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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.

 

LGBT people and substance abuse: A problem that needs a new approach

America’s LGBT community has been in the news a lot this year. The U.S. Supreme Court recently legalized same-sex marriage nationwide, there have been disputes in some states about the scope of anti-discrimination laws against sexual minorities, and the Caitlyn Jenner story has mainstreamed an issue that was long ignored.

Sadie Hosley

Sadie Hosley

There have also been stories about health problems in the LGBT community. Statistics from the CDC show metro Atlanta has one of the highest rates of new HIV cases in the country, concentrated among African-American males who have sex with males.

There’s another health problem, though, that’s taking a significant toll in the LGBT community, and awareness is the first step to making significant inroads against it. According to the National Institutes of Health (NIH), it’s estimated that up to 33 percent of the gay and lesbian population abuses alcohol and drugs, compared to less than 10 percent of the general population. This number is even higher for transgender individuals.

What’s more, LGBT youths are anywhere from two to five times more likely to use drugs and alcohol than heterosexual youths, the NIH has found.

The underlying reason for higher rates of substance abuse is the stress caused by the discrimination and stigmatization that this population faces on a daily basis, which contributes to their much higher rates of depression and anxiety when compared to heterosexuals. This is compounded by a dearth of health care services – both in general care, preventive medicine and addiction treatment – tailored specifically to this population.

When people from the LGBT community receive health care services in mainstream settings, many are not forthright about their sexual orientation because of fear of discrimination, and also a reluctance by many providers to take a full health history, thereby reducing the likelihood of success with the treatment plan.

There is hope, though. Health care that’s designed specifically for the LGBT population, and that will provide a safe, supportive and affirming environment, has a greater success rate than mainstream health care. A 2015 NIH research report emphasizes the necessity that addiction treatment programs establish treatment programs that are transgender- and/or LGBT-specific.

In order to successfully help LGBT individuals, providers must be formally trained in treating this population.

Tina Black

Tina Black

For instance, these providers must understand the health issues that are especially serious in the LGBT community. For instance, research suggests lesbians are more likely to be obese and to smoke, and are less likely to receive general, preventive treatment.

The providers also must have cultural competence in dealing with the LGBT population and ensuring that such patients feel safe in their care. They need to advance communication and provide patient-centered care.

In order to make significant improvements to the health status of this growing population, a fundamental shift must occur in the mindset of the health care system and health care providers. Individual people can, with support, make changes and make things better, as we are trying to do.

 

 

Sadie Hosley, MA, LADC, LPCC, is the regional recovery representative of Georgia Detox and Recovery Centers’ LGBTQ program focused on addiction treatment; Tina Black, LCSW, is the vice president of operations with Georgia Detox and Recovery Centers, a RiverMend Health treatment center.

A ‘yes’ vote could save kids’ lives

Rhonda Butler

Rhonda Butler

Atlanta will soon host what could be a pivotal event in the fight against vaccine-preventable diseases. When CDC officials meet in the city this month, they will, for the first time, have the power to ensure that children and other at-risk groups can access protection against all five of the most common strains of bacterial meningitis.

While vaccinations against four meningococcal strains are widely available, the Food and Drug Administration recently expedited the approval of new vaccines against the fifth type – meningitis B – which has become the most common cause of meningococcal disease in children and adolescents.

With FDA approval complete, it’s now up to the CDC’s Advisory Committee on Immunization Practices to make sure that meningitis B vaccines reach the public. CDC action is critical, because most health care providers and insurers need a CDC recommendation in place before a new vaccination can be offered.

With the ability to vaccinate against all five strains of meningitis now within our reach, we must make sure that all children get that chance at protection.

It’s a chance my little girl never got.

I remember March 17, 1989, like it was yesterday. My 4-year-old daughter Brooke woke up with a high fever, which continued to spike throughout the day. At the doctor’s office, it took hardly any time all to realize we needed to head to the hospital. Our doctor knew it was meningitis.

