Why Are Pregnant Women Forced to Choose between X and Y?

Before reading today's posting, please read Wednesday's and Thursday's (October 28 and 29th) posts.

Yesterday, I made the point that whichever choice a woman makes to have her baby, it is not the safest possible choice, BECAUSE the safest choice does not exist.

When I ask obstetricians: “Under what circumstances would you consider performing out of hospital birth?” the usual response is: "If they could have an epidural and have an operating room right there!"

I already hear the out-of-hospital chorus screaming, "The reason for out-of-hospital birth is to AVOID epidurals and operating rooms!"

To which the obstetrician might respond, "Why does a woman's choice have to be: in- hospital without pain or out-of-hospital with pain?"

I can tell you how the out-of-hospital and normal birth community would respond, but instead, let's all take a very long, deep breath, and examine this. As a person that has run birth centers and has had tons of face-to-face interaction with pregnant women seeking alternatives, I would like to tell you what I heard the pregnant women say when they came into the birth center:

"Can I get something for the pain?"… "Is there a doctor available in the event of an emergency?"….. "What if the baby crashes, and I need an emergency cesarean?"

Myself and my staff were thoroughly trained in how to respond to these questions. We extolled the virtues of natural birth, the benefits for the baby, the fact that we monitor and can usually pick up problems before the emergencies and that we get to the hospital. relatively quickly.

Obstetricians are not happy with the current constraints placed upon their practices, especially by hospitals and insurers. But what is their option? A natural birth center, with no cesarean capability? They are not trained to practice like this. More importantly, they don't believe that the pregnant women that they come in contact with really want a natural birth, without pain meds. They believe that they are meeting the demands of the vast majority of their patients.

So why can't a woman choose an out-of-hospital birth with pain medication and emergency cesarean section capability? I'm sure that many of you will start sending me all the reasons that this is bad. I ask you to hold off on that, and bring the list to the Controversies in Childbirth Conference, where this topic will receive a major airing, with all the goods the bads and the uglies.

I want to examine this a bit from a free-market perspective. Assume that physicians are able to open some type of out-of- hospital facility, where epidurals can be given and emergency cesareans can be performed. This will put the physician in the place of the hospital, the same way that midwife-run birth centers replace the hospital. The physician-owner will look for ways of driving business to his birth facility and lowering costs.

Should market research show that women would prefer midwives in this facility, he/she would undoubtedly hire midwives. If a woman has a vaginal birth, she could go home earlier, thereby saving the facility money and thus the facility might work to keep a low cesarean rate. The physician-owner would be very attuned to what his patients are saying on the Internet about him and would probably become more customer- centric, in the same ways that hotels work to avoid negative comments from appearing on TripAdvisor and other comparison sites.

It's estimated that ONLY 27% to 32% of U.S. OB/GYNs are still delivering babies. That means the competition has been severely reduced. Giving physicians a reason to go back to delivering babies will spur competition and give women more choices. How many women do you know have had to choose a new OB because the obstetrician that they loved has stopped delivering babies?

Birth advocacy is about giving women what they want. If obstetricians believe that women want a different experience than the hospital, but will not buy in to homebirth or natural birth centers, why shouldn't they be free to pursue a model that they believe is what patients want?

BUT- the devil is in the details!! There will be much discussion about what you could or should do and not do in one of these facilities. I'm inviting this discussion to be held February 19-21, 2010 at the Controversies in Childbirth Conference in Tampa, Florida. The plan is to have one session with an obstetrician who is experienced in both hospital- and birth center births to discuss from a clinical standpoint what he believes obstetricians and patients want and what could safely be made available to them in this setting. We also hope to have an obstetrician who has a birthing facility in another country, very much like the I am proposing.

The next day, there will be a panel session with representatives of obstetricians midwives. consumer advocates etc. to discuss all the intricate details and to see if people would come together to make this work or oppose it and what the trade-offs would be.

Full conference information is available at: www.birthconference.org.

I myself had a paradigm shift when this model was first described to me. I'm not sure I agree with it! Nor do I think I disagree with it! I do know that I want to discuss it.

Please register today for the conference (http://www.birthconference.org/)

Have a GREAT weekend
Alan
alan@birthconference.org

Hospital, Birth Center, Home,…. Which Is Safest?

In yesterday's blog (scroll down a little and read it first). I asked the question: ”Could anything be done, so that obstetricians become hearty supporters of out-of-hospital birth?”

Before I delve into that question, I want to ask a different question: "Where is the safest place to have a baby? In a hospital with physicians? In a hospital with nurse midwives? In a birth center with nurse midwives? In a birth center, with direct entry midwives? At home with nurse midwives? Or at home, with direct entry midwives?" (Let's assume that we are talking about low risk women).

I believe if you ask an obstetrician that works in hospital, he or she will say "in hospital with physicians." If you ask a Licensed Midwife or Certified Professional Midwife, they would say: "at home with direct entry midwives."A birth center CNM would say, "at a birth center with nurse midwives."

Can they all be right? Are they all wrong? I  know that, each discipline will believe, what they do is the safest and is in the best interest of moms and babies.

