Subscribe to Commentary


Prenatal programs for the poor need a bigger role in Georgia

Georgia recently dropped from a grade of “C” to a “D” on the March of Dimes Premature Birth Report Card. The report shows 10.8 percent of our babies are born before 37 weeks of pregnancy, with some cities in the state showing an even higher rate.

Callan Wells

Callan Wells

To put that in perspective, Malawi, a small, impoverished African nation, has the highest rate of preterm births in the world at 18.1 percent. That rate is just 5 percentage points greater than the one in our own city of Columbus.

Experts such as Dr. Valerie Montgomery Rice of the Morehouse School of Medicine and Dr. Larry Matsumoto, a perinatologist at the Center for Perinatal Medicine at Northside Hospital, say a big reason for premature births is suboptimal health of mothers before they become pregnant.

If the state wants to see mothers giving birth to healthy, full-term babies, it should start by publicizing available health programs and help women get enrolled and use their benefits fully.

Georgia has not extended Medicaid to adults with low incomes so that women have routine access to care to address diabetes, obesity, cardiac stress and other chronic conditions that increase the risk of preterm births. But it does have a program that can help.

A little-known existing Medicaid program called Planning for Healthy Babies (P4HB) allows women to address some of the risk factors for preterm birth and other reproductive health issues. P4HB is available for women between the ages of 18 and 44 and provides access to contraception, treatment for sexually transmitted infections, family planning services, patient education and counseling, and prescriptions for vitamins and folic acid (beneficial for women in early stages of pregnancy).

Further, P4HB offers a free annual family planning exam that could allow women to discover and address the risk factors for a preterm delivery. Women who have already given birth to a low birth-weight baby can receive even more benefits through P4HB.

This Medicaid program can also be used by women who want contraception and annual exams with no plans for getting pregnant. The Planning for Healthy Babies program is available for women with incomes up to 200 percent of the Federal Poverty Level, or $32,664 per year for a household of two.

Though technically available for many currently uninsured women, P4HB is not widely publicized, and barriers to enrollment remain due to breakdowns in the state’s application and eligibility systems.

Once a woman becomes pregnant, she may be eligible for Pregnant Women’s Medicaid for her prenatal services, a safe delivery and post-partum care. While half of all births in Georgia are covered by Medicaid, many women are not able to utilize these benefits to their full extent. Some have never had health coverage before or have low “health literacy.” Some experience significant delays in care as they go through the process of enrolling in a Care Management Organization (CMO), as is now required by Medicaid policies.

Georgia Legal Services Program has a Benefits Hotline that assists potential applicants in getting and maintaining Medicaid and offers information on how to fully utilize their services. Those who are interested should call Georgia Legal Services Program at 1-888-632-6332 for more information.


Callan Wells, M.S., a Georgia native, is the Benefits Hotline supervisor at Georgia Legal Services Program.

Big insurance deals are bad news

The past decade has witnessed dramatic consolidation in every dimension of the metro Atlanta health care market. Spurred by changes from the Affordable Care Act, hospitals are hastily marrying each other and buying up smaller medical practices in their quest to expand.

Dr. Deep Shah

Dr. Deep Shah

Such activities tend to increase costs by 20 percent or more in an already concentrated market like ours.

But two recently proposed insurance mergers – Anthem-Cigna and Aetna-Humana – may have more impact. They would represent unprecedented consolidation of Georgia’s health insurance market.

Adding Cigna beneficiaries to Anthem-owned Georgia Blue Cross and Blue Shield of Georgia would boost its total enrollment to nearly 3.6 million. Aetna’s takeover of Humana would bring its membership to some 1.4 million.

Together, the two megacorporations would be responsible for half of the state’s insured population. The number of large commercial insurance carriers in Georgia would be reduced from five to three.

Combined with recent hospital mergers and acquisitions, the creation of these new insurance powerhouses would leave our community’s health in the hands of an oligopoly.

What would the health insurance companies’ strengthened market positions mean for Georgia’s businesses and ordinary citizens?

1. Lower wages: Increased costs for employers will ultimately be shifted to employees.

2. Higher premiums and deductibles: Consider that under the current system, with five large commercial insurers, premiums in Georgia are set to rise 8 percent to 29 percent in 2016. These rates will likely increase more steeply once there is less competition.

3. Small provider networks getting even smaller: Consider that 83 percent of plans currently offered through the Georgia health insurance marketplace limit patients to narrow or very narrow networks. More leverage for insurers will likely worsen this problem.

The American Hospital Association and the American Medical Association (AMA) have convincingly shown that further consolidation in the health insurance market will narrow patient choice, shrink access to care, and inflate costs for patients and employers nationwide.

