Nonphysician Clinicians

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Midwifery

July 2, 2010 in Nonphysician Clinicians | 11 comments

I recently watched a video advocating for increased use of midwives during births.  There is little doubt that using a midwife reduces costs.  In addition, many studies have shown that home births with midwives have comparable health outcomes to those in the hospital setting.  In fact, even births using non-nurse midwives have  health outcomes similar or better to when a doctor is involved.

What was surprising about the video was the following observation: 33.7% of Massachusetts births in 2007 were caesarean sections.

Why are there many caesareans?  Dr. Gene Declerq claims the reason is the cascade of intervention.  Dr. Declerq defines this term using the following scenario: “…they come in and they’re relative low risk, but to be cautious, they put a fetal monitor on them…because things do not appear to be going as quickly as they would like, they induce them or stimulate the labor.  And then because the contractions–as a result of the induction–become very strong, they have to do an epidural to try to relieve the pain from those now stronger  than natural contractions…that may slow labor a little further and then they have to keep adding intervention upon intervention to the point where at the end, somebody says ‘we’re going to do a Caesarean.  Thank god we’re able to do the Caesarean’ whereas if they hadn’t start that series of interventions in the first place, we may have never gotten to that point.”

An economist would simply claim that physicians do Caesareans because they are revenue enhancers.

Why aren’t midwives more popular?  Couldn’t midwives be the first option and only if there are problems would the patient be transferred to the hospital?  One reason is that obstetricians want to protect their turf.  Having midwives perform more births will not only take a large chunk of the birth market share, it may also drive down price.

Economists may to often run to the conclusion that financial incentives are the sole driving factor motivating human behavior.  In this case, however, one cannot help but arrive at the conclusion that hospitals and physicians have made giving birth a high-cost, high utilization process to increase their revenue.

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“The country’s dismal rates of vaginal birth after Caesarean”

March 9, 2010 in Nonphysician Clinicians, Physician Compensation | No comments

From the N.Y. Times:

The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.

In fact, the rate of vaginal birth after Caesarean (VBAC) is now below 10%.  Some doctors claim that VBACs risk tearing the mother’s scar tissue on her uterus, but others–including the profiled women on a Navajo reservation–successfully undergo multiple VBACs.  Why are the rates VBAC rates so low?

  • Fears of malpractice
  • Physicians make more money Caesarean rather than a vaginal birth
  • Caesarean’s use fewer physician hours than vaginal births
  • Fewer expected number of pregnancies
  • Patient demand

Why are Caesarean rates so much lower on the Navajo reservation?  On the reservation, physicians are federally insured against malpractice, are paid a salary, and the use of midwives is much more common.  Additionally, Navajo “couples often want more than two children, but repeated Caesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery.”

To see further evidence of how different physician compensation methods can alter surgery rates, see my own study in Health Economics.

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Why does Acupuncture Work?

May 12, 2009 in Nonphysician Clinicians | No comments

A recent study found that “Acupuncture is an effective treatment for chronic back pain. People receiving acupuncture are more likely to get better.”

How does it work? The treatment’s placebo effect explains the study’s findings. Researchers found that acupuncture was effective whether or not the skin was punctured.

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Your Grocery Bag: Apples, Milk…and Cavity Filling?

September 17, 2008 in Current Events, Nonphysician Clinicians, Supply of Medical Services

In the UK, a dental clinic has opened in a Sainsbury’s grocery store.  The grocery store dental clinics aim to fill a patient need caused by the shortage of dentists in the UK.   BBC News reports,

“Dentist Lance Knight said the practice aimed at “making dental healthcare more accessible and convenient to better meet patients’ needs.”

The private surgery will go head to head with the NHS, charging £16 for a check up, which is slightly less than NHS fees.”

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Who goes to retail health care clinics?

September 15, 2008 in Nonphysician Clinicians, Supply of Medical Services

The Carpe Diem looks at who is going to retail health care clinics.

“Roughly 90% of the patients came for one of 10 relatively simple treatments… ‘Most of the conditions cared for in retail clinics likely do not require the level of training of a physician.’”

Insurance companies are starting to support these retail health clinics.  Insurance paid for 67% of visits.

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Insurers to cover retail clinic visits

July 28, 2008 in Health Insurance, Nonphysician Clinicians

The Boston Globe reports that some of Massachusetts largest insurers are beginning to cover medical visits made at retail clinics at CVS and Walgreens drug stores.  Blue Cross/Blue Shield of Minnesota is waiving copays for visits to retail clinics.  The American Association of Family Physicians (AAFP) is not happy about this.

Carpe Diem says the AAFP’s resistance to accept retail clinics can be understood follows: “The family doc cartel is worried about increased competition.”

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Adults need vaccines too

July 14, 2008 in Nonphysician Clinicians, Vaccinations

Most people believe that vaccines are for kids. The CDC and public health departments have done a good job of keeping vaccination rates high for children. With the advent of new vaccines for adults, the key now is to increase vaccination rates for these older groups.

The Wall Street Journal (“Get your shots“) details a few of the vaccines that adults should receive.

Vaccine Cost Age and dosage
Tetanus/diphtheria/whooping cough $65 19-64 years old, one dose.
Tetanus booster $45 All adults over 19, every 10 years.
Measles/Mumps/rubella $50-$65 19 to 49, one or two doses if not previously vaccinated or infected.
Shingles $220 Over 60, one dose.
Pneumonia $45 19-64, one or two doses when risk of disease is present. One dose after age 65
Influenza $20-$30 19-49, one dose/yr for high risk group. Over 50, one dose/yr

Not included in the list is the HPV vaccine against cervical cancer.

