Tough Choices: A Blurb About the Difficult Choices Facing Many Couples in Their Quest for Fertility

Posted on: October 31, 2009  |   Author: David
Filed Under: Drug & Device, HMOs & Health Plans, Health Information, Hospitals & Health Systems, Insurers/Payors, Technology   |   Leave a Comment

It may be one of the hardest decisions an expectant parent would have to make: Reduce the number of fetuses you are carrying or risk losing them all.

Sadly, that is exactly the decision Thomas and Amanda Stansel had to make. After undergoing the popular process of intrauterine insemination in which sperm is injected into Mrs. Stansel’s uterus following hormone injections, Mrs. Stansel received shocking news – she was carrying not one, not two, but six fetuses. However, the Stansel’s excitement was soon crushed when their fertility doctor gave them some additional startling news. Due to the increase in fetuses, the likelihood of delivering six healthy infants was near zero. To save some, he recommended reduction – through a process known as “selective reduction.” The Stansels decided not to reduce, instead relying on their faith to protect them and in August, Mrs. Stansel gave birth to all six babies. Unfortunately, at 14 weeks premature, all weighed in at roughly one pound. The hospital fought valiantly, but three babies died within two weeks. A few months later, another was lost. The two babies remaining continue to struggle, still attached to ventilators and feeding tubes and under constant care in the hospital neonatal intensive care unit.

For couples having difficulties becoming pregnant, there are several options available. First, most doctors recommend utilizing low-potency fertility drugs in order to stimulate the process. If unsuccessful, the next step is intrauterine insemination with hormone injections or in vitro fertilization. This decision is often influenced by two related factors: insurance and costs. The cost of in vitro fertilization costs between $12,000 and $25,000 while intrauterine insemination only costs $2,000 to $3,000 per attempt. As such, many insurance companies will cover multiple rounds of intrauterine insemination before one round of in vitro fertilization. The preference though, is not without drawbacks. Intrauterine insemination, while front-end cheaper, can present significant problems. Excessive hormone injections can lead to an overstimulation of the ovaries which in turn can lead to the increase in probability of having multiples. In fact, the Centers for Disease Control and Prevention supported this theory when it found that the intrauterine insemination process was more likely to result in multiples than in vitro fertilization. And with increased multiples, come increased risks, especially with premature births which carry the risk of long-term complications and disabilities. Multiples, like the Stansel babies, who arrive early, require the highest level of acute care for a longer time than any other patients. This can add up to astronomical financial hardships in the long-run. In addition to money, multiples with increased risks of complications can put families in very difficult decision like the one faced by Thomas and Amanda Stansel- whether to abide by religious beliefs against the perception of abortion or a doctor’s recommendations to reduce.

The current position taken by insurance companies is baffling. Intrauterine insemination is largely undocumented today, but has been shown to be less successful and more dangerous (with respect to increasing risks for premature multiples) than in vitro fertilization. The main upside, cost. Due to the less invasive nature of intrauterine insemination there is a significant cost difference between the two procedures leading many insurance companies to favor the treatment. In doing so, insurance companies may be overlooking two major issues. One, as this procedure becomes more popular, the costs associated with premature multiples will also grow- likely at a much higher rate than the cost of the initial fertility treatment. Second, many couples attempting to start a family do not understand the possible consequences of their actions – the psychological and financial considerations of having a tragic result. Insurance companies have long acted as a gatekeeper in providing medical treatment and should take a second look at their current preference towards intrauterine insemination.

The New York Times, October 11, 2009.

Medicare and Health Reform: Part II

Posted on: October 7, 2009  |   Author: Thomas L. Greaney
Filed Under: Access to Care, HMOs & Health Plans, Healthcare Reform, Hospitals & Health Systems, Medicaid, Medicare, Other, Tax & Finance   |   Leave a Comment

Baucus

Baucus

In his closing remarks to the Senate Finance Committee last week, Senator Baucus
pointed with special pride to the effect the Committee’s reform bill will have on shaping the health care system in the longer run:

One point I want to make… is about delivery system reform.  We are starting here in this bill to finally reform our delivery system so it’s based much more on quality and patient focus, moving ever so slowly, but inexorably, from fee for service….which causes a lot of the waste in our system. We’re not going to see savings, the benefits, to the system for a while… but after four, five, six years from now, we’re going to see the real benefits of reform.

There is no doubt that the Committee’s America’s Healthy Future Act devotes considerable attention to fixing what’s wrong with the existing delivery “nonsystem” and improving government oversight. Title II (Disease Prevention and Wellness), Title III (Improving the Quality and Efficiency of Health Care), Title IV (Transparency and Program Integrity) and Title V (Fraud Waste and Abuse) of the Act consume 143 pages of the 259-page Chairman’s Mark.

And well it should.  As Professor Bill Sage’s aphorism, “It’s the delivery system stupid,” suggests, changing the structure and interactions of health care providers has long been seen as critical to efforts to control cost and improve quality.  Given serious questions about the strength and effectiveness of competition among private health insurers, especiallywithout a public plan option to spur them, Medicare reform stands as the only viable means to bring about delivery system change.  Policy analysts have made the point that “Medicare is the place to start delivery system reform,” recommending payment reforms that reward accountable health organizations and move toward bundled payments  as a means to spur needed integration in health care delivery.

