatic inequity in wealth distribution is a moral problem that engenders social ills such as thievery, violence, and mistaken beliefs.
National Health Care Administered by the Government is a Bad Idea
Medicare and Medicaid reimburse physicians and hospitals at much less than the cost of doing business.
Several countries already have national health care systems in Canada and Europe. This approach has resulted in a two tiered system: A “private” system in which the wealthy can receive any and all healthcare when they desire it; and a “public” system in which the average person must sit on a waiting list for a year or more to have their knee replacement or their heart surgery. Many of these countries have high income taxes on the order of eighty percent to pay for their entitlement programs. The government decides how the individual citizen’s money is spent. Do you think the U.S. Federal Government has proven it is the best entity to determine how your health care dollar is spent? That is the inevitable outcome of a “National Healthcare System”.
A national health care system already exists in the United States. It’s called Medicare and Medicaid. These programs have failed miserably in several aspects: Lack of coverage: The number of uninsured citizens keeps rising despite the ever increasing money spent on Medicaid and Medicare. Those who are on Medicaid and Medicare are under-insured because these systems reimburse physicians at a rate of roughly twenty cents on the dollar. Most primary care physician practices’ overhead averages forty to fifty or more percent. Thus, physicians lose thirty cents on the dollar for every Medicaid and Medicare patient they see. This necessitates physicians to either refuse to accept Medicaid and Medicare; or to be forced to go out of business through lack of financial viability.
Disconnect between payers and consumers health care increases utilization and overall costs.
Entitlement programs charge working Americans twice, and in some cases three times, for the benefits they provide their recipients: through taxes, through cost-shifting of high insurance premiums; and through obligating physicians and hospitals to provide free care to anyone who walks through the door, be they tax-paying citizens or not.
Just so you’re under no illusions this is a small problem, look at the 2006 statistics published in the American College of Obstetricians and Gynecologists’ newsletter: Seven percent of obstetricians quit delivering babies altogether and another twelve percent curtailed services to accept only low risk clients. The reasons cited for this were declining reimbursement for deliveries and increase financial and emotional cost of malpractice insurance. A large portion of obstetric patients are illegal immigrants who are either uninsured or covered by Medicaid “Emergency Services Only” which pays dismally. This twenty percent reduction in obstetric services in a single year is truly astounding.
The main reason reimbursement by Medicare and Medicaid is insufficient is because there is a tremendous disconnect between the consumers of these benefits and those paying for these benefits. The payers are middle class working Americans. The consumers are retirees, people below the poverty level, and people who are illegal migrants. There is a complete disconnect between those who pay for the system (middle class Americans) and those who receive the benefits.
Disconnect between payer and recipient results in over-utilization of expensive services. If you don’t have to pay for something why hesitate to use it? Many people on Medicaid use the nation’s emergency departments like clinics because they don’t have to foot the several thousand dollar bill for an emergency department visit. If people are insulated from the cost of their prescription medications they are likely to use expensive heavily marketed drugs even if they have no proven benefit over older generic drugs.
Solving the health care crisis in this country requires increasing the connection between the payers and recipients and dispensers (health care providers and organizations) of health care services.
Profit Incentives…well…raise profits (and cost)
Why should commercial insurance companies and pharmaceutical companies make billions in profits when there are 46 million uninsured Americans? It just does not make sense. That is the multi-million dollar question. How can, for example the CEO of United Healthcare justify taking home a multi-million dollar annual compensation package when there are children and adults in this country who go without basic health care needs such as vaccinations and access to medical providers?
Commercial Insurance Companies:
Increasing Transparency and Evaluating “Managed Care”
Increasing Transparency
How do you know you’re getting the health care benefits for which you’ve paid? Do you understand your EOB (Explanation of Benefits) you receive in the mail after you’ve visited a health care provider or pharmacy? Have you checked to see if the insurance company has paid the correct percentage (accounting for deductibles and co-pays) according to your written policy? Have you read your insurance policy?
The average person (including me) has not read her insurance policy word for word. It’s usually a dense 50 or 60 page document written in legalese. The fine print within this document can contain many exceptions to the summary of the policy, of which you are unaware.
Does your insurance company pay for “out-of-network” providers in strict accordance with the written policy?
If you don’t know the answers to all these questions you may not be (probably aren’t) receiving the full benefits for which you are paying. Ask your insurance policy to account proportionally for every dollar of your premium – write to their CEO or CFO. They should at least send you an “annual report” – the company summary they mail yearly to investors. If you can’t get the information by asking, state you’re interested in investing in the company and can they send you an annual report? Money talks and information is power. We can’t do anything about rising health care premiums until we understand where each dollar goes. Once we understand where the dollars go, we can work to control the components eating those dollars.
Part of how insurance companies have made away with so much of our money is because we don’t demand the information. If we sit passively and complain it accomplishes nothing. Do something! Start by demanding an accounting of where your money goes. You have a right to know.
If we curtail existing entitlement programs we decrease the administrative burden of the Federal Government. There is a National body, the Joint Commission on Accreditation of Hospital Organizations (JCAHO), whose job is to regularly visit every hospital in the United States to see if they are living up to standards of safety and hygiene. Why not demand a Federal body that does for commercial insurance companies what JCAHO does for hospitals? Given that the largest portion of our national gross domestic product goes to health care it’s only appropriate the insurance companies be held accountable for responsible use of those dollars.
“Traditional” managed care has failed to control medical costs.Evaluating Managed Care
Managed Care is a model that originated in the 1980’s to attempt to control heath care costs. The original intention behind it was to link quality to cost and use the scientific method to evaluate the merit of various medical treatments. It has undergone much iteration over the past three decades. However, managed care has failed to control cost. Indeed costs have risen hundreds of percentiles over the past three decades.
Original versions of managed care involved a “gatekeeper” system in which insurance companies dictated patients must see a primary care physician before obtaining a referral to a specialist. Patients also had to jump through hoops to get basic services or tests ordered by the doctor covered. These factors caused great dissatisfaction among consumers of healthcare.
The present version of managed care involves “Preferred Provider Organizations” (PPO’s): establishing “in-network” and “out-of-network” benefits paid at different levels. The idea behind this is an insurance company negotiates “discounted rates” with a group of physicians or hospitals then drives consumers to use those physicians or hospitals. The advent of PPO’s has also failed to result in controlling health care costs.
Some of the greatest reductions in health care costs have come from hospitals and physicians themselves. Many physician groups and hospitals have taken the initiative to develop “Disease State Management Protocols” and “Clinical Pathways”. These are tools used to standardize care for common illnesses using evidence-based medicine and proven methods to control the cost of in-patient hospital care. These and similar efforts have produced the most dramatic control of health care costs, while actually improving and standardizing the quality of medical care delivered.
Pharmaceuticals
Newer drugs are not necessarily better than older ones; and they are usually more expensive.
The FDA incentivizes pharmaceutical companies to develop and market “new and better” drugs because patents on drugs expire after ten years and the drugs can then be produced as generics. Pharmaceutical companies are under minimal obligation to prove their “new and better” drug really is more effective than older, cheaper generic drugs. Pharmaceutical companies aggressively market new expensive drugs direct to consumers on television and to physicians without being required to prove they are more effective than their predecessors. Why? They should at least be required to disclose data about efficacy, just as they’re required to disclose side effects of their drugs.
Often new drugs are simply old drugs that have been “tweaked” by adding a minor chemical appendage so as to technically make them into new chemical compounds, although they don’t act any differently than their older predecessors. Some examples are “new” birth control pills touted to improve premenstrual syndrome and acne, which are variations on older generic birth control pills. Newer birth control pills sell for about $50 to $60 per month; whereas generic pills sell for about $7 to $10 per month. Both types of pills improve acne and premenstrual syndrome.
Another example is newer anti-depressants such as Lexapro and Celexa. These drugs are off-shoots of the old stand-by, Prozac (fluoxetine). Prozac is now generic (fluoxetine) and cheap whereas these newer drugs are not. They are touted to have fewer side effects; and they may indeed have fewer side effects. But they have not been required by the FDA to prove it in head-to-head randomized double-blinded, placebo-controlled trials. Are they required to disclose this fact in direct-to-consumer advertising? Why not? Moreover, there are new concerns about all the anti-depressants and increased risk of suicidal or violent behavior.
What is the logic insurance companies use to determine what they will and will not cover? For example, some insurance companies cover drugs to treat erectile dysfunction but they don’t offer maternity coverage, or coverage for contraception. Or they offer these benefits for additional premium. Why?
We certainly don’t want to discourage development of new drugs by removing the profit incentive. However, companies should be required to disclose efficacy data in marketing to consumers and physicians. Drug development must become more transparent to consumers so they can make the best choices for their physical well-being and the well-being of their wallets.
Malpractice Risk Drives Up Cost Via Defensive Medicine
You’ve all heard the politicians and the media bemoan the fact that malpractice risk increases costs for everyone so I don’t want to tire you with repetition of this other than to summarize. The high cost of malpractice insurance and the emotional toll of malpractice suits cause physicians and hospitals to engage in “defensive medicine”. Defensive medicine is ordering unnecessary tests in order to prove the patient doesn’t have a serious illness and thereby avoid a malpractice suits. There is no evidence that defensive medicine results in better medical care or reduces malpractice suit. The only reliable conclusion drawn by studies of defensive medicine is that it increases the overall cost of health care.
