Questions Every Pregnant Woman Should Answer

To be forewarned is to be forearmed. That is the mantra that should be adopted by all potential patients who are engaged in our present healthcare system and especially pregnant women. Information is power and you can never have too much regarding your health. There is a trend for pregnant women to write a birth plan regarding their delivery but there should also be an action plan during the third trimester.

Listed below are questions taken from Harvard Medical School’s Family Health Guide. I strongly encourage you to become familiar with these questions because they could inevitably save your life or the life of your baby. Many of them address the warning signs of pre-eclampsia (swelling of the hands and face) and preterm labor (leaking fluid).

 

  • Do you have adequate support at home from family or friends?
  • How do you feel? Have you had any problems since your last visit?
  • Have you had any vaginal bleeding or spotting?
  • Have you had any pain or uterine cramping?
  • Have you had any discharge or leakage of fluid from your vagina?
  • Have you noticed swelling of your face or ankles?
  • Have you had any problems with your vision?
  • Are you getting frequent headaches?
  • Have you noticed a change in the frequency or intensity of fetal movement?
  • Are you planning to breast-feed or bottle-feed?
  • Have you selected a pediatrician for your baby?
  • Are you taking classes on labor and delivery?
  • Have you made arrangements for your family’s health insurance to cover your baby when the baby is born?
  • Have you purchased a special car seat to hold your baby when riding in your car?
  • Have you decided on whether the baby will have a circumcision, if a boy?
  • Have you talked with your doctor about the length of your stay in the hospital?
  • Do you know the signs of going into labor so that you can call your doctor when labor begins? (These include uterine contractions and rupture of the membranes).

A good defense begins with a good offense. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.

How to Avoid Being a Victim of a Medical Scandal

My institute of residency training is in hot water again, and I groan in despair (see Heart Tests at Harlem Hospital Went Unread). The New York Times reported that Harlem Hospital had performed nearly 4,000 cardiac echo exams in a two year period and none of them had been read by a physician. The Times alleges that the responsibility of reviewing these labs reports had been given to the cardiac techs and now the consequences of that decision was coming back to haunt the entire hospital.

This scandal reminds me of another that occurred over 25 years ago. Hundreds of New York City women entrusted their PAP smears to city hospitals that were never read by a gynecologists. By the time the debacle was discovered years later, some of these women developed cancer. With a failing economy and budget constraints, I’m sure someone had the misguided perception that they could save money and resources if the technicians read the lab reports and reported the “abnormals” back to the physicians. The same principals apply to nursing. Medical assistants are now expected to perform duties traditionally done by nurses as a means of “saving” money. These “cost-saving” strategies have a chilling effect.

Harlem Hospital is an historical haven for the poor. Despite limited resources, its dedicated staff saves lives on a daily basis. However, please don’t push the envelope. The quality of medical care greatly diminishes as the volume of patients increases. Delegating a physician’s duties to a technician will NOT remedy this problem.

A team of 15 to 20 physicians from other city hospitals were assembled to review the cardiac records and miraculously no abnormalities were found. There were also disciplinary actions that resulted in the termination of a clinical director and the demotion of a physician. The take-home message for ALL patients regarding this debacle is to obtain the results of all of your medical tests. Do not assume “no news is good news.” And if someone wants to give you an injection, please verify that they’re truly a nurse.

Our present healthcare system is on automatic pilot. It’s up to you to grab hold of the wheel.

Doctors Perform C-Section on a Non-Pregnant Woman

Last week the Internet was replete with stories regarding two North Carolina obstetricians who performed a c. section on a non-pregnant woman (see ABC News).  Sadly, mistakes of this magnitude occur more often than the public is made aware to the detriment of both unsuspecting patients and unsupervised resident physicians.

Residency training is a pecking order and the neophyte intern is the first responder. He or she must evaluate the patient, and then report their findings to their senior resident or attending physician. More than likely this particular patient was obese and had “no previous prenatal care.” According to the ABC News report, the intern performed an ultrasound and was not able to “see a fetal heart tone.” It’s possible that the intern thought the patient’s baby had died and ordered an induction of labor for its delivery.  The “induction” allegedly lasted two days and the patient and her husband requested a c. section.  The case was allegedly discussed with a senior resident and attending physician who agreed with the intern’s management. Upon entry of the uterine cavity, a non-pregnant uterus was diagnosed to the chagrin of the physicians and the patient’s abdomen was quickly closed. 

Here comes the stampede of  lawyers.

Let’s rewind the tape, then hit the play button and describe what SHOULD have happened:

  1. The intern takes the patient’s history and then examines the patient to determine whether the patient’s cervix is dilated (open) and if the baby’s head is down. If she can’t feel the head, she needs to order an ultrasound in the radiology department. If it’s after hours and a radiologist is unavailable, she can do an “unofficial” scan and see if the scan can be read by either an offsite radiologist via telemedicine or her attending physician.
  2. She attempts to obtain a fetal heart tone. If none is obtained, she needs an OFFICIAL ultrasound to make certain the baby is alive.