Is it possible that the reason that everyone can believe that their way is the best, is because the best method does not exist in this country? Is it possible that women do not have the perfect option? Does every one of these choices cause women to sacrifice some degree of safety?

Let's pretend that there was a rather large birthing facility located inside the hospital that operates autonomously from the hospital? This facility follows the majority of the principles and standards of the American Association of Birth Centers. This facility offered a homelike birth setting, water birth, choice of position and even choice of midwife. That means a woman can choose either a nurse midwife or a direct entry midwife. The hospital’s staff, rules and bureaucracy have no influence on this birthing facility. This means that the facility does not even need nurses; it could utilize birth assistants to help midwives. This facility would give fantastic one-on-one care, yet, it operates at a large profit.

Furthermore, this beautiful birth facility would be connected by a short tunnel to the hospital operating suite, where obstetricians and anesthesiologist and OR Nurses were available around the clock. Likewise, this hospital has a top-of-the-line NICU. Of course, in our fantasy the birth facility even has a low transfer rate to the hospital. Furthermore , for the ultimate fantasy, the birth care professionals and staff at the hospital have a great relationship with the clinicians and staff of the adjacent birth facility.

Do you agree that this would be absolutely wonderful and all things being considered would be the safest model for mother and baby? If you're honest, you will agree!

Of course, this is a fairy tale, and does not exist. So why do I bring it up? Because, in tomorrow's blog posting. I will suggest another model. It will start an interesting discussion. Different sides will start taking different positions. You may see people start arguing that this model will not be as safe as the model they currently work in.

And that is my point! The safest model does not exist. For various reasons, the model that I described above is impossible to achieve. Occasionally, hybrids of this model have been tried and seem to fail, therefore, the fairytale that I described above will not be presented, because it is not workable.

It is important to realize that as we analyze the models. there will be pros and cons. Every model has its own set of risks. Each model has its strengths and weaknesses, and the argument will be made that, it is not as good or better than one of the other existing models.

I ask you keep an open mind, because, no matter what your position., we have just admitted that you are trying to preserve a flawed model.

Check back tomorrow.

Alan
alan@birthconference.org

Obstetricians, and Out-Of-Hospital Birth

The terms "obstetrician" and “out-of-hospital birth” are usually oxymorons or cannot be used in the same sentence without becoming the butt of a joke, such as "military" "intelligence."

Obstetricians are against Out-Of-Hospital birth! I know, they made an exception for birth centers, we'll get to that in a moment.

ACOG, originally put out a proclamation stating that “out-of-hospital birth” was unsafe. They later amended that statement and exempted accredited birthing centers. The wording of the ACOG statement is actually bit confusing on its face, because it only considers Certified Nurse Midwives or Certified Midwives (CMs have passed the American Midwifery Certification Board exam) , which excludes the CPM or licensed midwife. The wording allows for accredited free standing birth centers, but emphasizes that birth is only safe with immediate physician and cesarean section capability, which free standing birth centers don't have.

(Click here to read, ACOG statement)

Remember, the above is a revised statement, originally, free standing birth centers were not endorsed by ACOG.. so why did ACOG add accredited free standing birth centers to the approved list?

The popular belief is that ACOG is a trade association and is responsive to its membership. Free standing birth centers work very closely with obstetricians, in some cases are owned by obstetricians, but generally have backup and collaboration agreements with ACOG members. Allegedly, these member obstetricians put pressure on the organization to protect their own income and caused ACOG to reverse themselves. The above paragraph sounds totally plausible and is most probably, what actually occurred.

Even with the above statement, obstetricians are not in favor out-of-hospital birth, whether it is an accredited birth center, or whether it is homebirth! This makes the out of hospital midwives, furious, regardless if they are a ACNM certified or CPM certified.

Could anything be done so that obstetricians become hearty supporters of out-of-hospital birth? I believe the answer is YES, however, I don't think the midwives will be supportive of the steps necessary to make the OB's supporters.

Tune in tomorrow to see what it will take and what the backlash will be.

Alan
alan@birthconference.org

I Am Punting This Blog Posting

For the past week I have been in Florida, traveling the entire state meeting with representatives of different disciplines, including; public health, healthy start, midwives, birth activists, and obstetricians.

I did not arrive back in Austin until almost 2 AM last night. Therefore, rather than put up a blog post that's gibberish, I will just tell you that over the next week or two. I'm going to be discussing some major issues that may become very controversial, and also that will be incorporated into the Controversies in Childbirth Conference.

Please, check this blog tomorrow, for some hugely interesting discussions.

Alan
alan@birthconference.org

Politicians Promise Pregnant Women, More Choices Despite Shrinking Resources

How do politicians stay in office? Simple, promise voters that they can have whatever they want. When pregnant women start demanding more birth choices, politicians offer more childbirth choices. What happens when women are promised their birth choices, and then the politicians and bureaucrats are unable to deliver?

In the United Kingdom in 2007, top officials promised that by the end of 2009 (two months from now). ALL pregnant women will be given the choice of: hospital birth, birth center birth, or homebirth. Who can argue with giving women choices?