Malpractice suits have become something of a “lottery” – consumers looking for the multi-million dollar payoff. Defendants (physicians or hospitals) “win” eighty percent of malpractice suits that go to trial – usually after an expensive, drawn out, draining battle. The only people who truly win in these cases are the trial lawyers. Even the malpractice insurance companies take a hit but at least they can pass their cost onto the physician. Guess who the physician passes the cost onto?
However, if physicians passed on the entire cost of rising malpractice premiums to patients, no one would be able to afford to visit the doctor. Therefore, they only pass on a portion of the increased cost and they absorb the remainder. As malpractice insurance premiums rise, guess what happens to the business bottom line? This is a large contributor to the exodus of physicians from obstetrics: rising malpractice cost and declining reimbursement. If it actually costs you money to get up at 3 a.m. and go deliver someone’s baby, why do it? It makes no sense.
Money Spent on Extremes of Life
Ninety percent of the health care dollar is spent on the last six months of life. This often involves intensive care for people afflicted with terminal illnesses who are on life support. They
may require a tube to breathe, medication to keep their heart rate going and blood pressure normal, a tube for feeding in the stomach, or intravenous nutrition. We often die in hospitals hooked up to machines and being pumped full of drugs. We may not even be conscious. Is this how you want to die?
Just because we possess the technology does not mean it is best for us to use it. In the past we died with dignity in our homes, surrounded by family members. You should consider how you want to die at a time when you have full mental faculties and can make an advance directive. An advance directive is a document specifying what measures you want taken to extend your life should you not be able to decide for yourself. Don’t leave it up to your family members to make the decision because no one wants the responsibility of “pulling the plug”.
These extreme measures often consume the final dollars of a family’s savings and are a large component of Medicare expenses. This is money that could go to your children and grandchildren. It could pay for someone to go to college or someone to have a place to live. We have to decide for ourselves how much is enough and how much is too much?
Okay, so I’ve identified this, that and the other thing that are wrong with our health care system. What is right with it? Well we have access to advanced technology, well-trained physicians and nurses, antibiotics, and the best science money can offer. Too bad such a huge number of people struggle to get basic health care needs met. How do we get out of this mess?
Addressing the Big Four will “Fix” the United States Health Care System
In summary there are four big offenders in producing out-of-control health care costs:
Addressing each of these will decrease the cost of health care while preserving the advantages of technology and science, and increase access for everyone to basic health care services.
The silent underpinning of many of these problems is risk. So how we manage risk determines the cost of our health care.
The free market system works: competition encourages innovation and fosters incentives for cost control. We want to preserve the elements of the free market system that function well, while not sacrificing accountability and quality control.Connecting the Payer with the Recipient
It is crucial to connect the recipient of health care directly with the payer. The consumer needs to bear the risk of his health care decisions. The consumer of health care needs to directly feel the impact of system utilization in their wallet.
Eliminating or reducing the scope of entitlement programs would go a long way toward reducing the burden of health care costs for the middle class. Recipients of Medicaid should be required to prove they are U.S. citizens. Non-citizens should not be eligible to receive benefits for free. They should have to pay for their health care just like the rest of us.
If we do issue driver’s licenses or identification cards to non-citizens, it should be tied to proof of health insurance, proof of auto insurance, and proof of paying taxes.
We need to decrease the influence of the middle man and limit the role of private health care insurers and the government. One approach to this would be for groups of people to participate in pooled risk plans in which premiums and benefits are determined impartially by an actuarial company. This could be self-directed, for example, by employees of large companies or other pooled risk groups. Alternatively the existing insurance company framework could be restructured so as to decrease the “fat” in the system. This would require government or some outside agency regulating insurance profitability. What justification is there for the CEO of an insurance company making millions of dollars while many Americans go without basic services? Insurance companies would certainly balk at government regulation.
Consumers must demand greater transparency from commercial insurance companies regarding how their health care premium dollars are spent. Only when we understand where the money goes can we solve the problem of high cost.
Exert Your Own Cost Control:
· Examine Your Utilization
· Know Reasons for Tests
· Develop Advance Directive
Exert Your Own Cost Control
You have the power to control your individual health care costs. If everyone reduces her individual costs, the collective cost of health care will decline. Examine your utilization. The most expensive healthcare services are emergency room care, intensive care units (ICU’s), surgery, and advanced imaging studies such as MRI’s and CT scans.
Examine your utilization of the system. First, if you are ill after regular business hours, decide if you’re sick enough to need to go to the Emergency Room at a cost of thousands per visit; or can your condition wait until your doctor is available during regular business hours for a fraction of the cost?
Of course for emergencies like chest pain or hemorrhage you should proceed to the emergency room. But if you have chronic pelvic pain and have developed a worsening of pelvic pain the emergency department is not the best place to receive care for this problem. Childhood runny noses and rashes also don’t need to be seen in the Emergency department unless you’re concerned your child may be seriously ill (e.g. have a high fever, or is unable to keep food and water down).
If your doctor recommends a test, ask why? What is the doctor trying to learn with the test? What are the benefits, risks, and costs of the test? Will this test lead to further testing or surgery? Are you asking for the test because you want to know a certain result? Is the test going provide the information you desire? Will the test give you any useful clinical information to better understand your health? You should know the answers to all these questions before submitting to tests.
A perfect example of useless tests is “hormone levels”. Women ask me every day to check their hormone levels. If I can’t talk them out of it I usually oblige to satisfy them. However, female hormone tests do not tell us anything your own body can’t tell. For example, if you are having regular monthly periods your hormones will be “in the normal range”. The “normal range” is determined by measuring hormones of millions of “average” people to establish normal values. If you are over thirty, skipping periods, having night sweats, or have stopped having periods, your hormones will be in the “menopausal range” because these values are established by measuring hormone levels of millions of menopausal women. If you are skipping periods before age thirty, you probably have “polycystic ovary syndrome” caused by irregular ovulation.
I can test your hormone levels to confirm, but this is usually a diagnosis that can be made by asking questions and doing a physical exam.
If you are having raging premenstrual syndrome (PMS) I can test your hormone levels. They will most likely be “in the normal range” because hormone levels vary depending on time of cycle, age, and other factors. I can be of much more help by addressing your symptoms and developing a plan to manage them than I can by testing your hormone levels.
Knowing your actual hormone levels does not help us treat hormonal disorders most of the time because treatment is based on symptoms, not on a number from a lab.
If you have excess acne or hair growth it is likely your testosterone is high. I can measure it to be sure, but your body is telling me, by producing excess hair and acne that your testosterone level is high. Now if you have these symptoms a hormone level would be useful to exclude a testosterone-producing ovarian tumor. However, testosterone-producing ovarian tumors are exceedingly rare (<1/100,000). I will still recommend the test if I think it’s necessary based on your symptoms and physical findings.
Be careful of independent labs that offer “saliva tests” for hormones. These are expensive and can be misleading. Saliva levels of hormones can be quite variable from time of cycle and time of day.
Advance Directives
Develop an advance directive while you’re at an age when you have full mental capacity and you can consider these decisions in a thoughtful manner. Write it down. You don’t need an attorney to create an advance directive. Simply writing it down in one page or one paragraph is sufficient. If you want it to be “official” have it notarized. Make sure it answers crucial questions in a clear fashion for your relatives to understand. Advise your relatives you have an advance directive; review it with them; and make sure they know its location. At the end of life do you want to be kept alive with a breathing tube, intravenous feedings, or drugs? To what extent and expense do you want your body to be preserved, possibly with your mind in a vegetative state? Do you want to be resuscitated (brought back to life) if your heart or breathing stops? What would be the criteria you would want established for any of these measures to be taken?
Require Insurance Companies and Pharmaceutical Companies to Increase Disclosure, Transparency, and Accountability
We must hold big business accountable for making the most of the dollars we pay them.
We must hold big business accountable for making the most of the dollars we pay them. Insurance companies should be required to present policies in clear, consistent, standardized language to make it easy for the consumer to compare policies. An objective oversight body similar to the Joint Commission for Accreditation of Hospital Organizations (JCAHO) should be established to assess insurance companies and pharmaceutical companies to determine if they hold up to their promises.
Pharmaceutical companies or an outside agency (don’t we pay the FDA to do this?) should be required to conduct studies of efficacy of new drugs in an objective manner and disclose these results to the public along with the rest of their direct-to-consumer advertising.
The free market system works: competition encourages innovation and fosters incentives for cost control. We want to preserve the elements of the free market system that function well, while not sacrificing accountability and quality control.
Limit frivolous lawsuits to reduce the practice of defensive medicine.Doctors Can Impact Cost by Using Evidence Based Medicine and Resisting the Temptation to Practice Defensive Medicine
Doctors, nurses, and other healthcare providers can dramatically impact the cost of health care by resisting pressures to practice defensive medicine. One would not want to deny access to a necessary diagnostic test or treatment based on price. However, so many tests and treatments are ordered as “cya” measures.
Often patients request tests that are unnecessary. Usually one can explain the rationale behind testing or not testing and advise the patient to make an informed decision. However, some people are set on the idea that they need this or that test to understand their health. In this instance it is usually counter-productive to try to “talk” the patient out of it, and just go ahead and order the test.
In order for health care professionals to reduce the habit of defensive medicine, they need relief from the pressures to do so. A revamping of the “malpractice” system in the United States is long overdue.
Eighty percent of “malpractice” suits are won by the doctor or hospital being sued. This means in most cases that go to trial, evidence of malpractice cannot be found. The stress and cost of malpractice suits is discouraging good people from entering the field of medicine; and causing many to leave medicine or limit their practice to “low risk” disease conditions.
