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Message from the chair: Proposed changes to MICRA

Dr. Laurie C. GreggLaurie C. Gregg, MD

What would medicine in California be like if a patient with health insurance had great difficulty finding an obstetrician to take care of a high-risk pregnancy or a neurosurgeon to resect a potentially malignant brain tumor? How would our system, especially emergency rooms, handle the flood of patients if community clinics were to close? Would you, as a physician, move out of state or retire early if your liability coverage premiums doubled?

Unfortunately, we may have to investigate answers to these perplexing questions. On July 26, a ballot measure to change the Medical Injury Compensation Reform Act (MICRA), raising the noneconomic damages cap from $250,000 to $1.2 million with a mandated cost of living adjustment each year, was filed for November 2014.

Our district will be working closely with Californians Allied for Patient Protection (CAPP) to educate the public on the potential harms of such an initiative. According to CAPP, filing a ballot measure with the attorney general is the first step in a long and expensive process to qualify a measure for the ballot.

Patients need to know that this proposal is almost certainly going to limit their access to important medical care. California is already facing a shortage of doctors, and health care reform will undoubtedly bring many more insured patients into our system. If MICRA is changed, doctors may consider leaving California or retiring early from medicine. Patients could suffer with longer emergency room waits and less access to their physicians.

A higher limit on noneconomic damages will tax the medical and legal systems with potentially meritless lawsuits from an increasing number of patients seeking compensation for adverse outcomes associated with presumed negligence. This issue is one reason the Civil Justice Association of California, a coalition dedicated to improving California’s civil justice system, criticizes the initiative.  

Some say that raising the noneconomic damages cap will motivate medicine to be safer. However, since MICRA has been in place, District IX has been exceptionally productive in the arena of patient safety and quality improvement. Rather than encouraging continued productivity, the initiative will likely increase the cost of medical care as doctors practice more defensive medicine.

A nonpartisan legislative analyst estimated that increasing the cap from $250,000 to $500,000 would raise health care costs in California by at least $9.5 billion annually. If that cost is passed on to consumers, it would mean $1,000 more per year for a family of four. Imagine what those numbers would be if the cap were raised to $1.2 million and allowed to increase each year.

In the midst of health care reform, there couldn’t be a worse time for such an initiative. Our district, in partnership with CAPP, the California Medical Association, and many others will fight to keep medical care intact in California. If you would like to help, please contact Michelle Clark, District IX manager, at mclark@acog.org or Shannon Smith-Crowley, JD, MHA, District IX director of government relations, at shannon@partnersadvocacy.com.

 

California Prenatal Screening Program to include noninvasive testing

Monica Flessel   Sara Goldman     

Monica Flessel, PhD, and Sara Goldman, MPH, Genetic Disease Screening Program, California Department of Public Health

The California Department of Public Health’s Prenatal Screening Program (PNS) will begin incorporating noninvasive prenatal testing (NIPT) by November 2013. Noninvasive prenatal testing uses cell-free fetal DNA from the plasma of pregnant women and offers tremendous potential as a screening tool for fetal aneuploidy.

PNS currently offers three types of screening tests to pregnant women to identify individuals who are at increased risk for carrying a fetus with a specific birth defect: quad marker screening, serum integrated screening, and sequential integrated screening, which includes a first-trimester preliminary risk assessment for Down syndrome and trisomy 18 if a nuchal translucency ultrasound is performed.

If a maternal serum screening test result is reported as screen positive, indicating an elevated risk for a chromosomal anomaly or birth defect, genetic counseling and other follow-up services are provided free of charge at state-approved prenatal diagnosis centers (PDCs). 

PNS plans to offer NIPT through PDCs as an option for all women who screen positive for Down syndrome, trisomy 18, or a large nuchal translucency measurement following biochemical screening. These women will also retain the option of proceeding directly to a diagnostic test, such as chorionic villus sampling or amniocentesis. If an NIPT result is negative, no diagnostic tests or further follow-up services will be authorized. Women with a negative NIPT result in the first trimester will remain eligible for biochemical serum screening in the second trimester, with all analyte values reported. However, only a risk assessment for neural tube defects (NTDs) and Smith-Lemli-Opitz syndrome (SLOS) will be reported.   

