Saturday, May 13, 2006

If I ran health care

From Jamie:

If you were in charge, how would you structure health care for pregnant women in this country? Do you think OBs should be the default providers? (And BTW, do you have reservations about family practitioners providing obstetric care? They have so much else to cover in residency that surely they don't get a ton of time handling complicated OB cases either.)

If I ran health care, here are some of the things I would do. Let me say in advance that my plans have little to do with homebirth. That's because my chief goal would be to bring down the perinatal mortality rate for infants born to women from minority communities.

1. I would institute a single payer system to guarantee that all pregnant women had prenatal care and that there were no barriers (paperwork, etc.) to accessing that care.

2. I would make federal assistance (welfare) contingent on getting that care. In other words, if you don't show up for your prenatal appointments, you wouldn't get a check.

3. I would reform the tort system by instituting no-fault insurance. In other words, anyone whose baby was impaired would be compensated, regardless of whether it was anyone's fault or just an accident of nature. (This would hopefully decrease the amount of defensive medicine, since you wouldn't have to prepare every chart as if you might ultimately face a law suit.)

4. I would dramatically strengthen the power of Boards of Registration by increasing their funding and providing them with investigators. Right now most Boards are essentially toothless and cannot get rid of bad doctors.

5. I would ban social inductions and elective C-section for social reasons.

6. I would fund research that would try to understand if there are racial differences in pregnancy and birth. Perhaps we are treating minority patients improperly.

That's just a beginning. I'm sure I'll think of a few more and if so, I will post them inside.

8 Old Comments:

3. I would reform the tort system by instituting no-fault insurance. In other words, anyone whose baby was impaired would be compensated, regardless of whether it was anyone's fault or just an accident of nature. (This would hopefully decrease the amount of defensive medicine, since you wouldn't have to prepare every chart as if you might ultimately face a law suit.)

4. I would dramatically strengthen the power of Boards of Registration by increasing their funding and providing them with investigators. Right now most Boards are essentially toothless and cannot get rid of bad doctors.

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these 2 are related - though I would point that out incase you didn't realize it-- and you should talk to lawyers about the numbers of disgruntled people they do screen out-
I know that I spend quite a bit of time talking to people about talking to their provider first most feel they cannot or have already and have been dismissed then I recommend writing a letter of complaint that is CC'd to insurance companies and hospital admin and medical board.

By Anonymous Anonymous, at 11:12 AM  

looking at minorities and the poor
transportation is another aspect of getting care - right now gas-chits or bus pass will work for some- get it from the doc after the appointment-
but there are bigger cultural problems - and just like looking at 3rd world countries what is sustainable and going to work in the long run for these people --
an example LLL started a program for peer counseling that was different than their leader program as a type of outreach- instead of 1 year of nursing and a ton of reading it was scaled down to 3 months of breastfeeding and some training- many times this could be some grandma who standing in the grocery store line feels it is her place to say something to a young mom---- this is utilizing a social structure that is already in place but arming the culturally respected - with education

By Anonymous Anonymous, at 11:52 AM  

If you were in charge, how would you structure health care for pregnant women in this country?

I am biased, I don't think that OBs should be default care providers and I'd like to see a system where midwives provide the bulk of low-risk care both in hospital and out. I'd like to see all states recognize CPMs alongside CNMs and provide both types of midwives equal reimbursement by insurance (private and state provided). Last, more access to free-standing birth centers that meet the definition of birth centers set forth by the National Association of Childbearing Centers, rather than meeting the defiinition of out-patient surgicenters (NACC missed the boat by not legally defining birth center) to keep it pure and out of hospitals).

(And BTW, do you have reservations about family practitioners providing obstetric care? They have so much else to cover in residency that surely they don't get a ton of time handling complicated OB cases either.)

I don't have any reservations about FPs providing care. The FPs I have experience with in my area think similarly to midwives and in general provide low intervention care. They, as we, transfer care of complicated cases to OBs.

By Anonymous MetroMidwife, at 1:13 PM  

I had to read back to understand that Jamie was not being asked to answer those questions. So knowing it was Amy...

5. I would ban social inductions and elective C-section for social reasons.

This interesting and I'd add VBAC TOL as a SOC unless conditions indicate absolute prohibition on a case by case basis. Although I agree the ban of social inductions and elective Cesareans would quickly improve obstetric care, I wonder how this could be put into action. "My body, my baby, my choice." I can hear it already!

By Anonymous MetroMidwife, at 5:03 PM  

"Although I agree the ban of social inductions and elective Cesareans would quickly improve obstetric care, I wonder how this could be put into action. "My body, my baby, my choice." I can hear it already!"

It is pretty well established that medical procedures should only be performed for medical reasons. So, a woman might tell her doctor that she wants her gallbladder removed, but unless she has a medical indication for the surgery, no one is going to do it.

That's why I was so disappointed in ACOG's response. It is not an issue of automony and they were wrong to suggest that it was. It is an issue of medical procedures being used for non-medical reasons, and as such, should have received official disapproval.

Although many women try to induce themselves (castor oil being a favorite treatment), pitocin induction cannot be considered anything other than a medical procedure and, as such, should be reserved for medical indications. The case against elective C-sections for social reasons is even more stark.

The case in favor of TOL after previous C-section is different, since there is medical evidence to suggest that the risk of certain rare complications can be reduced by elective repeat C-section. In that setting, a woman is deciding between two different sets of possible complications. However, I strongly believe that every woman deserves the option to choose TOL and not be railroaded into an elective repeat C-section.

The hospital where I trained prohibited social inductions and absolutely banned C-sections for social reasons. No one ever challenged it during the years I was there.

By Blogger Amy Tuteur, MD, at 2:37 PM  

Amy, I sent a post about a German attempt to reduce PTL- I am not thrilled about the cervical closure but the pH info looks promising- I am hoping you received the post but didn't leave it on the list. I think that we all want a reduction in complications.

By Anonymous Anonymous, at 2:08 AM  

Anonymous:

"I sent a post about a German attempt to reduce PTL"

I did not receive it. Perhaps you can send it again.

By Blogger Amy Tuteur, MD, at 6:58 AM  

here is the link for the PTL info--

http://www.saling-institut.de/eng/index.html

By Anonymous Anonymous, at 11:40 AM