It has been suggested by consumer groups, physician groups, politicians, and government agencies that it is time to move to institutionalizing compensation for bad medical outcomes. The extent of damage and amount of compensation could be determined by an arbitration group. Funds for this should come from a number of sources: insurance premiums, lawyers, physicians, and consumers. Everyone should have to bear the cost of bad medical outcomes in order to curtail frivolous law suits and keep overall health care costs down over the long term.
It is much more effective to use a carrot to get people to do the right thing, than to beat them with a stick. For the most part doctors are smart, conscientious – often perfectionist – people who strive to do their best; and if you prove to them certain disease management protocols improve care and reduce cost, they will use these disease protocols. Doctors have studied long and hard to become physicians and it is a life-long learning process that involves accumulating “continuing medical education credits” throughout one’s career.
Evaluate How We Manage Extremes of Life
You can maximize your chances of having a healthy term baby by following the advice in DIY Baby! (Do It Yourself, Baby!). You have more control than you may realize. Overall, though, ninety percent of the health care dollar is spent on the last six months of life. Premature babies are expensive and we should strive to reduce prematurity.
This phenomenon has occurred because advances in technology have outpaced the study of ethics and responsibilities of a society to its members to provide the greatest good to the most number of people.
We need to decide as a society: How do we want to enter and exit life? Do we want to die hooked up to machines in a vegetative state? Is this the best use of our precious resources? Do we want to risk leaving a legacy of health care debt to our heirs?
You actually have complete control over this. By writing your advance directive, you remove the burden of your life’s decisions from others and take the initiative. I encourage you to write an advance directive and make your friends and family aware it exists. It doesn’t have to be long – a page or a paragraph. It doesn’t need to be written by a lawyer or notarized. However, if you take the trouble to have it notarized it may increase the likelihood it is taken very seriously.
You must consider all the possibilities: What if you’re completely paralyzed or brain damaged in an accident? Or rendered into a coma? What type of medical interventions do you want to take place? I urge you to think about these things and write them down: Your family’s lives depend upon it.
Only by tackling the four major factors increasing health care cost in this country can we obtain a safe, logical, cost-effective health care system. I encourage you to do your part.
We Must Do It Ourselves
“Problems cannot be solved at the same level of awareness that created them.”
--Albert Einstein
Identify the Components: Ones That Work and Ones That Don’t
We must understand the components of what isn’t working in order to develop a system that will serve everyone to the best extent possible.
The first step to solving any seemingly daunting problems is to break it down into component parts, identify what works about the existing status; and what doesn’t. It’s crucial to learn from the past.
As a physician and owner of a solo practice (small business) I’ve experienced the health care system from all sides. I’m intimately familiar with how Medicaid, Medicare, and for-profit insurance companies such as Blue Cross, United Healthcare, Aetna, and others work. I am also a consumer of health care services. I’ve had babies, knee surgeries, and other personal interactions with the American medical system. I have witnessed first-hand the extent to which non-citizens are receiving benefits paid for by working Americans. I am a small business owner so I’ve had to decide whether and how to offer health insurance to my employees. I, and others like me, am among the most qualified people in America to help fix the health care system because we have experienced health care from all angles: health care providers, patients, business owners, and tax payers.
In this chapter we’ll explore what works and what does not work about the existing U.S. health care system. We’ll also address how to fix what doesn’t work and improve upon what does work.
Entitlement programs separate the payers of health care from the consumers of health care.
What Does Not Work
Big Government Entitlement Programs
Big Government does not work. Entitlement programs such as Medicare and Medicaid have spiraled out of control, increased our debt, and are a huge burden to existing and as-yet unborn taxpayers. Many people have figured out how to “game” the system and receive benefits they don’t deserve.
In my county the office that determines Medicaid benefits is populated by some former illegal migrants who are now citizens. Through knowing people who work in that office and are dismayed by current practices, I am aware some staff members are dispensing Medicaid benefits to those who don’t deserve them. We all pay for this. I don’t want my children bearing the cost of the ballooning U.S. entitlement programs, as it will impact their and their children’s standard of living.
Medicaid “Emergency Services Only” is a perfect of example of an entitlement program gone woefully wrong. Don’t misunderstand me – some of the recipients of this entitlement program truly deserve it. However, this benefit is dispensed to some citizens and non-citizens alike who drive brand new large SUV’s, and reside in single family homes – I’ve literally seen them deliver a baby at the taxpayer’s expense and drive away in a shiny brand new Cadillac SUV. They pay through these luxuries with cash earned “under the table,” not subject to income tax.
The Medicare Part D prescription drug program is another example of an entitlement program which benefits pharmaceutical companies and wealthy Americans at the expense of middle class and younger Americans. Most beneficiaries of Part D are retired older Americans who did not pay enough into the system to cover this benefit during their working years. As a consequence working Americans and future working Americans as yet unborn will pay for this program. Pharmaceutical companies are guaranteed a “permanent” revenue stream through Part D unless the system is revoked or revamped. As drug costs increase, which they inevitably will, Part D will balloon out of control as has the rest of Medicare and Medicaid and be another source of national debt and excess tax burden.
Big government does not work because it’s too expensive to administer and it is too easy to take advantage of “the system”.Big government does not work because it’s too costly to administer and it is too easy to take advantage of.
For the first time in U.S. history we are seeing new generations’ standard of living decline compared to the generations that preceded them. This should be a wake-up call to all of us. If you live in the moment and have the attitude, “It won’t affect me,” think again. Your children or your friends’ children, or mother Earth will bear the brunt of our existing behaviors.
Examine your motives. Be honest. Do you feel like you need more money or more stuff? Do you really need these things? Or do you need a healthy earth in which you and your children can live sustainably? Now that you’re making a baby it’s up to you to create the best world possible for them.
Inequities in Wealth Distribution Harm Everyone
As a species we have not solved the problems engendered by unequal distribution of wealth. The rich getting richer and the poor getting poorer is not simply an economic problem. It’s an environmental and moral one: It’s hard to care about the pollution you create as an individual when you’re worried about how you’re going to feed your family from day-to-day.
Ostentatious displays of wealth accentuate inequities and engender jealousy. This sentiment leads to the emotion of rage and ultimately to behaviors of radical and violent extremism, terrorism being just one example.
Dramatic inequity in wealth distribution is a moral problem that engenders social ills such as thievery, violence, and mistaken beliefs.
National Health Care Administered by the Government is a Bad Idea
Medicare and Medicaid reimburse physicians and hospitals at much less than the cost of doing business.
Several countries already have national health care systems in Canada and Europe. This approach has resulted in a two tiered system: A “private” system in which the wealthy can receive any and all healthcare when they desire it; and a “public” system in which the average person must sit on a waiting list for a year or more to have their knee replacement or their heart surgery. Many of these countries have high income taxes on the order of eighty percent to pay for their entitlement programs. The government decides how the individual citizen’s money is spent. Do you think the U.S. Federal Government has proven it is the best entity to determine how your health care dollar is spent? That is the inevitable outcome of a “National Healthcare System”.
A national health care system already exists in the United States. It’s called Medicare and Medicaid. These programs have failed miserably in several aspects: Lack of coverage: The number of uninsured citizens keeps rising despite the ever increasing money spent on Medicaid and Medicare. Those who are on Medicaid and Medicare are under-insured because these systems reimburse physicians at a rate of roughly twenty cents on the dollar. Most primary care physician practices’ overhead averages forty to fifty or more percent. Thus, physicians lose thirty cents on the dollar for every Medicaid and Medicare patient they see. This necessitates physicians to either refuse to accept Medicaid and Medicare; or to be forced to go out of business through lack of financial viability.
Disconnect between payers and consumers health care increases utilization and overall costs.
Entitlement programs charge working Americans twice, and in some cases three times, for the benefits they provide their recipients: through taxes, through cost-shifting of high insurance premiums; and through obligating physicians and hospitals to provide free care to anyone who walks through the door, be they tax-paying citizens or not.
Just so you’re under no illusions this is a small problem, look at the 2006 statistics published in the American College of Obstetricians and Gynecologists’ newsletter: Seven percent of obstetricians quit delivering babies altogether and another twelve percent curtailed services to accept only low risk clients. The reasons cited for this were declining reimbursement for deliveries and increase financial and emotional cost of malpractice insurance. A large portion of obstetric patients are illegal immigrants who are either uninsured or covered by Medicaid “Emergency Services Only” which pays dismally. This twenty percent reduction in obstetric services in a single year is truly astounding.
The main reason reimbursement by Medicare and Medicaid is insufficient is because there is a tremendous disconnect between the consumers of these benefits and those paying for these benefits. The payers are middle class working Americans. The consumers are retirees, people below the poverty level, and people who are illegal migrants. There is a complete disconnect between those who pay for the system (middle class Americans) and those who receive the benefits.
Disconnect between payer and recipient results in over-utilization of expensive services. If you don’t have to pay for something why hesitate to use it? Many people on Medicaid use the nation’s emergency departments like clinics because they don’t have to foot the several thousand dollar bill for an emergency department visit. If people are insulated from the cost of their prescription medications they are likely to use expensive heavily marketed drugs even if they have no proven benefit over older generic drugs.
Solving the health care crisis in this country requires increasing the connection between the payers and recipients and dispensers (health care providers and organizations) of health care services.
Profit Incentives…well…raise profits (and cost)
Why should commercial insurance companies and pharmaceutical companies make billions in profits when there are 46 million uninsured Americans? It just does not make sense. That is the multi-million dollar question. How can, for example the CEO of United Healthcare justify taking home a multi-million dollar annual compensation package when there are children and adults in this country who go without basic health care needs such as vaccinations and access to medical providers?
