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Redesigning Maternal Care: OB-GYNs Are Urged to See New Mothers Sooner and More Often


By Nina Martin, ProPublica

This story was co-published with NPR.

Doctors would see new mothers sooner and more frequently, and insurers would cover the increased visits, under sweeping new recommendations from the organization that sets standards of care for obstetrician-gynecologists in the U.S.

The 11-page “committee opinion” on “Optimizing Postpartum Care,” released today by the American College of Obstetricians and Gynecologists, represents a fundamental reimagining of how providers, insurers and patients can work together to improve care for women after giving birth. “To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs,” the committee opinion states.

While an ACOG task force began rethinking its approach several years ago, the guidelines arrive at a moment of mounting concern about rising rates of pregnancy-related deaths and near-deaths in the U.S. As ProPublica and NPRhave reported, more than 700 women die every year in this country from causes related to pregnancy and childbirth andmore than 50,000 suffer life-threatening complications, among the worst records for maternal health in the industrialized world. The death rate for black mothers is three to four times that of white women.

The days and weeks after childbirth can be a time of particular vulnerability for new moms, with physical and emotional risks that include pain and infection, hypertension and stroke, heart problems, blood clots, anxiety and depression. More than half of maternal deaths occur after the baby is born, according to a new CDC Foundation report.

Yet for many women in the U.S., the ACOG committee opinion notes, the postpartum period is “devoid of formal or infor­mal maternal support.” This reflects a troubling tendency in the medical system — and throughout American society — to focus on the health and safety of the fetus or baby more than that of the mother. “The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”

The way that providers currently care for pregnant women and infants versus new mothers exemplifies this difference. During the prenatal period, a woman may see her OB-GYN a dozen or more times, including at least two checkups during her ninth month. Her baby’s first pediatric visit usually occurs a few days after birth. But the mother may not have a follow-up appointment with her own doctor until four to six weeks after delivery — and in many cases, insurance only covers one visit. “As soon as that baby comes out, [the mom] is kind of an afterthought,” said Tamika Auguste, associate medical director of the MedStar Health Simulation Training & Education Lab in Washington, D.C., and a co-author of the ACOG opinion.

For working mothers, having to wait four to six weeks makes it harder to arrange a check-up.

Some 23 percent of mothers employed outside the home are back on the job within 10 days of giving birth, a 2014 report for the U.S. Department of Labor found; another 22 percent return to work within 40 days. Lack of childcare and transportation can also present significant hurdles to accessing care. According to ACOG, as many as 40 percent of women skip their postpartum visit; for low-income women of color, the rates are even higher.

“You may have a woman that has asthma, is having problems lactating, and is obese, and when they come to see you at six weeks, we have missed the boat here,” Auguste said.

Nor is a single visit enough time to address a new mother’s questions and concerns, especially if she had a complicated pregnancy or is suffering from chronic conditions such as hypertension, diabetes or a mood disorder. “We’re trying to address all of the issues that women are dealing with after having a baby in one 20-minute encounter,” Stuebe said. “And that’s really hard to do.”

Under the new ACOG guidelines, women would see their providers much earlier — from within three days postpartum if they have suffered from severe hypertension to no later than three weeks if their pregnancies and deliveries were normal— and would return as often as needed. Depending on a woman’s symptoms and history, the final postpartum visit could take place as late as 12 weeks after delivery and ideally would include “a full assessment of physical, social, and psychological well-being,” from pain to weight loss to sexuality to management of chronic diseases, ACOG says.

In another significant change, ACOG is urging providers to emphasize in conversations with patients the long-term health risks associated with pregnancy complications such as preterm delivery, preeclampsia and gestational diabetes. “These risk factors are emerging as an important predictor of future [cardiovascular disease],” the recommendations state. “ … [B]ut because these conditions often resolve postpartum, the increased cardiovascular disease risk is not consistently communicated to women.”

Earlier, more frequent and more individualized care could be a step toward addressing the stark racial disparities in maternal and infant health, said ACOG’s outgoing president,Haywood Brown, who has made reforming postpartum care one of the main initiatives of his term. Black mothers are at higher risk for many childbirth complications, includingpreeclampsia, heart failure and blood clots, and they’re more likely to suffer long-lasting health consequences. They also have higher rates of postpartum depression but are less likely to receive treatment. Regardless of race, for women whose pregnancies are covered by Medicaid, the postpartum period may be their best opportunity to get help with chronic conditions before they lose insurance coverage.