Another point of interest is that it is increasingly difficult for physicians to supply vaccines to patients. With so many vaccines, the logistics of ordering all these perishable vaccines is very difficult. Further, as vaccines costs have increased, physicians will have to invest more and more capital into vaccine inventory.

For this reason, alternative providers such as pharmacies may a solution. With a vast experience in storage of drugs and supply chain management, pharmacies can easily absorbed the increased adult vaccine demand.

In the Wall Street Journal article, we have the following story:

The doctor didn’t have the shingles vaccine in stock, and recommended they try a walk-in clinic at a nearby drugstore, where the nurse practitioner provided a two-page handout on the vaccine and answered some of their questions. Though the price was about $219 each, all but $40 was covered by their drug benefit plan.

The next time you get a shot, it may be at your local CVS or Walgreens and not at the doctor’s office.

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Immigrants reduce health care costs?

March 26, 2008 in Nonphysician Clinicians, Physician Compensation, Supply of Medical Services

David Williams of the Health Business Blog reviews an article from the Boston Globe (“Immigrants…“)  stating that immigrants reduce the cost of health care.  How can this be with so many immigrants relying on government programs and free clinics to receive their care?

While it is true that immigrants are consumers of medical care, they are also producers as well.  A study of the health care workforce in Massachusetts finds that 40% of pharmacists, 28% of physician assistants, 22% of opticians, 21% of licensed practical and vocational nurses, 17% of dentists and 14% of paramedics are foreign born workers.  Twenty-eight percent of physicians and surgeons are foreign born.

An increased supply of health care workers from foreign countries can help decrease labor costs for medical care.

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Minute Clinics come to San Diego

November 8, 2007 in Nonphysician Clinicians

Looks like the convenience clinic trend is coming to my neck of the woods in Southern California.  According to the San Diego Union-Tribune (“Are retail clinics a healthy choice?“) six Minute Clinics are opening in San Diego county with ten more on the way before year’s end.

These clinics likely will lower the cost of obtaining a flu shot.  Not only will providing the flu shot be less expensive for the provider, the patient will have fewer time costs waiting for a doctor or driving to an inconvenient physician location.  These clinics are likely just as safe as a physician’s office if the patient is healthy.  However, if a patient has multiple diseases and needs a more in depth check-up, these convenience clinics will be poor substitutes in terms of quality.  There is always a tradeoff.

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Midwifery-Promoting Public Policies and Health Outcomes

October 16, 2007 in Nonphysician Clinicians

Many health care policy researchers believe that non-physician clinicians, such as physician assistants, nurse practitioners and midwives can help to reduce cost while maintaining quality. Midwifery has gained in popularity over recent years. Groups such as the American Public Health Association, Public Citizen and the National Organization for Women all support increased access to midwifery care.

The question remains whether or not midwife care during pregnancy is inferior, equivalent, or superior to physician care. Amalia R. Miller attempts to answer this question in her 2006 B.E. Press paper.

Differences between midwives and physicians

  • Skills: Physicians receive an MD while midwife training is comparable to a nursing background. Only physicians can preform surgery such as a cesarean delivery.
  • Financial Incentives: Physicians have a financial incentive to recommend cesareans since they will reap the financial rewards of preforming the surgery. Since midwives do not receive any compensation from surgery, they may be more likely to look out for the best interest of the patient.
  • Attitude toward childbirth: The midwifery model of care views birth as a natural process and gives the mother more input towards shaping the birth experience. The physician’s medial approach “…highlights the risks of childbirth, viewing the event as inherently medical, even pathological, requiring hospital admission and technological intervention.”

Quality

One problem with measuring the quality of care received by those who use midwives is that of selection bias. For instance, healthy women may be more likely to use a midwife. Pregnant women with serious complications will be more likely to use physicians. Thus, a researcher may erroneously conclude that pregnant women treated by physicians are more likely to have cesareans, when a more appropriate conclusion would be that physicians treat a less healthy patient base and thus preform more cesareans.

The best study preformed to date is a Chambliss et al. (1992) paper. The authors conducted “[a] randomized blinded clinical trial was conducted in which 492 low-risk patients were assigned to either physician or midwifery management.” Unlike most non-randomized trials, the authors found a small positive relationship between midwifery and cesarean rates.

Methods

The Miller (2006) paper looks at how midwifery affects cesarean rates. They use 1989-1999 Natality Detail Files as well as the 1989-1999 March Current Population Surveys (CPS) as her data source. The author considers a simple OLS regression using cesarean rates as the dependent variable and the use of midwifery–along with other covariates–as the independent variables. The problem of selection bias remains.

Thus, the authors use the enactment of Any Willing Provider laws as a proxy for state-wide midwifery usage. These laws “prohibit discrimination against a class of providers.” While Any Willing Provider laws are not directly related to midwives, the authors also use specific state midwifery reimbursement laws to proxy for midwifery usage. The claim made by Ms. Miller is that these laws are exogenously enacted; this creates a natural experiment and allows a difference-in-difference regression.

Results

Ms. Miller finds that midwifery reimbursement laws, unsurprisingly, do increase midwifery usage by pregnant women but more general Any Willing Provider laws do not alter midwifery usage rates. The authors continues to state that “…The main finding of the Chambliss et al. (1992) study is confirmed: there is no evidence that the expansion of midwifery led to a reduction in cesarean section rates. Hence, the results from the small randomized trial appear to generalize to the population at large, while the non-random trials likely suffered from selection bias due to inadequate controls for patient health and preferences. ”

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