Commercial Insurance Companies:
Increasing Transparency and Evaluating “Managed Care”
Increasing Transparency
How do you know you’re getting the health care benefits for which you’ve paid? Do you understand your EOB (Explanation of Benefits) you receive in the mail after you’ve visited a health care provider or pharmacy? Have you checked to see if the insurance company has paid the correct percentage (accounting for deductibles and co-pays) according to your written policy? Have you read your insurance policy?
The average person (including me) has not read her insurance policy word for word. It’s usually a dense 50 or 60 page document written in legalese. The fine print within this document can contain many exceptions to the summary of the policy, of which you are unaware.
Does your insurance company pay for “out-of-network” providers in strict accordance with the written policy?
If you don’t know the answers to all these questions you may not be (probably aren’t) receiving the full benefits for which you are paying. Ask your insurance policy to account proportionally for every dollar of your premium – write to their CEO or CFO. They should at least send you an “annual report” – the company summary they mail yearly to investors. If you can’t get the information by asking, state you’re interested in investing in the company and can they send you an annual report? Money talks and information is power. We can’t do anything about rising health care premiums until we understand where each dollar goes. Once we understand where the dollars go, we can work to control the components eating those dollars.
Part of how insurance companies have made away with so much of our money is because we don’t demand the information. If we sit passively and complain it accomplishes nothing. Do something! Start by demanding an accounting of where your money goes. You have a right to know.
If we curtail existing entitlement programs we decrease the administrative burden of the Federal Government. There is a National body, the Joint Commission on Accreditation of Hospital Organizations (JCAHO), whose job is to regularly visit every hospital in the United States to see if they are living up to standards of safety and hygiene. Why not demand a Federal body that does for commercial insurance companies what JCAHO does for hospitals? Given that the largest portion of our national gross domestic product goes to health care it’s only appropriate the insurance companies be held accountable for responsible use of those dollars.
“Traditional” managed care has failed to control medical costs.Evaluating Managed Care
Managed Care is a model that originated in the 1980’s to attempt to control heath care costs. The original intention behind it was to link quality to cost and use the scientific method to evaluate the merit of various medical treatments. It has undergone much iteration over the past three decades. However, managed care has failed to control cost. Indeed costs have risen hundreds of percentiles over the past three decades.
Original versions of managed care involved a “gatekeeper” system in which insurance companies dictated patients must see a primary care physician before obtaining a referral to a specialist. Patients also had to jump through hoops to get basic services or tests ordered by the doctor covered. These factors caused great dissatisfaction among consumers of healthcare.
The present version of managed care involves “Preferred Provider Organizations” (PPO’s): establishing “in-network” and “out-of-network” benefits paid at different levels. The idea behind this is an insurance company negotiates “discounted rates” with a group of physicians or hospitals then drives consumers to use those physicians or hospitals. The advent of PPO’s has also failed to result in controlling health care costs.
Some of the greatest reductions in health care costs have come from hospitals and physicians themselves. Many physician groups and hospitals have taken the initiative to develop “Disease State Management Protocols” and “Clinical Pathways”. These are tools used to standardize care for common illnesses using evidence-based medicine and proven methods to control the cost of in-patient hospital care. These and similar efforts have produced the most dramatic control of health care costs, while actually improving and standardizing the quality of medical care delivered.
Pharmaceuticals
Newer drugs are not necessarily better than older ones; and they are usually more expensive.
The FDA incentivizes pharmaceutical companies to develop and market “new and better” drugs because patents on drugs expire after ten years and the drugs can then be produced as generics. Pharmaceutical companies are under minimal obligation to prove their “new and better” drug really is more effective than older, cheaper generic drugs. Pharmaceutical companies aggressively market new expensive drugs direct to consumers on television and to physicians without being required to prove they are more effective than their predecessors. Why? They should at least be required to disclose data about efficacy, just as they’re required to disclose side effects of their drugs.
Often new drugs are simply old drugs that have been “tweaked” by adding a minor chemical appendage so as to technically make them into new chemical compounds, although they don’t act any differently than their older predecessors. Some examples are “new” birth control pills touted to improve premenstrual syndrome and acne, which are variations on older generic birth control pills. Newer birth control pills sell for about $50 to $60 per month; whereas generic pills sell for about $7 to $10 per month. Both types of pills improve acne and premenstrual syndrome.
Another example is newer anti-depressants such as Lexapro and Celexa. These drugs are off-shoots of the old stand-by, Prozac (fluoxetine). Prozac is now generic (fluoxetine) and cheap whereas these newer drugs are not. They are touted to have fewer side effects; and they may indeed have fewer side effects. But they have not been required by the FDA to prove it in head-to-head randomized double-blinded, placebo-controlled trials. Are they required to disclose this fact in direct-to-consumer advertising? Why not? Moreover, there are new concerns about all the anti-depressants and increased risk of suicidal or violent behavior.
What is the logic insurance companies use to determine what they will and will not cover? For example, some insurance companies cover drugs to treat erectile dysfunction but they don’t offer maternity coverage, or coverage for contraception. Or they offer these benefits for additional premium. Why?
We certainly don’t want to discourage development of new drugs by removing the profit incentive. However, companies should be required to disclose efficacy data in marketing to consumers and physicians. Drug development must become more transparent to consumers so they can make the best choices for their physical well-being and the well-being of their wallets.
Malpractice Risk Drives Up Cost Via Defensive Medicine
You’ve all heard the politicians and the media bemoan the fact that malpractice risk increases costs for everyone so I don’t want to tire you with repetition of this other than to summarize. The high cost of malpractice insurance and the emotional toll of malpractice suits cause physicians and hospitals to engage in “defensive medicine”. Defensive medicine is ordering unnecessary tests in order to prove the patient doesn’t have a serious illness and thereby avoid a malpractice suits. There is no evidence that defensive medicine results in better medical care or reduces malpractice suit. The only reliable conclusion drawn by studies of defensive medicine is that it increases the overall cost of health care.
Malpractice suits have become something of a “lottery” – consumers looking for the multi-million dollar payoff. Defendants (physicians or hospitals) “win” eighty percent of malpractice suits that go to trial – usually after an expensive, drawn out, draining battle. The only people who truly win in these cases are the trial lawyers. Even the malpractice insurance companies take a hit but at least they can pass their cost onto the physician. Guess who the physician passes the cost onto?
However, if physicians passed on the entire cost of rising malpractice premiums to patients, no one would be able to afford to visit the doctor. Therefore, they only pass on a portion of the increased cost and they absorb the remainder. As malpractice insurance premiums rise, guess what happens to the business bottom line? This is a large contributor to the exodus of physicians from obstetrics: rising malpractice cost and declining reimbursement. If it actually costs you money to get up at 3 a.m. and go deliver someone’s baby, why do it? It makes no sense.
Money Spent on Extremes of Life
Ninety percent of the health care dollar is spent on the last six months of life. This often involves intensive care for people afflicted with terminal illnesses who are on life support. They
may require a tube to breathe, medication to keep their heart rate going and blood pressure normal, a tube for feeding in the stomach, or intravenous nutrition. We often die in hospitals hooked up to machines and being pumped full of drugs. We may not even be conscious. Is this how you want to die?
Just because we possess the technology does not mean it is best for us to use it. In the past we died with dignity in our homes, surrounded by family members. You should consider how you want to die at a time when you have full mental faculties and can make an advance directive. An advance directive is a document specifying what measures you want taken to extend your life should you not be able to decide for yourself. Don’t leave it up to your family members to make the decision because no one wants the responsibility of “pulling the plug”.
These extreme measures often consume the final dollars of a family’s savings and are a large component of Medicare expenses. This is money that could go to your children and grandchildren. It could pay for someone to go to college or someone to have a place to live. We have to decide for ourselves how much is enough and how much is too much?
Okay, so I’ve identified this, that and the other thing that are wrong with our health care system. What is right with it? Well we have access to advanced technology, well-trained physicians and nurses, antibiotics, and the best science money can offer. Too bad such a huge number of people struggle to get basic health care needs met. How do we get out of this mess?
Addressing the Big Four will “Fix” the United States Health Care System
In summary there are four big offenders in producing out-of-control health care costs:
FACTORS INCREASING HEALTH CARE COSTS:
Ø Disconnect between payers for and consumers of health care services
Ø Incentivizing profit without accountability
Ø Defensive medicine
Ø Money spent on extremes of life
Addressing each of these will decrease the cost of health care while preserving the advantages of technology and science, and increase access for everyone to basic health care services.
The silent underpinning of many of these problems is risk. So how we manage risk determines the cost of our health care.
The free market system works: competition encourages innovation and fosters incentives for cost control. We want to preserve the elements of the free market system that function well, while not sacrificing accountability and quality control.Connecting the Payer with the Recipient
It is crucial to connect the recipient of health care directly with the payer. The consumer needs to bear the risk of his health care decisions. The consumer of health care needs to directly feel the impact of system utilization in their wallet.
Eliminating or reducing the scope of entitlement programs would go a long way toward reducing the burden of health care costs for the middle class. Recipients of Medicaid should be required to prove they are U.S. citizens. Non-citizens should not be eligible to receive benefits for free. They should have to pay for their health care just like the rest of us.
If we do issue driver’s licenses or identification cards to non-citizens, it should be tied to proof of health insurance, proof of auto insurance, and proof of paying taxes.