Women with a positive NIPT result will be authorized to receive confirmatory diagnostic tests and other follow-up services. They will also remain eligible for biochemical serum screening in the second trimester for a risk assessment for NTDs and SLOS. Women who are drawn for NIPT outside of PNS will not be eligible for PDC follow-up services through the program.

Changes planned for September 2013
Fetuses with a large nuchal translucency measurement (greater than or equal to 3.5 mm) are reported to have more than a 20% risk for a chromosomal abnormality. These fetuses are also at risk for congenital heart defects. ACOG guidelines recommend a targeted ultrasound, fetal echocardiogram, or both for patients with a large nuchal translucency measurement. The inclusion of fetal echocardiogram for patients with a large nuchal translucency measurement has been problematic for PNS. Not all PDCs have offered this service, and the timeframe for a fetal echocardiogram makes these cases difficult for PNS and PDC staff to track.

As of September 2013, PNS no longer authorizes a fetal echocardiogram for patients with a large nuchal translucency measurement. These patients need to be referred to pediatric cardiologists using their own insurance.

In addition, PNS no longer reimburses patients for amniotic fluid alpha-fetoprotein and acetylcholinesterase analysis, unless the PNS result indicates an increased risk for NTDs. For patients who screen negative for NTDs, almost 99% have negative alpha-fetoprotein and acetylcholinesterase results following amniocentesis, including the majority of NTD cases for this group, which are identified primarily by ultrasound findings.

 

2013 District IX Resident Lobby Day

Dr. Laura L. SirottLaura L. Sirott, MD, District IX secretary

District IX held its 2013 Resident Lobby Day on May 22. Forty-six residents from 13 training programs throughout the state participated in the event, with eight additional team leaders. The teams completed 40 appointments with legislators and their staff members.

The day was filled with role-playing exercises and presentations on lobbying and how ACOG works with and in comparison to the California Medical Association. Residents focused on four bills, which were highlighted in talks by Laurie C. Gregg, MD, District IX chair; Susan D. Crowe, MD; and Shannon Smith-Crowley, JD, MHA, District IX director of government relations.

Assembly Bill 1308 requires the California Medical Board, by July 1, 2015, to revise and adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery and identifying complications necessitating referral to a physician. Senate Bill 402 improves breastfeeding policies in hospitals. Assembly Bill 900 and Senate Bill 460 reverse implementation of cuts to Medi-Cal provider rates. Our teams received great responses in their meetings and successfully spread our messages. 

       Resident Lobby Day
 

2013 District IX Resident Lobby Day participants 

 

 

Dr. Gregg, Ms. Smith-Crowley, and I presented Assemblymember Toni Atkins (D-San Diego) with an Award of Accomplishment on behalf of District IX for the bill she authored last year to limit the shackling of incarcerated pregnant women. District IX was recognized for its outstanding efforts on this bill at the 2013 ACOG Congressional Leadership Conference, The President’s Conference, in March.

Thank you to everyone who contributed to this great day of lobbying for the women and physicians District IX represents. Special thanks go to all the attending physicians who covered for residents so they could attend. I hope to see everyone again next year! The tentative date for the 2014 Resident Lobby Day is May 21. For more details, contact Michelle Clark, District IX manager, at mclark@acog.org.

  

District IX Committee on Physician Work-Life Balance promotes mindfulness

Dr. Joanne L. PerronJoanne L. Perron, MD, committee co-chair

The District IX Committee on Physician Work-Life Balance is composed of 12 members and is co-chaired by Robert J. Wallace, MD, and me.

The committee’s mission is to further ACOG’s goal of providing quality care to patients by actively promoting physician wellness in mind, body, and spirit, realizing that a healthy and happy physician serves as a role model and provides higher quality care to patients.