But how quickly can all this be accomplished? The Kaiser Family Foundation report, Strategies for Reining in Medicare Spending Through Delivery System Reforms: Assessing the Evidence and Opportunities throws some cold water on Senator Baucus’ hope for realizing significant savings in 5-7 years.  It concludes that some popular ideas–medical homes, electronic health records, bundled payments, accountable health records, and comparative effectiveness  research, while promising significant help in the long run, will need considerable fine tuning and are “unlikely to reduce costs significantly in the next five to ten years.”

At the same time the KFF report describes a number of steps that the Medicare Coordinate Care demonstrations indicate have the potential to reduce Medicare growth in the next five to ten years, such as care coordination and efforts to reduce hospitalizations and readmissions; extending the Resource Use Reporting project to inform physicians about relative resource usage; alteration in the bidding and incentive structure of the Medicare Advantage plans; and other steps to improve the infrastructure supporting quality and efficiency.  The key question of course is: how do we implement these changes ?

Ultimately, realizing either short or long-term benefits depends on patience and politics. Pham, Ginsburg and Verdier have set forth a variety of changes in the  decision making process governing Medicare provider payment and other reforms to the delivery for the program that would serve “to ensure that the crafting and refinement of reforms, particularly those affecting payment for providers, is driven as much as possible by data rather than politics.” Notably the Committee’s America’s Healthy Future Act (at page 189) takes an important step in that direction by creating a fifteen member, bipartisan Medicare Commission that would be tasked with presenting  to Congress for fast track consideration proposals that:

(1) to the extent feasible target reductions to sources of excess cost growth;

(2) to the extent feasible, improve the health care delivery system, including the promotion of integrated care, care coordination, prevention and wellness and quality improvement;

(3) to the extent feasible, protect beneficiary access to care, including in rural and frontier areas;

(4) to the extent feasible, consider the effects of provider payment benefit changes on beneficiaries;

(5) to the extent feasible, consider the effects of proposals on any provider who has, or is projected to have, negative profit margins or payment updates; and

(6) to the extent feasible, improve the quality of care delivered to Medicare beneficiaries;

(7) to the extent feasible, consider the unique needs of individuals dually eligible for Medicare and Medicaid; and

(8) prior to December 31, 2019 not impact providers scheduled to receive a reduction to their inflationary payment updates in excess of a reduction due to productivity in a year in which the Commission’s proposals would take effect.

Open Market for Organs?

Posted on: August 7, 2009  |   Author: Daniel
Filed Under: Access to Care, Bioethics, Fraud & Abuse, Health Information, Hospitals & Health Systems, Liability & Litigation, Public Health Policy, Technology   |   Leave a Comment

In New York, the average waiting period for a kidney transplant is nine years. The only legal option for those who choose not to or cannot survive this extended period of time is to find someone willing to voluntarily donate an organ. The options are limited based on the fact that, currently in the United States, it is illegal to buy and sell organs. Despite similar bans in most developed countries, there remains a worldwide market for transplantable organs. As such, the World Health Organization estimates that 10% of the 63,000 kidneys transplanted worldwide each year from living donors have been bought illegally.

In 2008, authorities in India broke up an illegal ring involving doctors, nurses, paramedics, and hospitals that had performed 500 illegal transplants of organs to wealthy Indians and foreigners. Among the donors, most were poor laborers who were paid as much as $2,500 for a kidney, while some were forced to surrender their organs at gunpoint.

Recently, a Brooklyn businessman and self-proclaimed “matchmaker,” was arrested in New Jersey for trying to broker the purchase of a kidney for $160,000. Levy-Izhak Rosenbaum told an undercover investigator that he had been successfully brokering the sale of organs for 10 years. Rosenbaum would concoct a fake relationship between the donor, usually from a poor community, and the recipient, so that the donor could pass the hospital’s psychological screening interviews prior to surgery.

Dr. Michael Shapiro, the chief surgeon at Hackensack University Medical Center’s transplant unit, said he suspects that many would-be live donors are looking to be paid for their body parts, but fear getting caught. According to Dr. Shapiro, sometimes it is necessary to sit down with the donor and receive assurances that he or she knows that it is illegal to sell organs. However, as doctors are becoming more aware of the practice of selling organs, many feel powerless in deciphering the true motive of the donors. He notes that doctors are not educated in interrogating donors to prevent schemes like Rosenbaum’s.

Living organ transplantation has opened up a Pandora’s Box of questions that no government has been able to answer. For years, the World Health Organization has been weighing the possibility of legalizing organ sales, but the issue continually sparks intense debate.

Commentary: The average person waits five years for a new kidney, which is an amount of time that many cannot afford. An estimated 10-20 people die every day waiting in vain for their new organ. If voluntary organ donations were sufficient to satisfy the donation list, the supply of organs would be large enough to satisfy demand, and there would be no need to change the present system. However, with the demand for organs far outnumbering the number of donors, many economists and health care professionals are taking a controversial stance by urging the adoption of market-based innovations. It is the opinion of this blogger that, in the United States, there are already markets for blood, semen, human eggs, and surrogate wombs. Merely extending markets to include other organs, which can be obtained with reasonable safety, could be beneficial. An open American market in organs would sharply curtail the present black market and ensure the highest-quality medical care. However, there must be a systematic approach to eliminate coercion and establish a fair market price. This would protect those who are currently most vulnerable and ensure that all parties involved would receive the intended benefit.

N.Y. Times , July 29, 2009

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