Of course, as we all know, resources are getting scarce and money to pay for these choices might decrease as the economy slides. In the UK, a just-released report shows that only 5% of women are being offered all of the birth choices that the government promised . Remember, there are only two months left to fulfill the promise of 100% of pregnant women being offered all the birth choices.


(Click here to read UK Guardian article).

In the UK, giving women a choice between hospital, birth center, and homebirth is not unusual, as midwives deliver the majority of babies there The government firmly believes that giving women more maternity choices is in the best interest of the government and the people.

So how does this relate to the United States? I don't believe anyone would say that women should not have choices in maternity care. However, just like in the UK, saying it and offering it are two different things. With hospitals closing labor and delivery units, and obstetricians and midwives leaving practice , we must question if it is feasible to offer women more choices, while the number of providers shrinks?

The midwife advocates will say that the answer is more midwives. If midwives are in fact the answer, then we must ask the question: “For every obstetrician that stops delivering babies, how many hospital midwives will it take to replace the OB? How many birth center midwives will take to replace the OB? How many homebirth midwives will take to replace the OB?”

With two months to go ,the United Kingdom is falling short by 95% of its goal. What is the goal of the US, and what are our chances of achieving that goal?

Alan
alan@birthconference.org

Improving Birth, or Setting It Back 40 Years?

22 years ago, I was a clueless father-to-be. My at-the-time wife, and I were expecting a baby, (my first). Please remember that this is before internet, before everybody had a cell phone, and before they put wheels on suitcases. I had a decision to make: when it was time for the birth. Do I leave the labor room or do I stay for the birth of our daughter? At that time, men could have chosen either way, and it was socially acceptable. I chose to stay. I will always remember crying the first time I held my little girl. I would not have changed that experience for anything in the world. My daughter and I are very close, and I attribute that to the promise I made her right after she was born, which was: to “always love her and always be there for her, no matter what”. It is a promise I have always kept. Today, it is socially desired and accepted for men to be at the birth if they want to have any involvement in the life of their child. When I was running birth centers, and some of the dads were iffy about being at the birth, I would talk with them and convince them that it was the right thing to do. Recently, Michel Odent MD, a French obstetrician, who is revered as a god in the midwifery and natural birth movements and ignored by the mainstream medical establishment, stated that he thinks that men should be banned from the delivery room. This includes male obstetricians as well as fathers. He believes that only midwives and the mom should be in the room. (Click here to read article). As you know from having read last Friday's blog, Patrick Houser, the author of the Fathers To-Be Handbook is leading a workshop at the Controversies in Childbirth Conference (www.birthconference.org) on the importance of dads being involved in the pregnancy and the birth. Patrick believes that the dad, is the most important variable in giving the mother a good pregnancy, birth and breast-feeding experience. On the other hand, Dr. Odents ays: “If she can’t release oxytocin, she can’t have effective contractions, and everything becomes more difficult. Labor becomes longer, more painful and more difficult because the hormonal balance in the woman is disturbed by the environment that’s not appropriate because of the presence of the man.” It appears that Patrick Houser and Michelle Dunn cannot both be right on this issue. Therefore, the Controversies in Childbirth Conference, which is being held in Tampa, Florida, February 19-21, 2010 will extend an invitation to Dr. Odent to debate Patrick Houser on this issue. We will let you know if he accepts this invitation. I do have some questions that the birth media has not asked: A) If the mother does not want midwives, does that mean that the dads can be in the room? B) If there are only male obstetricians in the hospital, does that mean the woman is better off delivering along? IS it a choice between dad and midwife? C) If mlel obstetricians were banned from the delivery room because they interfere with the birth process, does that mean that. Michel Odent’s lifetime of work should be ignored, because HIS presence in the delivery room may have actually hurt women? D) What would be the implications for society be, as a result of banning men from the delivery room? As the conference coordinator for the Controversies in Childbirth Conference (www.birthconference.org). I must remain officially neutral on this issue. I've had a number of conversations about this issue in the last few days with both professionals and moms and dads AND, without exception they all asked the same question: "Is he crazy??" Hopefully, Dr. Odent will be able to defend his unusual position at the Controversies in Childbirth Conference. Have a great weekend. Alan