The new guidelines urge doctors to take a proactive approach, helping patients develop a postpartum care plan while still pregnant, including a team of family and friends to provide social and other support. According to ACOG, one in four new mothers surveyed recently said they didn’t even have a phone number of a health care provider to contact with concerns about themselves or their babies.

ACOG isn’t the only organization calling for a reinvention of postpartum care; patient-safety groups, researchers, nursesand midwives have also tackled the issue, recasting the three months after birth as akin to a “fourth trimester.”

“The postpartum period has become a priority,” said Debra Bingham, a professor of nursing at the University of Maryland and executive director of the Institute for Perinatal Quality Improvement who has participated in many of these initiatives.

Some providers, including Brown, who is affiliated with Duke University, are already incorporating some of ACOG’s ideas. Still, putting the reforms into common practice may take years. One of the biggest impediments is insurance reimbursement. Currently, payment for prenatal care, delivery and a single post-birth visit is bundled together into one global fee, creating a disincentive for doctors to see patients more than once, Auguste said.

The disincentives are greater for women on Medicaid, which pays for about half of U.S. births. What’s more, in many states Medicaid coverage ends at two months postpartum. The ACOG opinion didn’t estimate the cost of implementing its recommendations.

Brown agreed that revamping how postpartum care is reimbursed is critical, and insurance representatives — along with members of other medical specialties — were on the ACOG task force that drafted the new guidelines. “I want to make sure that I get some employee health plans and some health systems to adopt this nationally,” Brown said.

Indeed, although the guidelines are aimed at OB-GYNs, they would require changes throughout the maternal care system. That’s what ACOG is hoping for. “It’s really a societal call to action,” Stuebe said.

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CDC: After Claiming 52 lives in CT, Flu Season has yet to Peak


WASHINGTON – The U.S. Centers for Disease Control and Prevention on Friday said the peak of the flu season, which has killed 52 people in Connecticut, is still to come.

“Our latest tracking data indicate that flu activity is still high and widespread across most of the nation and increasing overall,” said Dr. Anne Schuchat, the acting CDC director.

The CDC said there were an additional 16 flu deaths among children last week,  bringing the nationwide total this season for youngsters to 53.

About half of those children apparently had been healthy and had no special vulnerability to this viral disease, Schuchat said. She also said 20 percent had received a flu vaccine.

There has been one pediatric flu death in Connecticut.

Schuchat said this is a banner year for hospitalizations caused by the flu.

“So far this year, the cumulative rate of hospitalizations is the highest since we’ve been tracking in this way, which goes back to 2010,” she said. “This is a very difficult season.”

Schuchat also said “it’s not too late to get (a flu) vaccine.”

Caused by viruses, flu is a contagious respiratory illness with mild to severe symptoms that can sometimes lead to death. The flu season begins in October and can last up to 20 weeks.

The very young and very old are most susceptible to dying from the flu.

The CDC said that overall, there were 17,024 new laboratory-confirmed cases of illness during the week ending Jan. 27, bringing the season total to 126,117. But those numbers do not include all the people who have had the flu, as many do not see a doctor when sick.

The Connecticut Department of Public Health on Thursday said a total of 1,154 patients have been hospitalized with confirmed cases of flu this season.

The CDC said there are several strains of flu making people sick this winter. But the agency said most people with influenza are being infected with the H3N2 virus.

“In  seasons where H3N2 is the main cause of influenza, we see more cases, more visits to the doctor, more hospitalizations, and more deaths,” said Dan Jernigan the director of the Influenza Division at the CDC.

As the nation is gripped with a particularly severe and dangerous flu season, there is a shakeup at the CDC.

Brenda Fitzgerald resigned as head of the CDC Wednesday, a day after Politico reported Fitzgerald’s purchase of tobacco stock after she took the position at the nation’s top public health agency.

“Despite recent leadership changes, the CDC remains committed to our 24/7 mission to protect the health, safety and security of our nation,” Schuchat said.

