The Business of Medicine, Continued by Steven Vaughn MD, PhD

We have nothing left for medicine but increasing hype disguising the dwindling quality of American healthcare.

Here’s some excerpts from blatant ad copy fed to a writer in a Major Metropolitan Newspaper. The writer obligingly took the press release up to parrot as Health News. It takes only a few minutes to pick out the scary details, if you are a thinking reader. The industry is banking on the disappearance of thinking and reading in the populace.

To fool most of the people most of the time, the Medical Industry has rolled out some tried-and-true advertising tricks, to sell what cannot sell itself by its own merits.

• Modernize, modernize. “New and improved” sells, no matter whether the ad copy represents a product that is either new or improved. The excitement about “creative destruction” of American medical care pretends that the leaders at the forefront have a vision which the average person can’t quite grasp. This stale concept brought about Fascism and Communism in the 20^th Century, shrouded in the pretense of objective, scientific approaches to modern society. Flog confusing statistics – bad statistics with bad presentation makes for wrong inferences.

“Birth centers typically offer the midwifery model of care, which places heavy emphasis on supporting natural birth for healthy women with low-risk pregnancies… but childbirth is the leading cause of hospitalization in the United States…”

The phrase “unnecessary hospitalization” whispers from the last phrase.

• The enemies of reform are just stubborn and old-fashioned. Those crusty old doctors are wedded to their paper charts and paternalistic ways! says the ad copy. Any objections from those old docs is just from fear and ignorance – nothing they say has any relevance, just ignore them!

The World Health Organization mentions several inconvenient truths worldwide: “more than 3.3 million babies are stillborn every year; one in three of these deaths occurs during delivery and could largely be prevented….Stillbirths account for over half of all perinatal deaths. One third of stillbirths take place during delivery, and are largely avoidable. Ninety-eight per cent of the deaths take place in the developing world…. In developing countries, just over 40% of deliveries occur in health facilities and little more than one in two takes place with the assistance of a doctor, midwife or qualified nurse…” Neonatal and perinatal mortality: country, regional and global estimates © World Health Organization 2006

• Take back our system! Nothing appeals like phony populism. Business interests know better than to announce they have a five-year plan to gain market share. They hide behind an Astroturf populism pretending it’s the will of the people.

The director of the birth center states: “A lot of women feel like it’s a little scary to be at home, but they don’t want to be at the hospital,” – said. “Birth centers are a middle ground.” Hospitals play a vital role in maternal health, especially for women with risk factors or complications. But for healthy, low-risk women, hospitalization may not be necessary…”

The speaker knows (or should know as a midwife) that human birth is a rather complicated process. Evolution has made it far dicier than for our fellow mammals – and women’s fears of things going wrong is pretty well grounded in reality. In general, there’s no way to put a gold star on a pregnant woman that assures her of an easy, uncomplicated delivery. Deliveries can go to hell quickly, even in the best candidates for safe birthing. At least 40% of moms in developing countries get it.

• Demand only the best; complain and sue if you don’t get it. High expectations is one of the most painful and sobering part of obstetrics. Everyone imagines the healthy, happy baby. Not everyone gets one. We should be aware of the inevitable risks under the best of delivery circumstances. Women in developing countries – many of them even illiterate – have a better grasp of the scientific risks of childbirth. They get help, and often hospitalization, in facilities that would seem crude and unspeakable to First World nations. Still, they are better than at home.

“Although birth centers do not perform C-sections, the percentage of women who require transfer to hospitals for C-sections falls to well below the rate recommended by the World Health Organization of between 10 percent and 15 percent of all births….”

Notice, BTW, that C-sections are not some evil conspiracy dreamed up by doctors to line their pockets, as wiggy critics like Ivan Illich howls about. They happen in 1-in-10 births, from Somalia to Singapore, to keep babies from dying – and moms, too.

So if a complication arises, and a woman needs a C-section, what does she do? A fevered, racing trip to the Emergency Room – and if she makes it, a risky C-section in the trauma room of the ER, done by a general surgeon or even an ER doc. Nobody offers that as an alternative – it makes for terrible ad copy.

Is it rare?

“In the study, 84 percent of the women delivered at birth centers. Although 16 percent of the women were transferred to hospitals either before or during labor, 93 percent of all the women in the study had spontaneous vaginal births.”

One in six have to ride the wagon. A little less than half of these get a C-section. The others have the thrill of vaginal delivery bouncing along with the EMT’s, or in the ER. And that jazz about “well below the rate of recommended C-sections” is bunk. 16% go in the wagon – the birthing center has nothing do to (or care about) what happens after the lights disappear in the distance. C-section? Uterine rupture? Who knows?

Why, an illiterate woman in Mali might ask – why would American women deliberately take this added risk?

The headline copy gives it away:

Mothers and mamas-to-be got some potentially good news from this year’s State legislative session that could deliver a greater range of birth options for healthy mothers. A new law creating a state license for free-standing birth centers could encourage their growth.

“A state license will give birth centers the chance to seek Medicaid reimbursement for facility fees, which hospitals already receive. That’s important because it gives birth centers – seen as a “middle ground” between hospital birth and home birth – a chance at becoming economically viable ventures for the midwives who choose to create them.”

Back to the Facility Fees story.

“The Affordable Care Act mandates that Medicaid reimburse birth centers for facility fees, which, unlike the fees for care, cover the overhead associated with running a birth center, including the costs of a lease, equipment and administrative staff. The mandate requires that birth centers be licensed in the state where they operate.”

With a license, the birth centers can bill as obstetric centers, but roll the bad apples down the road to the ER. When the bad outcomes happen, it’ll be at the hospital ER, not at the birthing center. Well, they tried.

There is an unwritten tradition learned in residency training by most good doctors: “Do Not Fiddle With What You Can’t Fix.” [The word ‘fiddle’ is often substituted.] I’ll bet I could do a decent appendectomy as an Internist – I’ve seen a few, and the ones that go well are a piece of cake – zip, zam, done! The thing I can’t do is open a disastrous mess of an abdominal problem and then fix it. If you have to call for a better surgeon in the middle of a surgery, that’s just not cricket, in the surgery world. That rule is vanishing. Birthing in a place where you can’t do sections is just wrong, especially if one-in-six goes in the Wagon to Elsewhere.

In fifty-so years, our economy has slid from domestic civilian manufacturing, which brought general prosperity, to the shuffling of money here and there, largely rewarding the astoundingly wealthy money shufflers. The money from productivity has dried up; we are trying to survive on the leavings. And business will be business.