For Midwives, Getting Into Health Reform May Not Be the Answer

I write this blog entry as homebirth midwives from all over the United States are heading to California to the annual conference of the Midwives Alliance of North America (MANA). I have many friends that will be at the MANA conference, and I wish I could join them, since it is always a fun time. I believe that this blog entry becomes a talking point at the conference. First, a little background: In the United States there are two types of midwives; nurse midwives, and non-nurse midwives generally referred to as direct entry. (I am aware that there are a few other classifications, but I'm trying to keep this as simple as possible). Nurse midwives generally deliver in hospitals and are called Certified Nurse Midwives and direct-entry midwives generally deliver out-of-hospital. and are rapidly embracing a designation known as "Certified Professional Midwife." Many CPM's (Certified Professional Midwives) attend the MANA conference. While nurse-midwives are legal in all states and are a mandated service under Medicare and Medicaid, the CPM’s do not enjoy the same status. The CPM's are working very hard to be included in the federal health care reform legislation working its way through Congress. The importance the CPM's are placing on getting into health care reform cannot be underestimated, for if they fail, they could conceivably find it impossible to attract new patients (clients). Many believe that being excluded from healthcare reform will doom the profession. I hope I can word. my next point, very carefully so as not to be misunderstood by my friends at the conference. Assuming the CPM is successful in getting into health care reform, what will they do differently so as not to allow legislative success to become their albatross?? I'm sure many of you are scratching your head, asking, “What is Alan talking about??” Let me give you a little Florida midwifery history. First of all, in Florida, direct entry midwives are called “Licensed Midwives” and are automatically qualified as CPMs (although they are NOT required to become CPM's). In 1992, Florida Gov. Lawton Chiles signed a law giving Florida the best direct entry midwifery legislation in the United States. The governor may have been America's most powerful midwife advocate, after his daughter was aided by a midwife during her birth. Basically, the Florida law coupled with the Governor’s and his daughter’s ongoing support gave Florida Licensed Midwives everything could have asked for. They got licensure, midwifery schools, a requirement for insurance companies to pay Licensed Midwives, they could be autonomous (work without supervision of a physician), they can receive Medicaid reimbursement and if there were any regulatory hoops, the Governor's daughter held a seat on the Florida Council of License Midwifery, which meant that every Dept. of Health employee worked for her father. This combination was considered the Royal-Flush of midwifery legislation! In fact, when the governor signed the 1992 law, he said that in 10 years, the Licensed Midwives will handle 50% of the births in the State of Florida. So what were the results? The number of licensed midwives increased from 30 to 300 between 1975 and 1990, the number of licensed birth centers from none to 20, and the percentage of births attended by midwives (10 percent) was one of the highest rates in the nation. Remember, this is before the governor signed the best direct entry midwifery legislation in the country. In the year 2007, 98.9% of the resident births occurred in hospitals; .6%, in freestanding birth centers; .4% were home births; and .1% happened either en route to a delivery facility or in some other location. Medical doctors attended 83% of the births; osteopathic physicians delivered 5% of the babies; 10.8% were delivered by certified nurse midwives; 0.6%, by licensed midwives; and 0.6%, by some other person As of August 2008, there were more than 540 certified nurse midwives (CNM) with active Florida Advanced Registered Nurse Practitioner licenses. Approximately 293 locations in Florida have certified nurse-midwives providing comprehensive maternity care and/or well-woman care services. In 2007, CNMs attended 25,861 births, or 11% of Florida births for that year (Florida CHARTS). Since 1988, CNMs are able to write prescriptions under a joint practice protocol signed by the certified nurse midwife and the physician. During the most recent reporting period, there were 34 licensed non-nurse midwives practicing - 18 working in individual practice and 16 in a 12 multi-practice setting. Of the 1,126 clients who gave birth under the care of a licensed, non-nurse midwife, 328 gave birth at home and 798 gave birth in a birth center. Medicaid was the payer for 471 of these women. (Click Here Tao Read the Florida Dept of Health Report citing the above stats) Recapping: in 2008 there were 34 licensed non-nurse (CPM type) midwives practicing, delivering less than 1% of the babies in the State of Florida So, I again repeat the question, if the CPM's get everything they want nationally, what will they do differently so as not to repeat any mistakes that were made post-Florida legislation? I wish the MANA midwives, a fun, wonderful and productive conference. Alan

If People Are Dying Now, Why Are We Waiting until 2012?

As congressional Democrats meet behind closed doors to hammer out a health care reform bill, I keep wondering why the media is not asking a key question. On every talk show, we keep hearing that we must do healthcare reform NOW because people are dying everyday. Yet, if we passed a bill tomorrow, the provisions requiring insurance companies to cover pre-existing conditions and accept everyone regardless of health won't kick in until 2012. So the question to be asked is: If we have to pass this bill immediately, why are we NOT covering the most vulnerable Americans, immediately?” Of course, among the most vulnerable Americans are pregnant women. They need coverage, so they know that their at prenatal care and birth will be paid for. Why is this not being covered immediately? Can you imagine calling the fire department and being told that fire trucks will arrive in three years? Why is the media not asking the most simple of questions? In fact, if we can cover every baby born immediately, that would cut down the number obstetrical lawsuits from parents that have no choice but to sue the obstetrician, midwives, and hospital so that they can get medical care for their uninsured baby for any birth injury. What is the rationale for waiting until 2012, to cover babies? I know this blog post is not one of the more sexy ones I've written, and that is because this one is so simple. If Passing a Bill Today Is Crucial Because Americans Are Dying, Then Let's Pass a Bill That Is Effective Today, . So No More Americans Die!! Alan

What Does My GPS and Electronic Medical Records Have in Common?