Compared to other states, Georgia is at even greater risk of adverse outcomes. The AMA’s September 2015 analysis of the mergers demonstrated that Georgia and Kentucky are the only two states in which both the proposed mergers would 1) enhance the companies’ market power and 2) dampen competition.

The inevitable premium hikes will make purchasing coverage unaffordable for individuals and business owners. And many providers – forced to accept unfair payments from the newly formed monopolies – will lose the ability to expand, innovate and improve care for their patients.

‘Sumo wrestlers’

If we doubt these consequences, we can examine the effect that mergers have had on Georgia’s hospital market.

As a February 2015 investigation by WSB-TV revealed, patients treated at metro Atlanta outpatient clinics bought by large hospitals are now being charged double and triple for the same services, including outpatient chemotherapy. Why? Consolidation has strengthened hospitals’ market power and bargaining power with insurance companies.

Healthcare CostNow imagine how much worse it will be if the already large commercial insurers combine into virtual monopolies.

“Experience suggests that a showdown between the sumo wrestlers [i.e., large hospitals and insurance companies] may well result in a handshake rather than an honest wrestling match,” health and antitrust law expert Thomas L. Greaney said Sept. 10 at a U.S. House Judiciary Committee hearing on the state of competition in health care. As he emphasized, “[the insurer] has little incentive to pass along the savings to its policyholders.”

If federal regulators approve the Anthem-Cigna and Aetna-Humana mergers, a few insurance companies – negotiating with a handful of large hospital-owned systems – could dictate access, choice and costs for individual Georgians and put further strain on businesses.

That would leave it up to the Georgia General Assembly and the state’s insurance commissioner to step in and scrutinize the deals. An honest assessment would likely reveal the potential for greater harm than most people anticipate.

For the good of patients, providers, and our local economy, these mergers should be halted.


Deep Shah, MD, MSc, is a senior medical resident at Emory University School of Medicine and an active member of the American College of Physicians’ Georgia chapter.  A native Atlantan and American Rhodes Scholar, Dr. Shah plans to practice primary care in metro Atlanta. Follow him on Twitter @DeepShahMD. Views expressed in this Commentary are his own.

Prostate health requires public awareness

It’s counterintuitive that the second-leading cause of cancer death in men is also one of the most manageable when detected early, but this is the reality of prostate cancer.


Dr. Vahan Kassabian

According to the American Cancer Society, approximately 220,000 American men (7,500 of them in Georgia) will be diagnosed with prostate cancer this year. And more than 27,000 Americans will die from the disease in 2015. The good news, though, is that when prostate cancer is detected early, almost 100 percent of men are disease-free five years after their diagnosis.

Prostate cancer, one of the few cancers affecting only men, typically strikes those who are older. In fact, it’s very rare for a man under 40 to be diagnosed with it – only 1 in 10,000. Men over 50 account for 97 percent of all diagnoses. Because of the slow nature of many prostate cancers, treatment for the disease is sometimes different from what’s commonly expected for cancer. Treatment for prostate cancer can range from simply monitoring the condition to such other responses as surgery, radiation or medicines.

Except for skin cancer, prostate cancer is the most prevalent malignancy among men. But it does not receive the attention it deserves, which results in less awareness. Because the disease is so treatable when detected early, it’s imperative that men understand the risk factors and how to ensure early detection so that they can increase their chances of being a prostate cancer survivor.


Dr. Bradley C. Carthon

The first step is understanding your risk of developing the disease. One of every seven men will be diagnosed with prostate cancer at some point in their lives, and for African-American men, the numbers are worse. One out of five African-American men will be diagnosed with prostate cancer, and African-American men are 2.5 times more likely to die from the disease.

The exact cause of prostate cancer has not been pinpointed, which is why it has not been possible to completely prevent it. But there are things that can be done to maintain a healthy lifestyle: regular physical activity, a healthy diet and maintaining a healthy weight. Regular physical activity and maintaining a healthy weight have been linked to a slightly lower risk of developing prostate cancer. Diets that are high in fish or certain vegetables (e.g., tomatoes, broccoli, cauliflower) may also reduce your risk of prostate cancer.

The final and most important step to early detection is taking responsibility for your health and having open communication with your physician. This includes ensuring that your physician is aware of your risk factors, especially your family history, so they can make appropriate recommendations for what types of screening you should receive, and when.

Dr. Peter J. Rossi

Dr. Peter J. Rossi

We still need more scientific advances. For now, early detection of prostate cancer, plus the appropriate treatments, and close communication between physicians and patients, are required to potentially decrease the 27,000 deaths caused by prostate cancer each year.


Dr. Vahan Kassabian is a urologist at Georgia Urology, Dr. Bradley Carthon is an Assistant Professor of Hematology and Medical Oncology at Winship Cancer Institute of Emory University, and Dr. Peter Rossi is an Assistant Professor of Radiation Oncology at Winship Cancer Institute of Emory University



Drug price controls are dangerous

I should be dead.