Doing steps 1 and 2 would have documented an empty, non pregnant uterus and eliminated unnecessary surgery. Also, the intern’s senior physician and attending should have BOTH examined the patient to confirm or dispute the intern’s exam.  

Our ob-gyn protocols are clearly established. Why on earth can’t we follow them?

Hospital Fraud Finally Exposed

Kudos to CNN reporter Elizabeth Cohen for reporting on hospital waste; the “open” secret has now been revealed.  See Healthcare Industry Sick With Medical Waste. Physicians and nurses have known about inflated hospital charges for years and now the public does too. As Cohen reported about $1,000 toothbrushes and $121 pacifiers I thought about my own horror story.  Physicians aren’t exempt from illness and in 2008 I developed an acute eye condition that threatened my vision. At the recommendation of my optometrist, I saw a retinal specialist who admitted me to a local hospital for a same day procedure. In retrospect, I regret both having the procedure (that failed) and being admitted to an institution that provided less than exemplary customer service and gave me a over inflated bill.

As a physician, I know exactly what medication costs and was incensed when I received my $13,000 hospital bill. Charges of $181.00 for a $4.00 generic drug, implausible costs for intravenous medications and “Star- Wars-type” surgical tools made me see red.  I challenged the outrageous bill but to no avail. I went through layers of billing clerks who were both rude and useless; and spoke with a hospital auditor who defended the charges. I complained vehemently to my insurance company, advising them that they were being duped but they paid their portion and never investigated my complaints. I ultimately paid my portion of the bill but felt like I had been extorted by the Mafia. In retrospect, here’s what I wish I had done:

  • Requested an estimate of hospital charges BEFORE I was admitted
  • Wrote a letter of complaint to my state’s Insurance Commissioner; and
  • Consulted the services of a medical billing advocate

Most pregnant women will give birth either in a hospital or birthing center so it behooves you to be as pro-active as possible regarding scrutinizing your bill. Healthcare has become a business. Make sure you’re an educated consumer.

Will Americans Die Because They Are Poor?

“Let them eat cake” was the response uttered by a French aristocrat upon learning that her impoverished citizens did not have bread to eat. The US State Medicaid offices have essentially said the same thing. (See US States Slash Medicaid by Tom Eley) If the proposed Medicaid cuts are enacted, being poor will become equivalent to having a death sentence in one of the most prosperous countries in the world.  Don’t believe it? A 76-year old woman in Michigan died from dental abscesses in Michigan when her dental coverage was revoked.

If you’re poor and need eye services? Forget about it. Live in Arizona and have children in the CHIP program? It might very well disappear. Have mental health problems and live in poverty? You might not be treated.  Pregnant and live in California? You’ll have to be poorer than dirt in order to receive insurance. Your doctors’ Medicaid and Medicare payments have been slashed severely so very few will be able to treat you. No one wants to work for free. Are you incontinent with urine? Sorry, no more adult diapers. If you live in Tennessee, please don’t have a car accident or heart attack. Your state is only going to pay a lifetime Medicaid benefit of $10,000 for inpatient care.

If state legislators need money to fund our healthcare system why don’t they start by commandeering the obscene salaries and fiscal perks of insurance CEOs? Make the lobbyists empty their deep pockets. Raid the trust funds of spoiled brats who never did an honest day’s work in their lives.  Empty the bank vaults in the Cayman Island and bring home all of that tax-free money. Tell the oil barons in Dubai to stop milking us dry. How about manufacturing something “Made in the US” for a change?

Billy Graham once said “Hot heads and cold hearts never solved anything.” Performing slash-and-burn maneuvers will NOT eliminate our healthcare’s fiscal problems. The poor are sick and the sick are poor.  Please do not increase their numbers.

Health Care Reform: An Unkept Promise

 When I heard the final Senate version of the healthcare reform bill, I had a complete meltdown (please see An Open Letter to President Obama). I had been sucker-punched by people who I thought I could believe in and it was clear that the democratic process had been replaced by corporate agendas.

 Louisiana Senator Mary Landrieu received an additional 100 to 300 million dollars for Medicaid, Nebraska Senator Ben Nelson cut a deal that guaranteed federal Medicaid payment for life (although this is now being challenged by several State Attorney Generals) and Connecticut Senator Joe Lieberman killed a public option because of his wife’s affiliation as a consultant and lobbyist to pharmaceutical and insurance companies.  Hadassah Lieberman was a consultant for Pfizer, who is one of the largest U.S. pharmaceutical companies and recently ordered by the U.S. Department of Justice to pay a $2.3 billion dollar lawsuit for healthcare fraud. Government lawyers settle $2.3 billion dollar Pfizer fraud lawsuit.

On Christmas Eve, the US Senate’s version of HR 3200, aka America’s Affordable Health Choices Act of 2009 passed. The House of Representative and Senate bills must now converge into one bill. The dynamics of that process will be interesting and we will need to watch our backs.