I love my GPS! I can travel all over, and not have to look at a map. I am comfortable that `Maggie" my Magellan GPS knows how to get me there and will lead me in the right direction. Maggie increases safety by letting me know if there is a left or right turn coming up before the signs tell me. She also allows me not to think!! I have an excellent sense of direction, however, since Maggie and I have become an item, I don't pay attention to where I'm going, so therefore I can never find the place again, without Maggie's assistance. Four years ago, Lenox Hill Hospital in New York, adopted an electronic medical records system in their L&D unit called “Peribirth.” This system is used by 34 hospitals nationwide and checks 6500 best practices and protocols and alerts nurses and physicians when there may be a possible error. Click here to read full article from Nurse.com As it has been my standard, I am not taking a position for or against this system, just asking some questions. I have no doubt that “Peribirth.” has caught errors and saved lives. Yet, I keep thinking about my “Maggie.” I know I don't have to think as much! I know if I continuously use Maggie, my sense of direction will begin to wither. Sometimes, Maggie is wrong , and I ignore her and follow my gut. I have been driving for over 35 years and have only been relying on Maggie for a year. What will happen in another three or four years? Will my gut tell me that Maggie is wrong and will I listen to my gut or will I do as Maggie says? Regardless, whether Maggie's right or wrong, the end result is a loss of a little bit of TIME. Maybe I go 5 or 10 miles out of my way before I realize she's wrong and get back on the right path. What about the doctors, nurses and midwives? Do you really believe that if they continue to rely on improved technology to catch errors, they will be able to listen to their gut when it tells them something's wrong? What about the new obstetricians, will they ever develop a gut feel? Will they deliver by the numbers and if they don't develop a gut feel, is that a bad thing? Alan

If This Is a Birth Blog, Why so Much Health Reform?

I hear this question a lot from people that read my blog. The answer is rather simple, but tells all. I write this blog to attract people that don't read birth blogs! I of course welcome and want all the so-called "birth people" and I know that at the early stages the “birth people” are the only people reading this. However, there are many wonderful birth blogs to rile the blood of any birth advocate. This may be the only blog that people that are involved in birth, but are not considered part of the "birth world." may actually read. In other words, if VBAC is your issue, there are blogs that deal with VABC everyday. If homebirth is your issue, go to Dr. Amy. If natural birth or unassisted birth is your issue, tere are multiple places you can go to. However, if you are among the vast majority (over 90%) of obstetricians, nurses, pediatricians, hospital administrators, etc. I doubt you have ever been on a birth blog, nor have you ever been to a birth conference. Birth is a tiny part (approximately 2%) of healthcare spending. I know that labor is the greatest reason for hospital admissions, but that has more to do with coding the actual number of people having babies. In fact, there are approximately 4.5 million births in the United States and 85 million hospital admissions. The claim of single greatest admission is overemphasized because there are multiple ways of coding chest pains but only one way to code labor. Birth care cannot be performed in a vacuum. Doctors midwives and hospitals do not get paid enough to deliver babies. Any talk of reducing their reimbursements reduces the number of doctors and hospitals and midwives who wish to continue delivering babies I will tell you the secret that everyone knows but no one is will say: “Many decisions in birth are made for financial reasons." Although everyone knows this, they can't admit to it. Just like the Congress has to deal with the budgetary effects of the healthcare reform bill, birth care providers are constrained by the reimbursement of the insurance company. A scheduled C-section takes 15 minutes in the middle of a workday. Whereas a "normal" birth can take hours at 2 AM on Sunday morning, you the obstetrician would be paid the same. Health care reform is about money and the medical system. How the money is distributed and/or allocated will have a major effect on birth practices. That is why this blog focuses on financial issues, because that effects ALL birth issues. Alan

Fathers to Be, Do You Take Them for Granted?

Once a week I blog about the Controversies in Childbirth Conference. Today is the day. Imagine in the labor room, a person who is not a patient and is not even a relative. This person is a guest of your patient. This person may have even come to a few prenatal visits with your patient; you don't even know this person's name. When you deliver the baby, this person’s status has changed. This person now has the right to make demands. This person has the right to file a lawsuit against you even if you're patient says no. This person is" "the baby's father." Birth care providers such as obstetricians, nurses, midwives, doulas, childbirth educators, even administrators believe that they are treating the father of the baby GREAT, but how do they really know? The patient gets the survey, not the father. The patient (baby’s mother) goes back for six weeks of follow-up visits, but not the father. The patient has a total support system, from hospital follow-up to mothers and mothers-in-law's, but not the father. Patrick Houser, the author of: "The Fathers to Be Handbook" will present a half day workshop on Thursday, September 18th, where he will go over what fathers encounter, how they feel, what the perception is, what they want and how you, the birth care professional can benefit by accommodating them. Did you know that the greatest single variable for the success of pregnancy, birth and breast-feeding is the father? You will learn that when fathers are supportive women have a better chance of remaining low risk . Further, when fathers to be (and fathers postpartum) are treated well, the risk of a lawsuit is substantially diminished. Often the father is the instigator in a med-mal suit, sometimes in conflict with the mother's wishes. This workshop will have a definitive impact on your bottom line, as well as reducing obstacles in your practice. Go to www.birthconference.org to register for the conference and workshop. Have a great weekend. Alan

How Much Will My Insurance Pay?