I’ve survived two cancer diagnoses, two strokes, a heart attack, kidney failure, a coma, arthritis and systematic lupus. I’ve fought my way out of a wheelchair, abandoned my crutches, and relearned how to walk.

Dorothy Leone-Glasser

Dorothy Leone-Glasser

None of that would have been possible without the development of new medical treatments, which have saved and improved my life and the lives of 133 million Americans suffering from chronic diseases. Now, some politicians could jeopardize continued medical progress by capping pharmaceutical prices.

Price controls will sap drug companies’ incentives to invest in new treatments. To encourage development of lifesaving medicines, lawmakers across the country — and in Washington — must steer clear of price controls.

For half a century, there was no treatment specifically targeting lupus, an autoimmune disease that causes swelling and organ damage. The 1.5 million Americans diagnosed with the condition were forced to turn to painkillers, steroids, and anti-malarial drugs, which caused a host of unpleasant side effects, including bone fractures and infection.

But in 2011, the FDA approved Benlysta, a breakthrough treatment that significantly mutes the disease’s activity for many patients.

The medicine improves patients’ quality of life, and is also good for our economy. Between treatment, hospital visits and lost productivity, each lupus diagnosis costs the American economy $20,000 a year. Previously, two out of three such patients could not work full time. Benlysta enables many patients to manage their disease and return to the workforce, boosting economic output.

Pharmaceutical innovation has also improved the lives of those who suffer from HIV/AIDS, which was a death sentence just a generation ago. The introduction of powerful “drug cocktails” cut the death rate from HIV/AIDS by 85 percent, preventing more than 860,000 premature fatalities. The resulting increase in productivity has helped the economy grown by $615 billion, according to Truven Health Analytics.

The pace of medical innovation is increasing. People at risk of contracting HIV can now take a pill that prevents infection. Today, 3.2 million Americans with hepatitis C can use several drugs that boast 90 percent cure rates. These medicines didn’t exist just a few years ago.

Such medical progress has immeasurably improved many patients’ lives. And it has offered hope to millions of other people, who are afflicted with diseases that are still untreatable or incurable.

However, lawmakers could undermine this progress by imposing price controls on the newest — and thus the most expensive — medicines. On average, it costs pharmaceutical companies $2.6 billion to bring a new drug onto the market. And for every 10 drugs to hit the pharmacy shelves, only three will ever turn a profit. Capping prices on these successful drugs will deprive companies of the revenue that funds development of future treatments.

Massachusetts legislators are pushing a bill that would explicitly cap drug prices. Other states, including Pennsylvania, New York, North Carolina and Oregon, are considering laws that could lead to price controls. And federal officials want to install de facto price controls in the Medicare Part D program that provides medications to 37 million seniors.

Price controls are doubly harmful. In pursuing lower drug costs through price caps, lawmakers will deprive patients of treatments and cures. And without those medications to keep patients healthy and productive, the economy will suffer, too.

If lawmakers want to ensure patients receive effective care, they should abandon plans to cap drug prices.

Dorothy Leone-Glasser is the executive director of Advocates for Responsible Care, which is based in Atlanta.

Poverty and pregnancy should not be fatal in Georgia

Recently the Department of Community Health decided not to move forward with a plan to improve health care access for the uninsured people of the state. Georgia officials said the plan was just “too costly, with administrative costs alone estimated at $3.5 million.”

Dr. Carla Roberts

Dr. Carla Roberts

Georgia has among the highest rates of uninsured people among the 50 states, and many of Georgia’s uninsured live in rural areas, where access to care is already somewhat limited.

The plan that was scrapped by the state would have included federal matching of Medicaid dollars to set up pilot sites that would help provide coverage to those uninsured. These sites would have initially included Grady Memorial Hospital in Atlanta, Memorial Health in Savannah and a small group of rural hospitals.

This plan would not be considered the kind of Medicaid expansion that is suggested by the Affordable Care Act. But it would have been an innovative way to keep Georgia taxpayers’ dollars — which have already been collected — working within our state to help our uninsured, rather than going to fix other states’ health-access deficiencies.

The 1115 waiver plan was modeled after the Cleveland MetroHealth Care Plus program in Ohio, which was found to markedly reduce state health care costs. But Georgia officials say these plans to improve access to health care in the state are “just too costly.”

Meanwhile last week, two Georgia hospitals, Emanuel Medical Center and Barrow Regional Medical Center, closed their labor and delivery units, citing high costs and low reimbursements. They were the latest among many. Georgia now has fewer than 75 hospitals with labor and delivery units, out of more than 180 hospitals currently operating in the state. This is a health care issue that is truly “costly” in our state of Georgia.