As we arrived at Egleston Hospital and rushed through the emergency room entrance, it suddenly became real. I felt utterly helpless as my little girl was immediately quarantined from the rest of the hospital.

I was finally able to be with Brooke, though I was not at all prepared for what I saw – my child in a hospital bed, in a tangle of tubes and IVs, with machines monitoring every breath.

She fought so hard to stay with us. “I love you,  Mommy,” she said in a feverish voice as the doctors worked to save her. Those were her last words to me, just 26 hours after being diagnosed. By the time we knew what we were up against, it was already too late.

There’s not a day that goes by that I don’t think of those moments or wish that Brooke could have been protected against the disease that took her life.

As Brooke’s story shows, bacterial meningitis is devastatingly fast-moving, and it can be deadly even with prompt treatment. Since losing my daughter to meningitis, I have met many others who have suffered at the hands of this disease. Many of those who were fortunate enough to live through it were left with permanent disabilities, such as loss of limbs, scarring, loss of hearing and brain damage.

My daughter’s life was over before the age of 5, because she was born earlier than the vaccine that could have prevented her suffering and mine. The CDC should act swiftly to make sure children are protected against all five forms of meningitis. These vaccinations will save lives, just as they would have saved Brooke’s.

 

Rhonda Butler is the Georgia team leader for Meningitis Angels, a nonprofit organization supporting families affected by bacterial meningitis. She lives in Locust Grove.

 

Malpractice reform in America needs a further look

What’s the price tag of a leg amputated as a result of a doctor’s negligence in the operating room?

Katja Ridderbusch

Katja Ridderbusch

It can easily be $3 million in the United States. In my native Germany, it may be $30,000.

That’s a catchy and somewhat unfair comparison, of course. But it points to a highly controversial subject: medical malpractice reform.

A recent proposal to fix the broken tort system came in Georgia’s Patient Compensation Act, or Senate Bill 86.

Introduced by Sen. Brandon Beach (R-Alpharetta), the bill would have created an administrative system to handle patients’ claims outside the courts. Patients would not need lawyers to propel their cases forward; health care practitioners would have to pay into an administrative fund instead of purchasing costly malpractice insurance; and payments to patients would be made within months rather than years.

SB 86 was introduced in the Georgia Legislature in February. It was hailed by physicians, attacked by trial lawyers, and never passed out of the Senate Health and Human Services Committee.

But SB 86 could make a comeback in next year’s General Assembly, as other proposals for tort reform are springing up around the country.

 

A broken system

 

Many health care experts say the U.S. tort system is costly, unreliable, ineffective and counterproductive – in short, broken.  Even though the number of claims has declined, medical litigation costs in America are still more than twice as high as in other developed countries, such as Canada, England and Germany.

According to a RAND study from 2011, 99 percent of physicians in high-risk specialties, such as neurosurgery and obstetrics, face at least one malpractice claim during their careers. For their colleagues in Europe, there’s only a roughly 20 percent chance of a lawsuit.

iStock_000023217379LargeThe premium for medical liability insurance for a general surgeon in the United States can be as high as $130,000 to $190,000 in areas such as Long Island, N.Y., or Miami. In Germany, it’s between $5,000 and $10,000.

The main reason for the dire state of the U.S. medical malpractice landscape seems to be that the system offers patients too many incentives to sue doctors for bad outcomes (and sometimes for overall bad luck in life) rather than for bad treatment.

While there’s no medical malpractice nirvana, and foreign liability models may not fully translate into the American system, looking beyond U.S. borders may still offer some insights and, possibly, inspiration.

Take, for example, the fact that in Canada, Japan and most European countries, judges, not juries, try medical litigation cases.  One benefit of such systems is that they increase reliability and consistency in rulings.

Keeping the jury out of the courtroom also helps soften the adversarial, high-drama litigation style that’s common in jury trials, and helps keep extreme claims and awards in check. In Germany, standardized reimbursement tables for economic and non-economic losses guide the judges’ rulings.

