Comment & Controversy

“ ‘NO-FAULT’ INSURANCE THAT Menopause of our patients. Some recent “improve- COVERS A AND BIRTH” and cognitive decline ments” are making things worse. Physi- PAUL L. OGBURN, JR, MD (JULY) Staples, or sutures, to close the skin after cesarean delivery? cians and nurses spend more time trying

REIMBURSEMENT ADVISER Many liability cases are Coding realities collide to document (based on ever increasing with new “opt-out” HIV screening guidelines result of poor medical care A DOWDEN PUBLICATION | VOL 21, NO 7 | JULY 2009 | WWW.OBGMANAGEMENT.COM rules and regulations) than they can

I just fi nished reading Dr. Ogburn’s STRATEGIES FOR PRACTICE possibly spend at the bedside. Physi- thoughts on how to reform the medi- Chemoprevention cians spend more CME time and money of breast cancer cal malpractice system so that it works by Steven R. Goldstein, MD to learn the latest “new, improved” cod-

Which of your patients can benefi t? The author explains at for everyone. Here’s my problem with obgmanagement.com ing changes than they spend on any real

PLUS his proposal to off er an individual Dr. Barbieri’s call to action medical education. Th e 3MLI will at ObGyns must lead in policy for each gestation: As an “in- the battle against breast Ca least require each physician to partici-

UPDATE ON ENDOMETRIAL CANCER house” reviewer for a major medical Survival advantage is dubious pate in a detailed review of the case of a with pelvic lymphadenectomy malpractice insurer and a consul- and external-beam radiotherapy poor outcome with a panel of experts so A “no-fault” plan to defuse the OB malpractice insurance tant for many defense law fi rms, I am crisis—could it work? that the case can go into the database of IN JAMAICA, TANZANIA How 2 US ObGyns cross borders overwhelmed by the sheer number of to care for the poorly served all poor outcomes and the physician can Only at obgmanagement.com

med-mal cases out there—and many Follow us on Facebook and Twitter receive specifi c instructions on practice of them are legitimate. improvements, if needed (or be removed JULY 2009 When I began to review cases, from 3MLI eligibility, if need be). back in 2001, I expected the job to in- Patients taking out individual poli- volve mostly frivolous suits and mon- ›› Dr. Ogburn responds: cies is not new. What is new is that, ey-hungry lawyers. I was so wrong. We must® doDowden better than theHealth Mediaunder 3MLI, the physician or provider Many of the cases I have reviewed current system performs would pay for the policy, not the pa- are more than justifi ed, and many of Dr. Kramer raises some important tient. I want an insurance policy that them are “bad baby” cases. I Copyrightcan cer- points:For personal use onlywill take care of my patient and her in- tainly sympathize with the parents of Medical negligence is happening fant if they need it, no matter who is or these unfortunate children. and harming our patients. I agree. is not at fault. Th at is what I want; that What is needed is better training, Th is sad fact is as true today as it was is what my patients deserve. with more hours on call to follow the when we reviewed perinatal closed 3MLI is designed to help solve evolution of disease and course of claims in the mid-1980s.1 We found some of the problems that Dr. Kramer labor. Th e idea of being off so many that payments were made 50% of the raises even as it helps our injured pa- nights and working a shorter day in time when there was no negligence; tients. It can be instituted without tort- ObGyn just doesn’t cut it. Residents when there was negligence, payments reform legislation. For the sake of our are young; they can handle the work- were made 90% of the time. Th e current patients, we must do better than the load. We need to spend more time system requires someone to have been current medical-liability system does. with patients and learn more about negligent for the infant to get fi nan- Reference continuity of care. Th en, and only cial help. Th is leads to expensive (and 1. Ogburn PL Jr, Julian TM, Brooker DC, et al. Perinatal then, will there be fewer mistakes, wasteful) “discovery” and “expert testi- medical negligence closed claims from the St. Paul Company, 1980–1982. J Reprod Med. 1988;33:608–611. fewer cases, and lower settlements. mony” designed to convince a jury, not Th e idea of the patient taking out to get at the truth. Th e one person who an individual policy, as with airplane is not to blame is the infant. Under the “ : A SIMPLE, insurance, is not new. It was suggest- 3MLI system, the infant’s needs would EFFECTIVE, AND UNDERUTILIZED ed years ago but never made it to the be covered without the need to prove PROCEDURE” OZ HARMANLI, MD (JUNE) “big screen.” What we need are bet- fault. Th is fact alone makes 3MLI supe- ter, smarter, devoted physicians who rior to the current tort-based system. care more about their patients and Physicians need to spend more time Value of obliterative less about time off , vacations, how being trained and more time with their procedures for POP is their much they’ll make, and how quickly patients. Again, I agree with Dr. Kram- lower failure rate they’ll make it. er. Th e current system of health-care ed- I commend Dr. Harmanli on high- Barry Kramer, MD ucation and practice is not designed for lighting the importance of obliterative Bay Shore, NY overall effi ciency or for the well-being procedures for pelvic organ prolapse