The problem with health insurance reform is does not appear to reform the practice that makes the entire system “NUTS!!” Imagine going into restaurant and having a wonderful meal. When the check comes, you tell the owner that he will submit his bill to your restaurant paying service. Somewhere between two and six months, your restaurant paying service will send the restaurant a check for 80% of what they feel the meal was worth. NUTS???? That’s how insurance operates. The government and insurance companies buy in volume and negotiate. That is a key part of their cost containment. However, this buffer between the customer and care provider takes away from the customer’s (patient’s) ability to negotiate because they don't know how much the bill is. Then they are not told how much the insurance company will pay. For health-care reform, to be successful, the f secret negotiations must stop, unless the procedure is covered 100%. 80% -- 20% or 50% -- 50% or co-pays or out-of-pocket maximums makes no sense when the real numbers are hidden. More importantly, providers cannot run a business without knowing in advance, how much they get paid for the services they perform. If you really want healthcare reform, we need to look at this current insurance practice and realize that secret contracts make the patient/client, a bystander in their own healthcare. Alan. Early bird discount for Controversies in Childbirth Conference expires Saturday www.birthconference.org

Do Hospitals Know How to Market to Pregnant Women?

As many of you know, I do consulting with a company called "Business of Birth". I try to help birth care providers and facilities get their marketing message heard by the 20 to 40 year old females that are; The pregnancy target market. Hospitals are places for old sick people, and they do a great job marketing to these , old sick people. Pregnant women are not old, and they are rarely sick. So, it would make sense that the same message that would be targeted to older people would fall on deaf ears in the pregnancy population. Yet, when I talked to hospitals, or even hospital birth centers about simple marketing techniques such as: "A separate website for the maternity unit,." they are reluctant to tery something new. Ohio Valley General Hospital, just announced that they are closing L.&D. by the end of the year. Ohio Valley is in the Pittsburgh, PA region. In 2006 Ohio Valley spent millions of dollars opening new maternity unit trying to grow to 800 births a year from 300 births a year. They were unable to accomplish this, and have raised the white flag of surrender. Click Here to Read Article in the Pittsburgh Post-Gazette I have no personal knowledge of the steps that Ohio Valley took to try to grow the maternity unit. I am willing to guess that they did not reach out to the birth advocates, the birth bloggers, the birth movie people (Business of Being Born, Orgasmic Birth, etc.) to try to do anything really different. This is another example of one of my pet peeves. Hospital executives pay scant attention to what happens in the maternity unit. Then, when it is time to close the maternity unit, the hospital CEO gets up and explains why the maternity unit had to close. My question is? "Why do CEOs wait until they announce the closure of the maternity unit before they get involved in operation of the maternity unit?" Alan

Insurance Industry Report Confirms This Blog's Concerns

On Monday, the health insurance industry trade group, AHIP, realeased a report from their consultants on the effects to the future cost of insurance as a result of the Senate Finance Committee’s. Health Reform Bill.” Click here to read FULL report I have asked the question on this blog, "What about the people that still don't buy insurance?” Then I asked. "How do premiums go down, when insurance companies are required to cover all the sick people?" The insurance industry report using my two points, plus the additional taxes on insurance companies, says that under the health reform proposals, insurance premiums will go up and not down! (by a lot of $$$) Are the numbers that they project accurate? I don't know! But, the concept that premiums are going to rise more than expected is probably accurate. Let's look at some business projection truisms: A) Revenue will be less than projected! B.) Expenses will be more than projected! C.) If you give people a benefit, they will use it more than projected! D.), If people have to pay for something, less people will utilize it then projected!. The White House is blasting the industry report, but of course, they are experts at bringing things in under projected budget! Alan PS- Early bird rate expires Oct 17th for Conference: http://www.birthconference.org/

If the Patient Has Insurance, Are You Guaranteed to Get Paid?

Allow me to explain the basic difference from the provider's perspective between an HMO. and traditional insurance. If the patient has an HMO, the agreement to pay the claim is between the provider and the insurance company. Under traditional insurance, the payment agreement is between the insurance company and the patient. Put simply, with traditional insurance, the patient is still responsible to pay the provider. If the insurance company does not pay for any reason, the provider can turn the insured over to collections, or even start a lawsuit. The provider has no cause of action against the insurance company. By contrast, in an HMO, if the HMO does not pay the provider, the provider cannot sue the patient (assuming the patient is insured and authorization was received) the provider sues the HMO. . It appears that none of a health reform proposals, working their way through Congress addresses this issue. Many providers have seen patients receive reimbursement checks from insurance companies, and yet, never paid for their birth. Likewise, insurance companies are known for denying claims for any reason, and quite often simply losing the claim or the supporting documentation. For health-care reform to work, major changes need to be made in the daily battle between insurance companies and providers. It's not enough that everyone has insurance, the abusive claims practices must stop! Likewise, the explanation of benefit process must be simplified so that the average American can understand EOBs without hiring a medical claims consultant. Alan

What Does Rationing of Maternity Care Look Like?