I challenged Doctors for America, an organization of approximately 16,000 physicians to answer the following questions regarding HR3200:

  1.  Will the premiums for people with pre-existing conditions be higher and by how much?
  2. Will there be some outside regulatory agency to govern the insurance companies in the event of misdeeds?
  3. Will there by co-pays and deductibles and by how much?
  4. Will there be a limit of services provided by these so-called state regulated insurance plans, i.e., will the poor receive less services based on the type of insurance they have?
  5. How much assistance will poor people receive regarding insurance premium payments? 10%, 20%, or 30%?
  6. Is there a cap on how much an insurance CEO can earn?
  7. Will there be reductions in payments of Medicare and Medicaid to physicians?
  8. Will these plans be taxed to people who earn above a predetermined income?

To the organization’s credit, they provided the following answers:

         1.   Older people will have to pay higher premiums at a ratio of 2:1 in the House bill and 3:1 in the     Senate bill. This means that as an “older” person, my premiums will either double or triple           based on the new “reform”. If you are a smoker, be prepared to pay higher premiums as well     and no, you can’t conceal your habits because they can do urine and blood tests in search of        nicotine.

          2.  Insurance companies will be required to report to the government on their performance, profits,  etc. A health insurance’s ability to participate in the Exchanges will depend on its performance.   If an insurance company increases its premiums prior to the Bill’s final approval, they will be  excluded as a candidate for the exchange.

        3.    Yes, there WILL be co-pays but there will allegedly be no more lifetime or annual limits on how  much an insurance company can pay on your behalf.                                       

         4.   Allegedly, there’s a minimum benefits plan on the Exchanges, and then several levels of plans above that. The minimum benefits plan provides “significantly” more benefits than the average individual plan today.

         5.   People earning 400% below the poverty line will have their insurance premiums subsidized.       Who are these people? Any individual who earns $43,000 or less and families of four who earn  less than $88,000. The table listed below illustrates provides an example of a subsidy.                                

         6.   At present there is no cap on the earnings of insurance CEOs but allegedly companies must spend between 80 to 85% of their revenues on medical care. They are also required to report profits annually and pay dividends to their customers if their profits exceed the cap.

         7.   Allegedly, there will be no cuts to either Medicare or Medicaid physician payments.

          8.  There is allegedly going to be an “excise” tax on “Cadillac” plans described as plans that cost  individuals more than $8500 per year or families more than $23,000 per year. Individuals  earning more than $200,000 and families earning more than $250,000 per year will pay 2.35%  more in Medicare payroll tax.    

                What does HR 3200 offer small business owners? Small business, with payrolls less than $250,000 per year will be exempt from the employer responsibility requirement. Allegedly, new small business tax credit will be available for companies who want, but can’t afford to provide their employees with healthcare insurance.

 As a physician, my main concern is patient care and safety both which have declined under an insurance-driven market. Have no doubt about it folks, the insurance companies are running the show and “old-school” physicians like me are growing weary of fighting near-impossible battles.  With the demise of the public option, who’s going to ensure that insurance companies play by the rules? Proposing that states assume that responsibility as suggested by the Senate Bill is unrealistic. The federal government had to enforce the Civil Rights Act back in 1964 and the same principle applies now. Without federal intervention, state governments will do nothing and insurance companies will conduct business as usual.

President Obama admitted that members of the US Senate and Congress have the best health insurance plans in our country. Why should WE settle for anything less?

A Wish for Pregnant Women

I wish I could click my heels three times and be transported back to a time when healthcare was not a business and patients were more than a commodity. I am NOT a healthcare provider. I’m a physician who was taught to heal.

I wish pregnant moms had time to bond with their babies before being booted out of a hospital. And I didn’t have to threaten billing clerks for not admitting my patients for emergency tests because they didn’t have the “right” insurance.

I wish the ob hospitalists hadn’t sent a patient home inappropriately with low fluid and no further follow-up. The patient thought everything was “okay”, traveled to another state on vacation and had to be tracked down. She was advised to go the nearest hospital where she had an emergency c/section that saved her baby’s life.

I wish I could have avoided the hassle with a local hospital when I attempted to send a patient for a diagnostic test and they said they were “too full and too busy.” I ultimately sent the patient to a specialty hospital that was further away where she immediately had a cesarean section because the baby had stopped growing at 33-weeks. Both mom and baby are fine.

I wish the triage department at a local hospital had performed an ultrasound on a patient who complained of bleeding at 27-weeks. They listened to the baby’s heartbeat, said everything was fine and sent her home. When I sent her for an ultrasound, the radiologist contacted me emergently. The patient’s placenta completely covered the opening to her womb and there was a cord wrapped around the baby’s neck three times. I referred the patient to a specialty hospital where she remained for the next nine weeks until she delivered her baby with the cord still wrapped around its neck. However, both mom and baby are fine.

I wish I could run interference for ALL pregnant moms when somebody drops the proverbial ball . . . but I can’t. So I wrote The Smart Mother’s Guide to a Better Pregnancy instead.

“A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.”