We need to decrease the influence of the middle man and limit the role of private health care insurers and the government. One approach to this would be for groups of people to participate in pooled risk plans in which premiums and benefits are determined impartially by an actuarial company. This could be self-directed, for example, by employees of large companies or other pooled risk groups. Alternatively the existing insurance company framework could be restructured so as to decrease the “fat” in the system. This would require government or some outside agency regulating insurance profitability. What justification is there for the CEO of an insurance company making millions of dollars while many Americans go without basic services? Insurance companies would certainly balk at government regulation.
Consumers must demand greater transparency from commercial insurance companies regarding how their health care premium dollars are spent. Only when we understand where the money goes can we solve the problem of high cost.
Exert Your Own Cost Control:
· Examine Your Utilization
· Know Reasons for Tests
· Develop Advance Directive
Exert Your Own Cost Control
You have the power to control your individual health care costs. If everyone reduces her individual costs, the collective cost of health care will decline. Examine your utilization. The most expensive healthcare services are emergency room care, intensive care units (ICU’s), surgery, and advanced imaging studies such as MRI’s and CT scans.
Examine your utilization of the system. First, if you are ill after regular business hours, decide if you’re sick enough to need to go to the Emergency Room at a cost of thousands per visit; or can your condition wait until your doctor is available during regular business hours for a fraction of the cost?
Of course for emergencies like chest pain or hemorrhage you should proceed to the emergency room. But if you have chronic pelvic pain and have developed a worsening of pelvic pain the emergency department is not the best place to receive care for this problem. Childhood runny noses and rashes also don’t need to be seen in the Emergency department unless you’re concerned your child may be seriously ill (e.g. have a high fever, or is unable to keep food and water down).
If your doctor recommends a test, ask why? What is the doctor trying to learn with the test? What are the benefits, risks, and costs of the test? Will this test lead to further testing or surgery? Are you asking for the test because you want to know a certain result? Is the test going provide the information you desire? Will the test give you any useful clinical information to better understand your health? You should know the answers to all these questions before submitting to tests.
A perfect example of useless tests is “hormone levels”. Women ask me every day to check their hormone levels. If I can’t talk them out of it I usually oblige to satisfy them. However, female hormone tests do not tell us anything your own body can’t tell. For example, if you are having regular monthly periods your hormones will be “in the normal range”. The “normal range” is determined by measuring hormones of millions of “average” people to establish normal values. If you are over thirty, skipping periods, having night sweats, or have stopped having periods, your hormones will be in the “menopausal range” because these values are established by measuring hormone levels of millions of menopausal women. If you are skipping periods before age thirty, you probably have “polycystic ovary syndrome” caused by irregular ovulation.
I can test your hormone levels to confirm, but this is usually a diagnosis that can be made by asking questions and doing a physical exam.
If you are having raging premenstrual syndrome (PMS) I can test your hormone levels. They will most likely be “in the normal range” because hormone levels vary depending on time of cycle, age, and other factors. I can be of much more help by addressing your symptoms and developing a plan to manage them than I can by testing your hormone levels.
Knowing your actual hormone levels does not help us treat hormonal disorders most of the time because treatment is based on symptoms, not on a number from a lab.
If you have excess acne or hair growth it is likely your testosterone is high. I can measure it to be sure, but your body is telling me, by producing excess hair and acne that your testosterone level is high. Now if you have these symptoms a hormone level would be useful to exclude a testosterone-producing ovarian tumor. However, testosterone-producing ovarian tumors are exceedingly rare (<1/100,000). I will still recommend the test if I think it’s necessary based on your symptoms and physical findings.
Be careful of independent labs that offer “saliva tests” for hormones. These are expensive and can be misleading. Saliva levels of hormones can be quite variable from time of cycle and time of day.
Advance Directives
Develop an advance directive while you’re at an age when you have full mental capacity and you can consider these decisions in a thoughtful manner. Write it down. You don’t need an attorney to create an advance directive. Simply writing it down in one page or one paragraph is sufficient. If you want it to be “official” have it notarized. Make sure it answers crucial questions in a clear fashion for your relatives to understand. Advise your relatives you have an advance directive; review it with them; and make sure they know its location. At the end of life do you want to be kept alive with a breathing tube, intravenous feedings, or drugs? To what extent and expense do you want your body to be preserved, possibly with your mind in a vegetative state? Do you want to be resuscitated (brought back to life) if your heart or breathing stops? What would be the criteria you would want established for any of these measures to be taken?
Require Insurance Companies and Pharmaceutical Companies to Increase Disclosure, Transparency, and Accountability
We must hold big business accountable for making the most of the dollars we pay them.
We must hold big business accountable for making the most of the dollars we pay them. Insurance companies should be required to present policies in clear, consistent, standardized language to make it easy for the consumer to compare policies. An objective oversight body similar to the Joint Commission for Accreditation of Hospital Organizations (JCAHO) should be established to assess insurance companies and pharmaceutical companies to determine if they hold up to their promises.
Pharmaceutical companies or an outside agency (don’t we pay the FDA to do this?) should be required to conduct studies of efficacy of new drugs in an objective manner and disclose these results to the public along with the rest of their direct-to-consumer advertising.
The free market system works: competition encourages innovation and fosters incentives for cost control. We want to preserve the elements of the free market system that function well, while not sacrificing accountability and quality control.
Limit frivolous lawsuits to reduce the practice of defensive medicine.Doctors Can Impact Cost by Using Evidence Based Medicine and Resisting the Temptation to Practice Defensive Medicine
Doctors, nurses, and other healthcare providers can dramatically impact the cost of health care by resisting pressures to practice defensive medicine. One would not want to deny access to a necessary diagnostic test or treatment based on price. However, so many tests and treatments are ordered as “cya” measures.
Often patients request tests that are unnecessary. Usually one can explain the rationale behind testing or not testing and advise the patient to make an informed decision. However, some people are set on the idea that they need this or that test to understand their health. In this instance it is usually counter-productive to try to “talk” the patient out of it, and just go ahead and order the test.
In order for health care professionals to reduce the habit of defensive medicine, they need relief from the pressures to do so. A revamping of the “malpractice” system in the United States is long overdue.
Eighty percent of “malpractice” suits are won by the doctor or hospital being sued. This means in most cases that go to trial, evidence of malpractice cannot be found. The stress and cost of malpractice suits is discouraging good people from entering the field of medicine; and causing many to leave medicine or limit their practice to “low risk” disease conditions.
It has been suggested by consumer groups, physician groups, politicians, and government agencies that it is time to move to institutionalizing compensation for bad medical outcomes. The extent of damage and amount of compensation could be determined by an arbitration group. Funds for this should come from a number of sources: insurance premiums, lawyers, physicians, and consumers. Everyone should have to bear the cost of bad medical outcomes in order to curtail frivolous law suits and keep overall health care costs down over the long term.
It is much more effective to use a carrot to get people to do the right thing, than to beat them with a stick. For the most part doctors are smart, conscientious – often perfectionist – people who strive to do their best; and if you prove to them certain disease management protocols improve care and reduce cost, they will use these disease protocols. Doctors have studied long and hard to become physicians and it is a life-long learning process that involves accumulating “continuing medical education credits” throughout one’s career.
Evaluate How We Manage Extremes of Life
You can maximize your chances of having a healthy term baby by following the advice in DIY Baby! (Do It Yourself, Baby!). You have more control than you may realize. Overall, though, ninety percent of the health care dollar is spent on the last six months of life. Premature babies are expensive and we should strive to reduce prematurity.
This phenomenon has occurred because advances in technology have outpaced the study of ethics and responsibilities of a society to its members to provide the greatest good to the most number of people.
We need to decide as a society: How do we want to enter and exit life? Do we want to die hooked up to machines in a vegetative state? Is this the best use of our precious resources? Do we want to risk leaving a legacy of health care debt to our heirs?
You actually have complete control over this. By writing your advance directive, you remove the burden of your life’s decisions from others and take the initiative. I encourage you to write an advance directive and make your friends and family aware it exists. It doesn’t have to be long – a page or a paragraph. It doesn’t need to be written by a lawyer or notarized. However, if you take the trouble to have it notarized it may increase the likelihood it is taken very seriously.
You must consider all the possibilities: What if you’re completely paralyzed or brain damaged in an accident? Or rendered into a coma? What type of medical interventions do you want to take place? I urge you to think about these things and write them down: Your family’s lives depend upon it.
Only by tackling the four major factors increasing health care cost in this country can we obtain a safe, logical, cost-effective health care system. I encourage you to do your part.
Thursday, February 14, 2008
Free Healthcare
Your Baby Budget: Where does it come from; where does it go?
How do some people get it for free?
As of this writing, the cost to have a baby in the United States ranges from $10,000 to $25,000, depending on the region of the country in which you live. The highest cost states are those with the largest malpractice insurance premium burdens: New York, Pennsylvania, and Florida. There is a direct correlation between your cost of delivering your baby and the area in which you live.
Imagine being able to walk into a clinic or hospital and get your prenatal care and delivery for free? Would you stand in line for this?
I’ve practiced obstetrics in semi-rural Colorado since 1996. During that time I’ve witnessed the births to illegal immigrants rise to 70% from 30% of births at the hospital at which I deliver babies. Fifty percent of these births at my local hospital were paid for by “Emergency Services Only Medicaid” (ESO). The other fifty percent went entirely unreimbursed. In most states, illegal migrants do not qualify for public assistance. However there are two major exceptions: Medical or surgical emergencies and labor. A laboring woman is automatically defined to be in an “emergency” condition as dictated by EMTALA laws.