16 OBG Management | September 2009 | Vol. 21 No. 9

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16_OBGM0909 16 8/19/09 11:18:43 AM (POP). An obliterative procedure patients who might be candidates for should always be off ered to women obliterative and reconstructive , From June 2009 who are certain that they will not be the success rate of over 90% reported in having intercourse in the future. all of the colpocleisis case series may Which strategy Dr. Harmanli states that “the be an attractive reason to consider this would be your top fundamental reason for choosing an approach for many elderly patients. obliterative procedure…is to treat the However, I kindly disagree with choice to reform prolapse with the least invasive tech- Dr. Valley about the lack of evidence in health care in this nique in the shortest time.” I disagree. favor of LeFort partial colpocleisis. As country? Th e fundamental reason my I stated in my article, the patients who patients choose an obliterative pro- underwent concomitant vaginal hys- cedure is because it has signifi cantly terectomy with total colpocleisis had a 19% 10% less chance of failure than the alterna- procedure that was 52 minutes longer tives. Dr. Harmanli suggests that hys- than those who underwent the LeFort 14 % terectomy in this setting “often adds procedure, and 5% of them required 30 to 80 minutes to the procedure” laparotomy.1 No one can dispute that 24% and argues that the LeFort procedure the longer operating time and poten- % is better than followed tial for laparotomy may add to the 33 by colpectomy. Again, my experience morbidity of this high-risk surgical is at variance with this position. population. Th erefore, it is incumbent Th ere is no evidence that vaginal on those who advocate hysterectomy hysterectomy followed by colpectomy and colpectomy over LeFort colpoclei- carries more morbidity than a LeFort sis to support it with evidence. None Reduce use of tobacco procedure when a regional anesthet- I failed to fi nd any data indicat- and alcohol ic is used. In addition, if the genital ing that this more time-consuming and hiatus (levator hiatus) is closed at potentially complicated approach im- None Replace fee-for- the time of colpectomy, a separate proved the success rate. Th erefore, for service reimbursement with a capitation payment system anti-incontinence procedure is rarely frail single women, I continue to rec- needed because the urethrovesical ommend LeFort colpocleisis, which can 10% Reduce capital angle is supported by the approxima- be performed in less than 1 hour—even investments in hospitals and tion of the levator muscle. In a LeFort with sedation and local anesthesia— the equipment they use procedure, the urethrovesical angle by any gynecologist who knows how to is pulled down by the procedure and do colporrhaphy using the technique 14% Institute a national may increase the risk of stress urinary described in my article. electronic health record incontinence postoperatively. Reference for all citizens When one of my patients opts 1. Von Pechmann WS, Mutone M, Fyff e J, Hale DS. for an obliterative procedure, I al- Total colpocleisis with high levator plication for the 19% Develop a national treatment of advanced pelvic organ prolapse. Am J most always choose to perform a Obstet Gynecol. 2003;189:121–126. effectiveness commission to colpectomy. slow implementation of costly Michael Valley, MD new medicines and equipment St. Louis Park, Minn “ HEALTH CARE, A GORDIAN that only marginally improve KNOT OF COST AND ACCESS, public health FACES REFORM” ›› Dr. Harmanli responds: ROBERT L. BARBIERI, MD For frail elderly, LeFort 24% Reduce the use of (EDITORIAL, JUNE) futile end-of-life medical procedure is best interventions I agree with Dr. Valley that one of the Single-payer system is advantages of colpocleisis is its lower the only option 33% Reduce administrative failure rate. Although the literature Th anks to Dr. Barbieri for pointing costs by reforming insurance lacks a good comparative study, most out that the Massachusetts insurance company practices likely because of the diff erences between plan is not going to work on a nation- CONTINUED ON PAGE 38