 

A cap on damages

 

Also, in many European countries, mediation and arbitration are mandatory before a case can proceed to court, and that has yielded high success rates. While denying patients the right to be heard by a jury of their peers may raise constitutional concerns in this country, voluntary mediation does not.

Another common way to manage medical malpractice lawsuits – not only abroad, but in some U.S. states as well – is putting a cap on damages. In the United Kingdom, the amount awarded for pain and suffering is usually capped at about $400,000, though exceptions apply.  In Germany, a pain-and-suffering-award of $500,000 is considered high and applies only to the most severe cases of medical malpractice, such as those that result in birth defects.

Healthcare CostBut comparing awards in Europe and America can be misleading. In many European countries, social safety nets and welfare systems provide additional coverage for victims of medical malpractice.  In Germany, disability costs resulting from a treatment error are for the most part covered by the social security system. In the U.S., damage caps would not only put poorer and elderly patients at a disadvantage, they would also discourage lawyers from taking on a medical malpractice case.

This brings me to the next point: lawyers’ compensation.

In Canada and most European countries, contingency fees for lawyers are generally prohibited. In the United States, these fees are often 30 percent to 40 percent of the final award. They create a huge incentive to file a lawsuit and are seen by some physicians’ lobbyists as a “parasitic form of venture capitalism.”

In Germany, the loser often has to pay the other side’s legal costs – a rule that’s been heavily criticized by consumer advocates who argue that it puts low-income patients at a disadvantage. But many Germans have legal expense insurance, which covers policyholders against the potential costs of legal action. Low-income citizens who can’t afford such insurance may be eligible for government-subsidized legal aid.

 

The culture of doctors

 

Finally, different medical malpractice cultures create different types of doctors. Different cultures affect doctors’ behavior, and shape the doctor-patient relationship differently. Neither result may be desirable in the end. In the United States, many doctors feel pushed to practice “defensive medicine,” doing unnecessary tests on patients just to shield themselves from the accusation that they did too little. This phenomenon is starting to take hold in Europe as well. Still, American physicians today order 70 percent more CT scans per capita than their colleagues in Germany.

Also, many physicians in the United States report that they often feel pressured to settle cases that might be defensible in court, and hence they are manipulated into admitting to errors they didn’t make. If the doctors don’t settle, they fear that plaintiffs might try to destroy their reputations in online forums or by other means.

Three Surgeons Operating On A Patient

In most of Europe, parties engaged in a lawsuit are advised by their lawyers to refrain from publicly commenting on a pending case or on the other parties involved. Also, most European countries have tighter defamation-of-character and reputational-damage laws than America, where the right to freedom of speech would render most “gag orders” unconstitutional.

It’s probably true that doctors are protected in most industrialized countries more than they are in the United States – legally, ethically and socially.

But there’s a flip side, as seen in my native Germany. There, for many historical and cultural reasons, physicians still enjoy a reputation of being what Germans sarcastically call “demigods in white” – meaning they consider themselves as authorities not really to be questioned, more or less untouchable by law, defamation or any other pressure.

It seems that either system, in the end, somehow backfires on the patient. In America, it may be physicians who put up their guard and prefer to play it safe, having decided not to trust their instincts on what patients need. In Germany, it can be doctors who often consider themselves and their decisions above the law and treat patients with an air of arrogance and immunity.

With many best and worst practice examples under consideration, and the call for medical malpractice reform in the United States getting louder, Georgia’s Senate Bill 86 seems, after all, to deserve a second look – maybe even as a blueprint for a wider solution.

 

Katja Ridderbusch is an Atlanta-based foreign correspondent for German news media, including the national dailies “Die Welt” and “Der Tagesspiegel,” as well as German national public radio. She frequently reports about health care in the United States.    

 

Patients can be the greatest teachers

What physicians do isn’t normal.

I remember leaving the soccer fields of Emory University, where I was an All-American player, to arrive in medical school to a room full of cadavers.

Dr. Scott A. Kelly

Dr. Scott A. Kelly

That’s just not normal.