EMTALA laws governing hospital emergency care and transport require facilities and medical personnel to provide services to people in an “emergency situation” regardless of citizenship status, race, gender, and ability to pay. Although several states such as New Mexico and California have attempted to restrict non-citizen's access to free medical care in recent years, these measures have failed because they place the burden of identifying citizenship status on hospitals and healthcare providers, a practice that goes in direct violation of EMTALA laws and health care providers’ obligations to treat.
In 2006 an estimated 600,000 to 1 million of the 4.4 million babies born in the United States were to illegal migrants. This impacts some states more than others. By some estimates 70% of the births in California in 2006 were to illegals. As of 2006 Parkland Hospital in Dallas Texas delivered roughly 11,000 illegals annually.
At the low end, 600,000 births X $15,000 = $90,000,000,000 in uncompensated care for births to illegal migrants in 2006.
To put that number in some perspective, there are an estimated 43 million uninsured legal U.S. citizens and an additional estimated 12 million illegal migrants, most of whom are uninsured. So the 90 billion only addresses the cost of births to illegal migrants, not the overall cost of indigent care.
Where does this $90 billion come from? You. Your property tax, your income tax, your health insurance premium and “cost shifting”.
A 2003 study of 49 counties of varying populations in 24 different states revealed 80% of these counties have been paying for increased uninsured medical costs through general funds raised primarily through property taxes. So if you own your residence part of your property tax is paying for your county’s unreimbursed medical costs.
A significant portion of your federal and state income tax goes to fund Medicare and Medicaid. In many states the majority of Medicaid recipients are for “Emergency Services Only” (i.e. illegals, ESO). For example, at my local hospital 95% of the recipients of Medicaid obstetric services are ESO.
If you are a small business owner, self-employed, or just purchase your own health insurance out of pocket, you’ve seen astronomical increases in your health insurance premium over the past decades. At the same time, your deductible is higher, and/or you may have an “HSA” (Health Savings Account, another manifestation of “high deductible”). Part of your premium dollar is funneled into “cost shifting” by insurance companies and healthcare facilities.
Cost shifting occurs at several levels and is the unofficial practice by hospitals of charging ridiculous amounts of money for simple items (i.e. $10 for an ibuprofen or $500 for a bag of intravenous fluid) to supplement the enormous hit hospitals are taking in the indigent care arena. If you’ve been hospitalized recently, just for grins take a look at your itemized bill. Warning: sit down and take some Tums first. You’ll be shocked at what you see.
Cost shifting takes place in other fashions: the income from elective surgeries paid by insurance is used to offset losses for indigent care. Higher paying departments such as surgery, cardiology, and gastroenterology offset money losers such as obstetrics units and emergency departments.
The exact degree to which cost shifting occurs is impossible to ascertain because it doesn’t directly appear on a hospital’s balance sheet.
So don’t go into your local hospital and demand to see the CEO to interview him or her about cost shifting– at best they won’t be able to tell you; they might laugh at you, or at worst, they might rake you over the coals.
What to do about this problem? I can’t ethically argue for denying illegal immigrants access to care. This remedy is fraught with the moral dilemma of providing people in need with medical care. Requiring hospitals to establish citizenship prior to initiating is impossible and places too great a burden on these institutions and contradicts patient privacy laws.
A couple measures which may “stem the tide” are rescinding automatic citizenship: Requiring people to be citizens in order to give birth to citizens.
Stricter enforcement of who can receive Medicaid would help. My local County Medicaid office is staffed by Hispanics, many of whom are recent immigrants. The office has a reputation for handing out benefits to those who don’t qualify and of looking the other way regarding a family’s income producers in determining levels of benefit. It’s a classic case of the fox watching over the henhouse; these people are defrauding the system of your hard-earned tax dollars.
Raising income or property taxes to fund the 90 billion would cause economic disaster and be unfair because many illegals are paid on a cash basis and the income goes unreported and therefore untaxed. Perhaps a tax on something that even illegals would have to pay such as on gasoline household items (I’ll call it the Wal-mart tax). Although these measures might strain the economy in other ways, increasing the expense exposure (number of people needing the product or service) is really the only way to equitably fund medical care for illegal immigrants.
Or for those who want to issue driver's licenses to everyone, why not tie them to proof of payinig taxes, owning auto insurance, and health insurance?
At any rate, it’s time to think outside the box and design an equitable solution to fix this problem. The sheer number of births to illegal immigrants has strained the system beyond the breaking point, resulted in closures of obstetrics units, and caused obstetrics care providers to leave the field.
Anyone ready for a revolution? I think we’re long overdue for another Boston Tea Party…or a Texas Tequila Party?…
How do some people get it for free?
As of this writing, the cost to have a baby in the United States ranges from $10,000 to $25,000, depending on the region of the country in which you live. The highest cost states are those with the largest malpractice insurance premium burdens: New York, Pennsylvania, and Florida. There is a direct correlation between your cost of delivering your baby and the area in which you live.
Imagine being able to walk into a clinic or hospital and get your prenatal care and delivery for free? Would you stand in line for this?
I’ve practiced obstetrics in semi-rural Colorado since 1996. During that time I’ve witnessed the births to illegal immigrants rise to 70% from 30% of births at the hospital at which I deliver babies. Fifty percent of these births at my local hospital were paid for by “Emergency Services Only Medicaid” (ESO). The other fifty percent went entirely unreimbursed. In most states, illegal migrants do not qualify for public assistance. However there are two major exceptions: Medical or surgical emergencies and labor. A laboring woman is automatically defined to be in an “emergency” condition as dictated by EMTALA laws.
EMTALA laws governing hospital emergency care and transport require facilities and medical personnel to provide services to people in an “emergency situation” regardless of citizenship status, race, gender, and ability to pay. Although several states such as New Mexico and California have attempted to restrict non-citizen's access to free medical care in recent years, these measures have failed because they place the burden of identifying citizenship status on hospitals and healthcare providers, a practice that goes in direct violation of EMTALA laws and health care providers’ obligations to treat.
In 2006 an estimated 600,000 to 1 million of the 4.4 million babies born in the United States were to illegal migrants. This impacts some states more than others. By some estimates 70% of the births in California in 2006 were to illegals. As of 2006 Parkland Hospital in Dallas Texas delivered roughly 11,000 illegals annually.
At the low end, 600,000 births X $15,000 = $90,000,000,000 in uncompensated care for births to illegal migrants in 2006.
To put that number in some perspective, there are an estimated 43 million uninsured legal U.S. citizens and an additional estimated 12 million illegal migrants, most of whom are uninsured. So the 90 billion only addresses the cost of births to illegal migrants, not the overall cost of indigent care.
Where does this $90 billion come from? You. Your property tax, your income tax, your health insurance premium and “cost shifting”.
A 2003 study of 49 counties of varying populations in 24 different states revealed 80% of these counties have been paying for increased uninsured medical costs through general funds raised primarily through property taxes. So if you own your residence part of your property tax is paying for your county’s unreimbursed medical costs.
A significant portion of your federal and state income tax goes to fund Medicare and Medicaid. In many states the majority of Medicaid recipients are for “Emergency Services Only” (i.e. illegals, ESO). For example, at my local hospital 95% of the recipients of Medicaid obstetric services are ESO.
If you are a small business owner, self-employed, or just purchase your own health insurance out of pocket, you’ve seen astronomical increases in your health insurance premium over the past decades. At the same time, your deductible is higher, and/or you may have an “HSA” (Health Savings Account, another manifestation of “high deductible”). Part of your premium dollar is funneled into “cost shifting” by insurance companies and healthcare facilities.
Cost shifting occurs at several levels and is the unofficial practice by hospitals of charging ridiculous amounts of money for simple items (i.e. $10 for an ibuprofen or $500 for a bag of intravenous fluid) to supplement the enormous hit hospitals are taking in the indigent care arena. If you’ve been hospitalized recently, just for grins take a look at your itemized bill. Warning: sit down and take some Tums first. You’ll be shocked at what you see.
Cost shifting takes place in other fashions: the income from elective surgeries paid by insurance is used to offset losses for indigent care. Higher paying departments such as surgery, cardiology, and gastroenterology offset money losers such as obstetrics units and emergency departments.
The exact degree to which cost shifting occurs is impossible to ascertain because it doesn’t directly appear on a hospital’s balance sheet.
So don’t go into your local hospital and demand to see the CEO to interview him or her about cost shifting– at best they won’t be able to tell you; they might laugh at you, or at worst, they might rake you over the coals.
What to do about this problem? I can’t ethically argue for denying illegal immigrants access to care. This remedy is fraught with the moral dilemma of providing people in need with medical care. Requiring hospitals to establish citizenship prior to initiating is impossible and places too great a burden on these institutions and contradicts patient privacy laws.
A couple measures which may “stem the tide” are rescinding automatic citizenship: Requiring people to be citizens in order to give birth to citizens.
Stricter enforcement of who can receive Medicaid would help. My local County Medicaid office is staffed by Hispanics, many of whom are recent immigrants. The office has a reputation for handing out benefits to those who don’t qualify and of looking the other way regarding a family’s income producers in determining levels of benefit. It’s a classic case of the fox watching over the henhouse; these people are defrauding the system of your hard-earned tax dollars.
Raising income or property taxes to fund the 90 billion would cause economic disaster and be unfair because many illegals are paid on a cash basis and the income goes unreported and therefore untaxed. Perhaps a tax on something that even illegals would have to pay such as on gasoline household items (I’ll call it the Wal-mart tax). Although these measures might strain the economy in other ways, increasing the expense exposure (number of people needing the product or service) is really the only way to equitably fund medical care for illegal immigrants.