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17_OBGM0909 17 8/19/09 11:18:49 AM Comment & Controversy

al level. With insurance companies has a relatively low administrative “ IS OVARIAN CA SCREENING as we know them, $400 billion a year overhead and pays physicians quickly EFFECTIVE IN POSTMENOPAUSAL WOMEN?” are necessary to simply administer after a bill for professional services is ANDREW M. KAUNITZ, MD the system. (And the average salary submitted. However, in general, Medi- (EXAMINING THE EVIDENCE, JUNE) of a health-care insurance CEO is $15 care pays physicians at relatively lower million annually.) I say we take all this rates than commercial insurers. Don’t rush to adopt money and use it to pay for health A single-payer system will create UK screening algorithm care so that all of the uninsured can an insurance monopoly. An insurance for ovarian cancer be covered. Simply gather money monopoly will likely result in a reduc- Dr. Kaunitz posits that ovarian can- from taxpayers and pay it out to hos- tion in physician reimbursement. If a cer screening may be eff ective in pitals and doctors so that they can single-payer system were associated postmenopausal women—but even take care of everyone—especially the with a 30% reduction in physician that equivocation may be too strong 10% of the population that uses 70% reimbursement rates, would US phy- an endorsement of the practice. Al- of health-care services. Now that’s an sicians support the new insurance though the UK study he mentions eff ective means of insurance! monopoly? was large and very well designed, the Th e single-payer system is the As Dr. Maizels’ question suggests, algorithm it employed is not neces- only system that has a chance of rec- it is very diffi cult to precisely count the sarily applicable to US practice. tifying our corrupt system, and a ma- number of people without insurance Th e multimodal screening algo- jority of doctors and the American residing in the United States. Th e US rithm required the 4,315 women who public already recognize that fact. Census Bureau attempts to provide had an initial abnormal CA-125 level George C. Denniston, MD, MPH estimates of various key population to wait 12 weeks before the screen Seattle, Wash statistics, including insured and unin- was repeated. When it was, 1,008 sured US residents, on an annual basis. women had abnormal results again Its report is available at www.census. and had to wait another 12 weeks for Seeking clarifi cation gov (click on “Health Insurance”). Th e a third screen. Th is waiting period is What is the source of the 48 million report is based on a survey sample with critical because it is the constant rise fi gure cited in the headline of Dr. statistical extrapolation to the entire in CA 125, rather than the absolute Barbieri’s editorial? It was given as US population. value of the marker, that is associ- the number of people who do not How to treat migrant US residents ated with ovarian cancer. have health insurance, but was not for the purposes of this population sur- Ninety-six women in the UK referenced in the article. vey is controversial. Some authorities trial were deemed to be at interme- Does that number include ille- recommend counting all US residents, diate risk of ovarian cancer and un- gal aliens and non-US citizens? regardless of their status, because they derwent ultrasonography 6 weeks Max Maizels, MD are likely to seek health care in the later, approximately 7 months after Richmond, Va United States if they become sick. Other the fi rst abnormal blood test. Of the authorities would prefer to exclude 97 women in the study who under- ›› Dr. Barbieri responds: migrants who are in the United States went surgery, 42 had ovarian or tubal Single-payer system would without proper documents from the es- malignancy, but only 16 were early- create a monopoly timate of uninsured residents. stage (I/II). Th erefore, six I agree with Dr. Denniston that the Almost everyone agrees that the were performed to detect each case health-insurance administrative bu- number of uninsured US residents is of early ovarian cancer, and early in- reaucracy creates unnecessary waste. very high, whether it is 40 million, 45 tervention should have made a dif- Many commercial insurance compa- million, or 50 million. Interestingly, ference in survival. However, within nies have excessively high overhead based on the census surveys performed a year of screening, four additional and pay their executives outsized com- from 1992 to 2007, the percentage of women developed ovarian cancer pensation packages. Th ese wasted re- uninsured US residents has remained (false negatives). sources could be better used to provide steady at about 15% of the population. Surgery is not without risk in health care. Clearly, we have a big problem, postmenopausal women; indeed, In contrast, Medicare, one of the and it is going to be very diffi cult to 3% of women in the UK study suf- largest insurers in the United States, solve. fered major complications, including