Several years later, I was working as a resident in the emergency room at Atlanta’s Grady Memorial Hospital. I had to tell two girls, ages nine and 10, that their mother had just expired as the result of a car accident,  that she wouldn’t be there to hold their hands and walk them through life.

I wanted to linger with those children and comfort them as best as I could. Yet duty called. Grady is a major trauma center, and I was informed that another patient in critical condition required my immediate attention.

Having to leave those two young girls like that — that’s just not normal.

I am not unique. My experiences as a spine specialist with Resurgens Orthopaedics are no different than those of any other physician. We have all been present during emotionally grueling circumstances. Over the years, we have hardened ourselves to these situations, perhaps owing to necessity, to one degree or another. I know that I have been guilty of misplacing my priorities at times.

Being a physician is a great responsibility and not something to be taken lightly. I treasure that responsibility. Part of that responsibility, I believe, is to bring compassion back to the doctor-patient relationship.

I think back to when I was at the Medical College of Georgia and I was struggling with the vision of medicine that was being presented. It was quite different from what I expected, and I was somewhat disillusioned. So I went during office hours to seek the advice of Dr. Thomas Weidman, an assistant anatomy professor.

“Create your own vision,” he told me.

Those are words I have tried to take to heart during my career as a physician. When I ponder the subject of showing more compassion to patients, a couple of passages from the modern Hippocratic Oath come to mind (the italics, for emphasis, are mine):

“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”

“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

 

A young mother’s illness

 

The surgeon’s knife and the chemist’s drug – those are the skills that we learn in medical school, during our residencies and as young physicians. They are the skills of the trade and without them, we cannot practice.

However, we must remember the humanity in our patients and, perhaps equally as important, in ourselves. Think of an orchestra conductor who only looks at his sheet music without listening to the efforts of the musicians performing before him. If he does not feel what they are emoting and respond in kind, his efforts will fall flat. He will fail.

Such is it with medicine. As a young medical student, resident and impressionable young doctor, I kept journals. I can think of a memorable instance in which listening to a patient helped me to make a correct diagnosis and, significantly, offered the patient some peace.

It was the fall of 2000 and I had just started private practice. A married mother of two young children – I’ll call her Katie – had begun experiencing numbness. She was training for a marathon and her primary care physician counseled her to rest.

The symptoms, however, continued. She visited her primary care physician again and was referred to a psychiatrist. She was advised of the effects of stress on her body, which the psychiatrist thought might be causing Katie some depression. He offered a prescription drug.

A friend of hers encouraged her to see me for a second opinion. I sat and listened to her story. A highly educated woman, Katie suspected that she might have multiple sclerosis and asked me if I would order an MRI of her brain. I agreed. Her relief was palpable.

I spoke to the radiologist the next day. The MRI revealed, in fact, that Katie had MS. As I waited in my office later that day for her to arrive and hear the results, I kept thinking of the impact the disease would have on her life, her marriage and her children.

I tried to comfort her as I broke the news. “I knew it,” she said. She was laughing and crying at the same time.

Katie told me that even though the news was terrible, she felt relieved in a way to know that she was not crazy, that what she felt was “real.” Again, what we physicians do is not normal, so we should try to bring as much “normality” as possible to a patient in a moment like that. In a way, listening to a patient can be empowering.

In recounting this story, my intention is not to gloat. I detest few things more than a doctor’s gloating when another misses a diagnosis. In a case like Katie’s, I don’t feel I deserve any credit for making the diagnosis. Katie did it. All I had to do was to listen to her.

When a patient’s symptoms fall outside the norm, I often think of Katie. She serves as a constant reminder to me to listen to my patients. She has made me a better physician.

And what I learned from her remains true. Regardless of how technologies change, we actively seek as physicians to improve quality of life and relieve pain, and the most important tools that we physicians will ever have are our ears.

 

Scott A. Kelly, M.D., is the co-medical director of Resurgens Orthopaedics’ Spine Center and the author of “What I’ve Learned From You.”

 

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