Critics of healthcare reform say, that it will lead to healthcare rationing. It should be noted that rationing takes many forms, such as: long waits for care, denial of procedures, and forced cheaper alternatives (ie; generic drugs, etc). Belfast, Northern Ireland, which has totally "FREE" healthcare, faces a major budget deficit. and all departments are required to enact cost saving measures. The maternity hospital has decided to send women home between 6 and 12 hours after having a baby. Click here to read, October 6, 2009 BBC article. Interestingly, the article notes that there is NO medical reason why a woman, after normal birth, cannot go home after six hours, assuming NO complications. Rather, they argue that the new mom either; needs rest, breast-feeding support or instructions in parenting skills. It was only about a dozen years ago that the Kennedy-Kassebaum law, forbade early discharges for maternity care. Prior to that, insurance companies were pushing hospitals for what was known as: drive-through deliveries (deliver and out next day). On the other hand, laws and standards for birth centers in the United States allow a mother to go home after a approximately 4-6 hours, assuming NO complications. In many jurisdictions, stays longer than 24 hours are prohibited, without medical cause. So, is the Belfast model an aberration, caused by the financial requirements of socialized healthcare? OR, is it a futuristic model, for better birthing care? Have a great weekend. Alan

Hands-On Internet Marketing Workshop Announced at Controversies Conference.

What do you call people of childbearing age? If you're 40 and over, you would call them twenty or thirty something’s. If you're under 40, they are known as; millennials or digital natives. Most obstetricians, midwives, family physicians, childbirth educators and administrators are in the over 40 category. They need to get their message heard by pregnant women, i.e., millennials. Just as you didn't like your parents music, and your children don't like your music, most birth care providers don't know how to create and place a message that the millennials will hear and act upon. At the 2009 Controversies in Childbirth Conference, super geek, and frustrated birth advocate, Laureen Hudson, presented an amazing seminar on getting your message heard. Of course, one hour is insufficient to learn how to bridge the digital generation gap. Laureen has agreed to a, full afternoon, hands-on workshop with participants encouraged to bring your laptops, so you not only learn, but you actually: Create an online presence on; Websites, Facebook, Twitter, Linkedin and Blogs. Including: How to build an audience How much time will it take The importance of your online reputation How to be found on search engines What works What you should avoid and much more... Space is extremely limited because of the limited number of WiFi connections and you are urged to register now at the conference website: http://www.birthconference.org The Controversies in Childbirth Conference will be held February 19-21, 2010, in Tampa, Florida. Laureen’s pre-conference workshop will be held on Thursday, February 18th. This is an amazing opportunity to improve your business marketing and learn to digitally connect with patients and clients. Hope to see you in Tampa! Alan

The Achilles‘ Heel of Healthcare Reform

Having spent 25 years in the insurance industry, I learned the Golden Rule: "You cannot insure a burning building!" Whether right or wrong, the working model for health insurance companies is: "You have to buy the insurance before you get sick.” If this was not a requirement, everyone would wait until they got sick, and then they would buy their insurance on the way to the hospital. Our current healthcare system, as well as all health reform proposals, struggle to balance the need for people to have health insurance versus turning people away when they need urgent care. Since a compassionate society does not turn away people when they need care, we have various safety nets to allow the uninsured. to receive the care they need. The question not being asked is: if we are requiring people to have health insurance as a matter of law, then it stands to reason that, compliance would be higher, if the punishment for not having health insurance were them being turned away at the emergency room. Thus, the counter argument is: If people can still get care at the emergency room even if they're not covered by the various insurance schemes, why should they bother getting coverage??? In many large cities; as many as 35% of the drivers do not have automobile insurance, even though it is required by law. As every driver knows, there is always a chance of getting pulled over for some reason by a police officer and being asked for your insurance card. So I ask; “If 35% of the people don't have mandatory automobile insurance and they're aware of the severe penalties, why should anyone believe, that requiring medical insurance, will have a better compliance rate, unless the penalties for not having insurance, are extremely severe?" Alan

Understanding Healthcare Profitability

Having a consulting company called, "Business of Birth International, Inc" can be an interesting experience. I often get calls from well-meaning birth advocates that go something like this: "How can you have a company called Business of Birth? How can providers care about profitability? Don't they know it's all about moms and babies? You should be ashamed of yourself!!!" Healthcare is a business. It is a huge business. It is one sixth of the United States gross domestic product. A hospital has to raise tens of millions of dollars (or more) for the building, for the renovations, and then for the equipment. Then they must pay a plethora of staffers from nurses to clerks to lawyers to housekeeping people. This does not include physicians who may or may not be paid by the hospital. There are four main methods of receiving revenue to keep the hospital open. Medicare/Mediad, private insurance and self pay. The fourth is; BEGGING the government, individuals or foundations for gifts and grants. The job of the hospital is for revenues to exceed expenses. If they do, then they are considered "profitable!" Physicians offices and midwives operate the same way. If, at the end of the day. they have brought in more revenue than they have expended than they are considered profitable. If they are profitable, they stay in business. If they are not profitable (outlays exceeds income) than they have to consider shutting the doors. It does not matter whether it's cardiology, pulmonology, orthopedics, a maternity, the rules are the same. They have to run in the black or they will not stay open. In order for moms and babies to have the most choices possible, it is imperative that birth care providers and facilities are operated profitably. In a future posting,. I will explain why a practice that is not profitable, may not be safe. Alan

Birth Advocates -- Venting or Finding a Solution?