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pulmonary embolus, deep venous 4 steps that one that is prescribed for 4 weeks we can take to end the thrombosis, hemorrhage, wound malpractice of treatment. Over 15 years, I have crisis

UPDATE ON MENOPAUSE dehiscence, perforation of a viscus, • Preserve the treated and essentially cured 55 pa- at hysterectomy • For many women, bowel obstruction, and bowel fi stula. it’s HT + CAM tients, though I have only followed • Denosumab: Novel bone antiresorptive Ovarian cancer is a terrible dis- A DOWDEN PUBLICATION | VOL 21, NO 5 | MAY 2009 | WWW.OBGMANAGEMENT.COM them for as long as 5 years. It is pos- ease, and we sorely need to fi nd an Vestibulitis and sible that symptoms may recur after eff ective method of early detection. 10 years or longer. But recent evidence suggests that Simple strategies My concern now is that the com- some serous “ovarian” cancers may for 2 common pany that has produced Alferon-N conditions

“An easy question will help originate in the distal tube and are, you diagnose vestibulitis” no longer does so. I’m looking into a obgmanagement.com therefore, at an advanced stage at similar interferon known as Intron, Is ablation or hysterectomy the outset and undetectable at an best for your AUB patient? which is also used for condyloma, as First, remove the guesswork Collect a healthy $ reward early stage using current screening for using EHR well as for various types of cancer and 4 underused tools for better modalities. drug therapy hepatitis. I’m not sure whether I want

EDITORIAL More proof: Circumcision works Th e bottom line, as the authors Take the Instant Poll at to try a new medication, especially at Who should perform it? obgmanagement.com

of the UK study and Dr. Kaunitz all Follow us on Facebook and Twitter dosages that may not be equivalent, acknowledge, is that it is too early but I would like to continue treating 0C1_r1_OBGM0509 0C1 MAY 4/20/092009 9:53:30 AM to tell whether this screening algo- this problem. Why? Because it is re- rithm will have a signifi cant impact warding to off er the patient a pain- on mortality. In the UK study, the with its emphasis on vestibulectomy free life, with complete resolution of cost-eff ectiveness of screening and and its assumption that interferon her symptoms. the psychosocial eff ects on partici- provides only moderate relief. Richard G. Hofmann, MD pants during the prolonged waiting I’ve treated vulvar vestibulitis Carthage, NY periods are still being evaluated, for 15 years and have used alpha-in- and are likely to be signifi cant is- terferon (Alferon-N) with excellent sues. Before we rush to reintroduce results. When I fi rst began managing “ INSIDE THE STIMULUS PACKAGE: CASH FOR USING ELECTRONIC routine CA-125 testing, which so far this disorder, it was poorly under- HEALTH RECORDS” has done more harm than good, we stood, and it took me a year or two G. WILLIAM BATES, MD, MBA (MAY) should understand that the complex to determine the best approach. I UK study algorithm cannot be ab- eventually concluded that vestibulitis Electronic health records breviated or we will submit many is caused by the human papillomavi- can pay for themselves women to unnecessary surgery. rus (HPV), though that link has not I agree completely with Dr. Bates’ ar- Until the complete analysis is avail- been proved defi nitively. However, it gument for electronic health records able, avoiding CA-125 screening is seems likely to me that a nonpatho- (EHR). I am a software developer prudent. logic subspecies of HPV causes this and provider of billing services, using William H. Parker, MD condition. Accordingly, I began pre- my own PMS software, and I know a John Wayne Cancer Institute at scribing alpha-interferon, following good deal about “real-world” experi- Saint John’s Medical Center the regimen for condyloma. I noticed ence. Dr. Bates is right: With an EHR Santa Monica, Calif that each patient began to improve af- in place, two important things can ter 5 or 6 weeks of treatment, and was and should happen:

“ A PRACTICAL APPROACH TO symptom-free by the end of 8 weeks. 1. You can see one or two more VESTIBULITIS AND VULVODYNIA” Most specialists treat the ves- patients each day. DAVID SOPER, MD (MAY) tibulitis patient with interferon for 2. If you will upgrade 20% of your 4 weeks. I have always treated the 99213 codes to 99214, based on what Surgery is not the only patient for 8 weeks, as it is only af- you did for the patient—and docu- effective treatment for ter 5 or 6 weeks that her symptoms mented—you can generate more vestibulitis begin to resolve. Th is improvement than enough “brand-new” revenue to I thought Dr. Soper’s article repre- is not dependent on the dosage of pay for virtually any EHR system. sented the typical, surgically orient- interferon, though I prescribe a dos- J.S. McMillan ed approach to vulvar vestibulitis, age that is markedly lower than the St. Louis, Mo

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Does the stimulus offer CCHIT suspended certifi cation for Prompt presentation can alleviate the extend to practices with 2009, awaiting defi nition of the term. 11th-hour crisis that often leads to di- existing EHR? Vendors expect the certifi cation pro- sastrous outcomes. Th e article on the stimulus pack- cess that qualifi es a practice to receive Once preeclampsia is diag- age prompts a question. Does this stimulus funds to begin in early 2010. nosed—or indications are that the cash allotment for using electronic case is moving in that direction—pa- health records extend to practices tient education becomes more criti- that are already fully functional and “ PREECLAMPSIA AND ECLAMPSIA: cal. In fact, it is often requested by using a Certifi cation Commission 7 MANAGEMENT CHALLENGES the patient and her family. Th e Pre- (AND ZERO SHORTCUTS)” for Health-care Information Tech- JOHN T. REPKE, MD, AND eclampsia Foundation can help phy- nology (CCHIT) certifi cation? We BAHA M. SIBAI, MD (APRIL) sicians bridge the gap in knowledge; have been using electronic records we provide not only credible infor- for 6 years. Is there a form or appli- Don’t overlook mation in print and online, but also cation we should be completing? the importance of patient comfort and support during an often Shelly Murphy education in preeclampsia anxious and trying time. Carson City, Mich It was great to read such a thorough Eleni Tsigas article on preeclampsia and eclamp- Executive Director Preeclampsia Foundation ›› Dr. Bates responds: sia. Th is subject is often relegated to www.preeclampsia.org Some aspects of stimulus are the “we don’t know much about it so still being determined why bother discussing it” category, I thank Mr. McMillan for his affi rma- which is clearly a problem consid- ›› Dr. Repke and Dr. Sibai respond: tion of the value of electronic health ering preeclampsia’s relatively high Signs and symptoms of records—independent of any external prevalence and sometimes disas- preeclampsia may be protean stimulus funds. Physicians should ex- trous outcomes. We are pleased to acknowledge Ms. pect a three-time return on investment Dr. Repke and Dr. Sibai (who are Tsigas’ important point about patient within 12 to 15 months of implementing both members of our Medical Board) education. Although our article was an EHR. did an excellent job of off ering a thor- written for a physician audience, pa- Ms. Murphy asks if the stimulus ough evaluation of some of the key tient (and physician) education about package (American Recovery and Re- challenges and underscoring the un- the sometimes-subtle signs of pre- investment Act) money will be avail- predictability of these disorders. Th e eclampsia is extremely important, es- able to practices that began using EHR one critical piece missing from their pecially in very high-risk individuals. before 2010. I don’t have an answer, recommendations is patient educa- We also agree that patient educa- but it would seem unfair for practices tion, which is especially important be- tion is a very important part of post- that took the initial plunge to be penal- cause diagnosis is sometimes diffi cult diagnosis management, as patients ized because they were early adopters. and maternal and fetal health can go are often confused by how well they I do know that current vendor south so quickly. Our research—and feel (in mild cases). A better under- CCHIT certifi cation (2008) is not suf- that of others—has shown that most standing of the potential severity and fi cient to qualify a practice for stimu- patients are not routinely and consis- swift progression of this disease can lus funds. Despite the marketing hype tently informed about the signs and aid in maintaining compliance with a of several vendors, none is certifi ed symptoms—information that is criti- management strategy and elicit earlier today with the “meaningful-use cri- cal to their understanding of when to reporting of signs or symptoms that teria” designated in the legislation. call or see their health-care providers. might suggest worsening of disease.

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