Past areas of focus have been on stress management, nutritional awareness and healthy eating, promotion of physical activity, and coping with litigation concerns. Currently, our area of focus is on the promotion of physician mindfulness to reduce stress and burnout and to enhance patient safety.

Mindfulness is the self-regulation of attention using curiosity, openness, and acceptance. It has been shown to improve working memory, cognitive flexibility, and focus, as well as diminish emotional reactivity. Mindfulness is the opposite of multitasking, which is often associated with medical errors.

The authors of a recent Journal of the American Medical Association article found diagnostic errors to be a direct result of knee-jerk responses and failures to recognize situations for what they truly are. In other words, cognitive bias leads to diagnostic error. The authors recommend the practice of mindfulness to reduce these types of errors and improve physician well-being.

Some experts believe that physician wellness should be included as a quality indicator. Research has shown that physicians who participated in an intensive mindfulness program demonstrated improvement in well-being and capacity for patient-centered care. According to an anonymous American College of Surgeons survey published in 2010, the presence of burnout (ie, emotional exhaustion, depersonalization, and diminished sense of personal accomplishment) is associated with increased surgical errors regardless of personal or professional circumstances.

In a recent Medscape survey, more female physicians reported burnout (45%) than male physicians (37%). The survey also found the rate of burnout to be highest among those in midlife (ages 46 to 55) and that ob-gyns ranked fourth highest in burnout of the 24 medical specialties surveyed.

Our committee believes that if physicians are given tools to understand, access, and practice mindfulness, then patient safety and physician wellness will be markedly improved. To further this goal, we have already scheduled Shauna L. Shapiro, PhD, associate professor of counseling psychology at Santa Clara University and an internationally recognized expert in mindfulness, to speak at the 2014 Annual District Meeting in Napa, CA.

In the meantime, visit the District IX Committee on Physician Work-Life Balance website for tips and updates on committee activities. I’ll also be leading sunrise yoga classes at the 2013 ADM in Maui. I hope to see you there!

  

Protect vulnerable infants from pertussis: Immunize mothers with Tdap during every pregnancy

Immunization Branch, California Department of Public Health

Pertussis is a continuing threat to Californians, though the magnitude of the threat varies by year as the number of susceptible people in the population waxes and wanes. More than 9,100 cases of pertussis were reported in California during 2010, the most in more than a half-century. Consistent with historical cycles of three to five years between years of higher incidence, cases are likely to increase between 2013 and 2015 in comparison to 2011 and 2012.

Young infants at highest risk of severe pertussis
Infants younger than two months are most susceptible to hospitalization or death from pertussis, but immunization against pertussis is not recommended until at least six weeks of age. However, infants can be protected by maternal antibodies that are transferred through the placenta. Early evidence suggests that vaccinating pregnant women with Tdap during the third trimester of pregnancy can prevent pertussis in young infants. 

Optimal timing of maternal Tdap administration
To maximize protection of young infants, the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommends that all women be given Tdap during every pregnancy, regardless of previous Tdap status, preferably between 27 and 36 weeks’ gestation. This recommendation is based on the following information:

  • Women immunized with Tdap during a prior pregnancy or during the first or second trimester of a current pregnancy appear to have low levels of pertussis antibodies at delivery
  • Transplacental transport of antibodies occurs mainly after 30 weeks’ gestation
  • At least two weeks are needed for a maximal response to immunization

If Tdap is not administered during pregnancy, it should be given immediately postpartum. This vaccination will not provide direct protection to the infant, but it may prevent transmission of pertussis from mother to infant. 

Other close contacts
Everyone (eg, parents, siblings, grandparents, child care providers, and health care personnel) who anticipates close contact with an infant younger than 12 months should receive Tdap if they have not already done so. ACIP is currently considering whether Tdap boosters are indicated for contacts of infants.

More information
Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination,” ACOG Committee Opinion #566, June 2013
ACIP Updated Recommendations for Use of Tdap in Pregnant Women
California Department of Public Health pertussis summary reports 
Importance of timing of maternal Tdap immunization and protection of young infants,” Clinical Infectious Diseases, February 15, 2013
Pertussis information for Ob-Gyns