In 2012, Georgia had 130,280 deliveries, which makes us the state with the seventh-highest number of deliveries. More than 78,000 of those women will lose their health care coverage within six weeks of delivery. But Georgia also has a high maternal mortality rate, meaning the rate of women who die within a year of giving birth. Our infant mortality ranking is 41st out of 50 states. Continuing the bad news, we rank 4th in recurrent teen pregnancies.


Where the ‘war’ talk applies


Politically, most Republican-led states see any form of Medicaid expansion as giving the Democrats a win and swelling the size of government.  Some in the Democratic Party respond to the Republican position with the mantra “war on women,” claiming that the GOP’s real intention is to restrict women’s health care and erode protections for them and their families. The political rhetoric is overheated, with vocal women on both sides of the party divide.

I say that today in Georgia, there is a real “war on women.” It can only be called a war when so many mothers are dying within a year after they deliver a baby. And it is a problem that rests on the shoulders of both parties.

Pat Cota, the executive director of the Georgia Obstetrics and Gynecological Society, reports that “40 counties in Georgia, or 1 in every 4, have no delivering obstetrician. We are lacking in real programs to address recruitment and retention of these trained women’s health specialists within our state. They are especially needed in rural areas. The state of Georgia is not reimbursing obstetricians fast enough or in the appropriate amount and currently uses outdated information about what women’s health needs are.“

Good prenatal care requires 10 prenatal visits. Georgia Medicaid currently reimburses each physician $300 in toto for these 10 visits. That is $30 per visit. This does not include the delivery fee paid to the hospital or the physician, but that reimbursement is similarly abysmal.

One well-touted way to increase access to care for rural pregnant women is to fill the need with family medicine physicians, but malpractice insurance is just one of the roadblocks to this solution. There is no increase in malpractice insurance for any physician taking care of a pregnant woman within the first 12 weeks of a pregnancy. But once a physician sees a patient in weeks 13 and above, the doctor’s malpractice insurance increases an additional $20,000 or more per year. There has been absolutely no movement in the Georgia Legislature to ease this burden on the physicians trying to improve access for pregnant patients in underserved areas.


Will the public rise up?


When a pregnant woman needs care, it is in effect a two-patient situation. But obstetricians, family medicine physicians and hospitals, which have the knowhow to care for women, pregnant and otherwise, are often just plain unable to stay in business in rural areas.

With the announced obstetrical closings of Emanuel Medical Center and Barrow Regional Medical Center, there are only 46 counties out of 159 in Georgia with labor and delivery units still open. When labor and delivery units close, so do the nurseries. Since 1994, at least one labor and delivery unit has closed each year, and the closure rate has steadily increased in recent years. The whole pattern of where mothers can safely have their babies in this state is changing. To put things in perspective, Augusta is surrounded by 17 counties. There are zero labor and delivery units in those counties. “Between Athens [and] Augusta, there’s no delivery hospital,” Cota says. “There are patients who have to drive 2 hours or more just to deliver their baby.”

Currently in Georgia, females constitute 51 percent of the population. In the 2008 and 2012 general elections, a clear majority of the voters who went to the polls in Georgia were female. It raises the question: Since Georgia’s maternal mortality is already high, what will it take before our state’s politicians work to improve the situation and declare that doing so is not “too costly?” Will it take that majority of the votes cast in the next election to persuade our elected officials to help the women and infants in Georgia? Would a poll help? Although the question can be written many ways, the answer will most assuredly be “Stop letting the mothers in our state die.”

To be fair, Dr. Dean Burke, an obstetrician, sponsored and passed a bill in the 2014 session that formally recognized the need for a committee, with appropriated state funding, to study the maternal mortality crisis in our state. That project is under way.

Undoubtedly, women’s health topics have held a place in the forefront of the recent political landscape. Our state is no exception. The issues are charged and divisive, and while political points have been lobbied and tallied, our state has watched its mothers die. There are thousands of obstetricians and gynecologists in our state who are yearning to work alongside our elected officials to help them craft medically sound legislation that would save our  mothers and babies. They are just waiting to be asked. What will it take for our legislators to work with this army of physicians who are truly the “trained warriors” necessary in the real war against women? Georgia’s pregnant women.

Carla Roberts, MD, PhD, is an expert in women’s health and health policy. Dr. Roberts has practiced in the medical field in Atlanta for over 21 years. She spent almost two decades on the faculty at Emory University School of Medicine in the Department of Gynecology and Obstetrics. She ran for a seat in the Georgia House of Representatives in 2012 and is now in private practice as the founding partner of Reproductive Surgical Specialists at Northside Forsyth Hospital in Cumming. Dr. Roberts is the vice chair of Legislative Affairs for the Georgia Obstetrics and Gynecology Society.


  • Sign up for our mailing list.