This post may hit a nerve. Almost all birth advocates are women. Having read "Men are From Mars, Women are From Venus" and having watched every episode of "Sex in the City" (any show where a bald Jewish guy (Harry) gets the prettiest girl (Charlotte) is worth watching). I know that women vent, and that men fix things. I have been to many conferences with birth advocates. I like to do a one-on-one exercise randomly with advocates. I say: "I am a hospital CEO. I am giving you 10 minutes of my busy schedule. What is it that you want?" Having done this over 100 times with different advocates, I have yet to have someone tell me while I’m playing the role of the CEO, “what it is they want me to implement ,that is also within my power and/or authority. Statements such as: "I want you to treat women better.” To which I respond "I don't know what that means and 98% of our delivering women are pleased with how they were treated based on the surveys they submitted.” Or, "I want you to train more midwives!" To which I respond, "We are a hospital, we hire midwives. Universities train midwives." Another good one is, "you're obstetricians don't respect women, they treat them like garbage!" To which I respond, "75% of our obstetricians are women!” Or, how about, "your hospital is doing too many interventions!" To which I respond:” I am the CEO of the hospital, I don't know what an intervention is, but I'm sure our physicians follow the current standards of practice. Your time is up, thank you for coming in." Last week I blogged about how effective Karen Fennel has been on Capitol Hill lobbying to put birth centers, into the Medicare law and the health reform bill. In the linked article, Karen said that if it is too complicated, she will actually write the bill for the legislatures. In doing so, Karen keeps it short and directly to the point, leaving out extraneous information. Hospital administrators, physicians, trade association executive directors, congressional staffers, as well as Congressmen and Senators themselves, have very busy schedules. Their time really is valuable, and if they choose to give you an opportunity to meet, I implore you, please, do not squander it. Have a game plan! Ask for things that are within their purview to give you. Be specific! Ask for more than you want and be prepared to compromise and know in advance that you will probably receive less than you want, but more than you already had. Alan Learn how to make allies of people that may not share your views, at the Controversies in Childbirth Conference, February 19-21, 2010, in Tampa Florida. http://www.birthconference.org/

Are Hospitals Giving Credence to an Argument in Favor of Out of Hospital Birth?

As public health officials start to panic over the H1N1 virus (formerly known as swine flu) hospitals are responding by restricting visitors who may be sick, from the maternity wards, so as not to infect newborns. A link to the story from KSL TV, can be found here. http://www.ksl.com/?nid=148&sid=8127580 One of the major reasons for having birth in an out of hospital birth center or a homebirth, is that a hospital is a place where sick people are congregated, and you would not want a pregnant woman or a newborn infant to come in contact with the sick people or their germs or viruses. We know that hospital personnel are often the carriers that spread diseases between patients. In fact, there's a fight brewing in New York State, because healthcare workers are being forced to be immunized against the H1M1 vaccine or be reassigned. Public-health officials are so concerned with healthcare workers spreading Swine Flu, they are making immunization mandatory. So here's the question: "is Swine Flu the worst possible disease that can be spread to newborns?" I believe that there are a lot worse viruses, diseases and infections that you would not want your infant to come in contact with, including: staph infections, seasonal flu and conjunctivitis. In fact, birth advocates have argued against taking the baby away from mom and putting them in the nursery with a bunch of other babies. In a homebirth or birth center the baby is not exposed to other babies. Having run a very large birth center, I can tell you the secret to an almost ZERO percent infection rate. No equipment and almost no personnel were moving between rooms. As an example, each room had a number of stethoscopes and those stethoscopes stayed only in that room. There were no medical personnel with stethoscopes around their necks moving from room to room. More about keeping infection rates near zero in future postings. Have a wonderful weekend Alan

2009 Conference Speaker Makes Waves on Capitol Hill.

An AP story published on Monday, September 28th talks about a Washington DC lobbyist who pounds the halls of Congress on behalf of birth centers and the American Association of Birth Centers. Click Here for article Karen Fennell, MS, RN, was a featured speaker at the 2009 Controversies in Childbirth Conference which was held in Fort Worth Texas. Karen's topic was “A Washington DC Update on Birth Care Issues.” Karen explained that government pressure on insurance companies to lower administrative costs is resulting in companies refusing to contract with small providers and instead to only contract with large integrative groups. Many of the conference participants protested and said that this move could force small practitioners out of business. They asked if there was any way to stop this trend? Karen said that the laws have already passed and the ship has already sailed. Small providers being forced into larger groups is not a question of, “if” it's a question of “when”. This was just one instance of information that was talked about at the Controversies in Childbirth Conference that has not been discussed at any other birth provider conference. I want to personally congratulate Karen on the great job she is doing and point out that she has gone toe to toe with the big dollar lobbyists, even though she has a miniscule budget by health lobbying standards. I have known Karen for quite a number of years and I will tell any birth related organization that is looking for lobbying capabilities to consider Karen. It would be the smartest decision you can make. Alan