Or for those who want to issue driver's licenses to everyone, why not tie them to proof of payinig taxes, owning auto insurance, and health insurance?
At any rate, it’s time to think outside the box and design an equitable solution to fix this problem. The sheer number of births to illegal immigrants has strained the system beyond the breaking point, resulted in closures of obstetrics units, and caused obstetrics care providers to leave the field.
Anyone ready for a revolution? I think we’re long overdue for another Boston Tea Party…or a Texas Tequila Party?…
New Wellness Paradigm
Introduction
A New Wellness Paradigm for Birth in the United States
Welcome to parenthood! My mission is for you to have a happy healthy pregnancy and a beautiful baby for you are about to embark on life’s greatest satisfaction. This is your road map to have the best pregnancy experience possible. While the twentieth century witnessed dramatic declines in maternal and infant mortality as a result of improved medical care, the twenty-first century presents novel challenges and opportunities. Some of these derive from within ourselves and we can exert complete control over them; while others arise from external forces. The three factors that will have the greatest impact on our health this century are lifestyle, finances, and technology.
I have delivered babies and cared for people for fifteen years and through the years I have learned we exert the greatest control over our health through our lifestyle. Here I define lifestyle as our work habits, eating habits, and exercise habits. Most illnesses are brought on by a chronically unhealthy lifestyle. It’s those little decisions we make day-to-day that pile up over time and cause us to enjoy good health or suffer bad health: whether or not to work those two hours of overtime, what to choose for lunch from the cafeteria, whether or not to exercise that day.
Lifestyle
My desire to impart to you an insider’s understanding of pregnancy and birth so you can take charge of your health engendered DIY Baby! (Do It Yourself Baby!). Pregnancy is a physically stressed state for the body. It’s a normal state, but it does test our physical limits which is why most pregnancy-related illness are a manifestation of or a first sign of common medical conditions such as diabetes, high blood pressure, and consequences of stress.
Over-eating causes diabetes and high blood pressure in the pregnant and non-pregnant state. It increases the risk of pre-eclampsia (high blood pressure), gestational diabetes, cesarean section, dysfunctional labor, infection, and heart disease. Over-work and stress cause preterm labor, high blood pressure, heart disease, anxiety, and depression, including post-partum depression. Inactivity exacerbates the ramifications of over-eating and over-work.
Finance
Health care expenditure occupies the largest portion of the gross domestic product. In itself there is nothing wrong with this as we are nothing without our health. However, it’s out of control on many levels such that more frequently our health care decisions are being determined by finances. As of this writing there are nearly 45 million Americans who lack health insurance. Many people with insurance have “high deductible” plans and bear a greater percentage of the cost of medical care out of pocket. Many insurance plans excluded maternity and contraceptive coverage or require payment of extra premium to obtain such coverage.
Even uninsured American citizens are paying for our healthcare system via any of three avenues: through state and federal income taxes to finance Medicare and Medicaid programs; through “cost shifting” – the subconscious practice of raising prices to offset losses incurred by the uninsured; and directly through rising health care premiums, or losses of benefits or jobs due to rising health care premiums. The middle class American citizen also pays a huge percentage of their health care dollar to fatten the coffers of the “middle man”: the insurance carrier. During the late nineties and early 2000’s we’ve witness CEO’s of insurance companies take home multi-million dollar pay packages while we watch our premiums jump double digits from year to year.
Illegal immigration has “snuck up” on us in the past decade to the point where it pressures the health care system to the “breaking point”. Many recipients of Medicaid in the State of Colorado are illegal immigrants who receive Medicaid “Emergency Services Only” (ESO) benefits to deliver their babies. When I began private practice in 1996 illegals constituted about thirty-five percent of the deliveries at the hospital at which I deliver babies. As of the end of 2006 they represented nearly seventy percent. Medicaid “ESO” reimburses physicians roughly twenty cents on the dollar. The average physician office overhead is fifty percent so I pay thirty cents on the dollar for every Medicaid ESO patient I deliver. This is simply unsustainable.
If you think the impact of illegal immigration has been minor, think again: In 2006 nearly seventy percent of babies born in California were to illegal immigrant mothers. This resulted in the closure of many smaller obstetric wards in the state. At Parkland Hospital in Texas the rate of births to illegals soared to the high eightieth percentile over the same time period. The early 2000’s witnessed closure of twenty-five percent of obstetric wards in the Philadelphia metropolitan area due to declining reimbursement and increased cost of malpractice insurance for hospitals.
This does not mean I advocate denying illegal immigrants access to healthcare or some other racist hogwash. However, they should have to bear the same financial burden as the rest of us middle class Americans to enjoy the benefits they receive. I simply ask they pay their way as we all do.
Figures from the American College of Obstetrics and Gynecology (ACOG), the national organization of women’s health care specialists, revealed that in 2006 seven percent of ob-gyns ceased offering obstetrics altogether and another twelve percent reduced their practice to accept only “low risk” patients. This represents a nineteen percent reduction in obstetric services in a single year. Obstetricians cited three major factors for reducing or eliminating their deliveries: declining reimbursement, stress and cost of malpractice issues, and lifestyle.
Obstetricians are not being replaced at the rate they are leaving the field. For several years in the late nineties and early 2000’s obstetric residency programs were under-filled, at times reaching as low as a sixty percent fill rate with American medical school graduates. The remaining slots in those years were offered to graduates of foreign medical schools. Some of these U.S. trained foreigners remained in the United States; but many returned to their native countries to practice.
Technology
Now is the best time in history to bear a baby in the developed world. Mortality rates of mothers and term infants are very low. The hospital “Maternity Ward” has evolved into the “Family Birth Place”. The homey LDR (Labor, Delivery, and Recovery Room) has replaced the sterile “closet” tiled in puce where women labored on gurneys and were transported to an operating room to deliver strapped in stirrups with their legs in the air.
A paradigm shift has occurred in the mentalities of obstetric care providers and labor nurses. The paternalistic patient-doctor or patient-nurse model has been replaced and providers now view themselves as expert support personnel. They see their role as the imperative to create as safe, individualized and fulfilling a birth experience as possible for everyone who walks through their doors. Women and families are more empowered in their birth experience than they were fifty or even twenty years ago. They possess greater information about their options and are savvier.
We’ve spent enormous resources and training to make hospital delivery as much “like home” as possible with the safety net of proximity to emergency services. However, while some obstetric emergencies are indeed unpredictable, most are predictable based on easily identifiable risk factors. The truly dire emergencies such as cord accidents and massive placental separation have an incidence of slightly less than 1/1000 births and cannot be prevented and may not always be “rescued” by delivering in a hospital. Even if the baby is “physically” saved in such a situation, he may suffer irrecoverable mental damage and live out a short one-to-two year life in a vegetative state hooked up to machines.
Many obstetrical “emergencies” are actually “urgencies” which can be mitigated by changes in labor position or administering medication to stop labor and other conservative measures. Fetuses endure a great deal of stress during labor and they have an enormous capacity for recovery and regeneration. We’ve learned the brain is more capable of growth than we previously thought and we prevail intact not only because of but despite our efforts
technology, which has been our greatest friend in the past century, is becoming one of our worst detractors. Ninety percent of the health care dollar is spent on the last six months of life; and a significant portion of the remaining ten percent is spent on permanently impaired premature babies. The 1996 cost of babies born between 25 to 36 weeks gestation rang up at $38,000,000. Present estimates put that figure at $2,000,000,000. We’re spending enormous resources on the extremes of life.
Despite the technological advances made in medicine in general we have not been able to lower the U.S. preterm birth rate. It has remained about ten percent for the past fifty years and has climbed slightly during that period. I posit this as attributable in part to our stressful lifestyle in addition to socioeconomic and medical factors.
A phenomenon which I’ll call the “medicalization” of life and death has seeped into our culture over the past century. In the past we used to die and were born in the home; we were cared for by relatives in the comfort and security of a familiar environment. Now we die and are born in hospitals. We are kept alive, often in a “vegetative” state at either end by machines connected to our bodies through tubes and wires. I ask is this the best way? How much value should we place on the quality versus quantity of life? When and how do we draw the line for a cost-benefit analysis? What other ways are there to be born and die? Is there a sweeter way?
DIY Baby!
Do It Yourself Baby! is not a missive for you to go out and have your baby in the back yard. It is intended to avail you of the tools to maximize your wellness through the factors you can control and make the best of those you cannot control. Knowledge is power and the more you know about pregnancy and birth, the healthier you will be throughout life. I offer you a new wellness paradigm to approach your pregnancy in a pro-active fashion. Assume responsibility for the health of yourself and your baby no matter where you plan to deliver. In DIY Baby! I explore the option of home birth. Is it time to reconsider how we enter the world in this country? Can a select portion of the population safely deliver at home? Should they? What are the logistics? What are the selection criteria? What are the advantages and disadvantages?
Pregnancy can be a time of uncertainty and it doesn’t help that all your friends and relatives feel compelled to divulge their worst horror story of their pregnancy, labor or delivery. Despite the availability of resources on the market my patients’ questions have made me realize the existing materials are not conveying the information in a manner that’s readable or stays with you.
I hope this guide will give you, in a short time, a practical overview of what to expect from pregnancy and delivery. I wish to assuage your worries, as most of you will have normal vaginal deliveries. You will gain an obstetrician and mother’s perspective and knowledge of pregnancy and birth.
If you’re going to be a new dad, I hope to provide a guide to the changes in your wife’s body, as well as a road map to how to navigate her hormonal and emotional changes; and your own changes in adapting to fatherhood.
For the scientifically curious I include some of the medical background information on why you are experiencing the symptoms you are.
Above all I want this guide to give you a sense of confidence and empowerment when it comes to your pregnancy and birth. I hope you enjoy the ride and above all, happy new baby!
A New Wellness Paradigm for Birth in the United States
Welcome to parenthood! My mission is for you to have a happy healthy pregnancy and a beautiful baby for you are about to embark on life’s greatest satisfaction. This is your road map to have the best pregnancy experience possible. While the twentieth century witnessed dramatic declines in maternal and infant mortality as a result of improved medical care, the twenty-first century presents novel challenges and opportunities. Some of these derive from within ourselves and we can exert complete control over them; while others arise from external forces. The three factors that will have the greatest impact on our health this century are lifestyle, finances, and technology.
I have delivered babies and cared for people for fifteen years and through the years I have learned we exert the greatest control over our health through our lifestyle. Here I define lifestyle as our work habits, eating habits, and exercise habits. Most illnesses are brought on by a chronically unhealthy lifestyle. It’s those little decisions we make day-to-day that pile up over time and cause us to enjoy good health or suffer bad health: whether or not to work those two hours of overtime, what to choose for lunch from the cafeteria, whether or not to exercise that day.
Lifestyle
My desire to impart to you an insider’s understanding of pregnancy and birth so you can take charge of your health engendered DIY Baby! (Do It Yourself Baby!). Pregnancy is a physically stressed state for the body. It’s a normal state, but it does test our physical limits which is why most pregnancy-related illness are a manifestation of or a first sign of common medical conditions such as diabetes, high blood pressure, and consequences of stress.
Over-eating causes diabetes and high blood pressure in the pregnant and non-pregnant state. It increases the risk of pre-eclampsia (high blood pressure), gestational diabetes, cesarean section, dysfunctional labor, infection, and heart disease. Over-work and stress cause preterm labor, high blood pressure, heart disease, anxiety, and depression, including post-partum depression. Inactivity exacerbates the ramifications of over-eating and over-work.
Finance
Health care expenditure occupies the largest portion of the gross domestic product. In itself there is nothing wrong with this as we are nothing without our health. However, it’s out of control on many levels such that more frequently our health care decisions are being determined by finances. As of this writing there are nearly 45 million Americans who lack health insurance. Many people with insurance have “high deductible” plans and bear a greater percentage of the cost of medical care out of pocket. Many insurance plans excluded maternity and contraceptive coverage or require payment of extra premium to obtain such coverage.
Even uninsured American citizens are paying for our healthcare system via any of three avenues: through state and federal income taxes to finance Medicare and Medicaid programs; through “cost shifting” – the subconscious practice of raising prices to offset losses incurred by the uninsured; and directly through rising health care premiums, or losses of benefits or jobs due to rising health care premiums. The middle class American citizen also pays a huge percentage of their health care dollar to fatten the coffers of the “middle man”: the insurance carrier. During the late nineties and early 2000’s we’ve witness CEO’s of insurance companies take home multi-million dollar pay packages while we watch our premiums jump double digits from year to year.
Illegal immigration has “snuck up” on us in the past decade to the point where it pressures the health care system to the “breaking point”. Many recipients of Medicaid in the State of Colorado are illegal immigrants who receive Medicaid “Emergency Services Only” (ESO) benefits to deliver their babies. When I began private practice in 1996 illegals constituted about thirty-five percent of the deliveries at the hospital at which I deliver babies. As of the end of 2006 they represented nearly seventy percent. Medicaid “ESO” reimburses physicians roughly twenty cents on the dollar. The average physician office overhead is fifty percent so I pay thirty cents on the dollar for every Medicaid ESO patient I deliver. This is simply unsustainable.
If you think the impact of illegal immigration has been minor, think again: In 2006 nearly seventy percent of babies born in California were to illegal immigrant mothers. This resulted in the closure of many smaller obstetric wards in the state. At Parkland Hospital in Texas the rate of births to illegals soared to the high eightieth percentile over the same time period. The early 2000’s witnessed closure of twenty-five percent of obstetric wards in the Philadelphia metropolitan area due to declining reimbursement and increased cost of malpractice insurance for hospitals.
This does not mean I advocate denying illegal immigrants access to healthcare or some other racist hogwash. However, they should have to bear the same financial burden as the rest of us middle class Americans to enjoy the benefits they receive. I simply ask they pay their way as we all do.
Figures from the American College of Obstetrics and Gynecology (ACOG), the national organization of women’s health care specialists, revealed that in 2006 seven percent of ob-gyns ceased offering obstetrics altogether and another twelve percent reduced their practice to accept only “low risk” patients. This represents a nineteen percent reduction in obstetric services in a single year. Obstetricians cited three major factors for reducing or eliminating their deliveries: declining reimbursement, stress and cost of malpractice issues, and lifestyle.
Obstetricians are not being replaced at the rate they are leaving the field. For several years in the late nineties and early 2000’s obstetric residency programs were under-filled, at times reaching as low as a sixty percent fill rate with American medical school graduates. The remaining slots in those years were offered to graduates of foreign medical schools. Some of these U.S. trained foreigners remained in the United States; but many returned to their native countries to practice.
Technology
Now is the best time in history to bear a baby in the developed world. Mortality rates of mothers and term infants are very low. The hospital “Maternity Ward” has evolved into the “Family Birth Place”. The homey LDR (Labor, Delivery, and Recovery Room) has replaced the sterile “closet” tiled in puce where women labored on gurneys and were transported to an operating room to deliver strapped in stirrups with their legs in the air.
A paradigm shift has occurred in the mentalities of obstetric care providers and labor nurses. The paternalistic patient-doctor or patient-nurse model has been replaced and providers now view themselves as expert support personnel. They see their role as the imperative to create as safe, individualized and fulfilling a birth experience as possible for everyone who walks through their doors. Women and families are more empowered in their birth experience than they were fifty or even twenty years ago. They possess greater information about their options and are savvier.
We’ve spent enormous resources and training to make hospital delivery as much “like home” as possible with the safety net of proximity to emergency services. However, while some obstetric emergencies are indeed unpredictable, most are predictable based on easily identifiable risk factors. The truly dire emergencies such as cord accidents and massive placental separation have an incidence of slightly less than 1/1000 births and cannot be prevented and may not always be “rescued” by delivering in a hospital. Even if the baby is “physically” saved in such a situation, he may suffer irrecoverable mental damage and live out a short one-to-two year life in a vegetative state hooked up to machines.
Many obstetrical “emergencies” are actually “urgencies” which can be mitigated by changes in labor position or administering medication to stop labor and other conservative measures. Fetuses endure a great deal of stress during labor and they have an enormous capacity for recovery and regeneration. We’ve learned the brain is more capable of growth than we previously thought and we prevail intact not only because of but despite our efforts
technology, which has been our greatest friend in the past century, is becoming one of our worst detractors. Ninety percent of the health care dollar is spent on the last six months of life; and a significant portion of the remaining ten percent is spent on permanently impaired premature babies. The 1996 cost of babies born between 25 to 36 weeks gestation rang up at $38,000,000. Present estimates put that figure at $2,000,000,000. We’re spending enormous resources on the extremes of life.
Despite the technological advances made in medicine in general we have not been able to lower the U.S. preterm birth rate. It has remained about ten percent for the past fifty years and has climbed slightly during that period. I posit this as attributable in part to our stressful lifestyle in addition to socioeconomic and medical factors.
A phenomenon which I’ll call the “medicalization” of life and death has seeped into our culture over the past century. In the past we used to die and were born in the home; we were cared for by relatives in the comfort and security of a familiar environment. Now we die and are born in hospitals. We are kept alive, often in a “vegetative” state at either end by machines connected to our bodies through tubes and wires. I ask is this the best way? How much value should we place on the quality versus quantity of life? When and how do we draw the line for a cost-benefit analysis? What other ways are there to be born and die? Is there a sweeter way?
DIY Baby!
Do It Yourself Baby! is not a missive for you to go out and have your baby in the back yard. It is intended to avail you of the tools to maximize your wellness through the factors you can control and make the best of those you cannot control. Knowledge is power and the more you know about pregnancy and birth, the healthier you will be throughout life. I offer you a new wellness paradigm to approach your pregnancy in a pro-active fashion. Assume responsibility for the health of yourself and your baby no matter where you plan to deliver. In DIY Baby! I explore the option of home birth. Is it time to reconsider how we enter the world in this country? Can a select portion of the population safely deliver at home? Should they? What are the logistics? What are the selection criteria? What are the advantages and disadvantages?
Pregnancy can be a time of uncertainty and it doesn’t help that all your friends and relatives feel compelled to divulge their worst horror story of their pregnancy, labor or delivery. Despite the availability of resources on the market my patients’ questions have made me realize the existing materials are not conveying the information in a manner that’s readable or stays with you.
I hope this guide will give you, in a short time, a practical overview of what to expect from pregnancy and delivery. I wish to assuage your worries, as most of you will have normal vaginal deliveries. You will gain an obstetrician and mother’s perspective and knowledge of pregnancy and birth.
If you’re going to be a new dad, I hope to provide a guide to the changes in your wife’s body, as well as a road map to how to navigate her hormonal and emotional changes; and your own changes in adapting to fatherhood.
For the scientifically curious I include some of the medical background information on why you are experiencing the symptoms you are.
Above all I want this guide to give you a sense of confidence and empowerment when it comes to your pregnancy and birth. I hope you enjoy the ride and above all, happy new baby!
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