This article was first published at ctmirror.org

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State Officials Urge Free Flu Shot for Residents


HARTFORD —  In effort to protect the public’s health and reduce the spread of the flu virus, the Connecticut Department of Public Health is teaming up with local health departments to provide free or low cost flu vaccine.

The department is strongly encouraging all Connecticut residents over the age of 6 months to get a flu shot. Free flu vaccine will be available at several locations across the state on Jan. 27.

It is not too late to get protection from the flu this season, state officials said.

The schedule and locations of Flu Clinics on Jan. 27 can be found on the DPH website:

Vaccine administered to children 18 years of age and younger will be made available free of charge. Vaccine for children comes from the Connecticut Vaccine Program. Managed by DPH, this program provides influenza vaccine free of charge for all children 6 months through 18 years of age. Adult vaccine will be provided at no cost to those without insurance.

Residents with insurance should bring their card and will be charged a small administrative fee, but will not be charged out of pocket for the vaccine. State health officials say flu activity in Connecticut continues to increase. As of Jan. 13, more 1,342 people have tested positive for the flu so far this season, and 615 have been hospitalized with the illness. There have also been 21 flu-related deaths so far this season.

Typical symptoms of the flu include sudden fever, aching muscles, sore throat, coughing, runny nose, headache, and eye pain.

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Facing Unaffordable Prices, Millions buy Medicine Outside U.S.


As drug prices have spiraled upward in the past decade, tens of millions of generally law-abiding Americans have committed an illegal act in response: They have bought prescriptions outside the U.S. and imported them.

One was Debra Miller, of Collinston, La., who traveled to Mexico four times a year for 10 years to get diabetes and blood pressure medicine. She quit in 2011 after the border patrol caught her returning to the U.S. with a three-month supply that had cost her $40. The former truck driver drew a stern warning not to do it again, but got to keep her pills.

“I didn’t know what I did wrong,” said Miller, 51, who now pays $120 a month at Walmart for her five medications while she waits to join Medicaid.

It’s no secret that some Americans regularly buy prescription drugs on the Internet or while traveling abroad. But the popularity of the approach is underscored by the results of a Kaiser Family Foundation poll conducted in November.

Eight percent of respondents said they or someone in their household had imported a drug at some point, a figure that would translate to about 19 million adults in the U.S. based on current Census population estimates.

Even the proportion found in the poll may be low, said Andrew Zullo, a clinical pharmacist and a doctoral student at the Brown University School of Public Health who has researched the subject. “People are uncomfortable talking about the cost of their own health care, and they don’t want to admit they are struggling to pay for their own meds,” he said. Some may also be reluctant to reveal they’ve broken the law.

Still, 8 percent is far higher than in surveys conducted by government interviewers, which suggested the number was about 2 percent in 2011 — though the government survey focused only on purchases in the previous 12 months. The Kaiser poll queried a nationally representative sample of 1,202 adults.

The Internet has made it easier for Americans to buy prescription drugs abroad, frequently from disreputable sources, according to Jaime Ruiz, a spokesman for U.S. Customs and Border Protection.

The Food and Drug Administration has cautioned that many online pharmacies aren’t what they seem to be. An international crackdown in 2014 found that many packages of medicines purportedly from Australia, Canada, New Zealand and the U.K. contained drugs from other countries, including India, China and Laos.

Zullo acknowledged that imported medications could be inferior or expired. Some could be counterfeits. But many medicines purchased from another country are the same as the ones patients buy in the U.S.

When purchased outside the country, many prescription medicines cost half or less of what they do in the U.S.

According to the FDA’s website, it is generally illegal for Americans to import drugs into the U.S. for personal use. The law isn’t rigorously enforced, in part because it is difficult to monitor the entry of medicine in suitcases and small packages. But in 2015 the FDA implemented a rule that would give government border inspectors expanded authority to destroy drugs imported for personal use at their point of entry.

In the poll, people who had imported medicines ranged from college students in their 20s to retirees in their 80s. They bought medications to treat chronic conditions — such as high blood pressure and thyroid problems — as well as acute problems such as sinus infections and acne.

Amanda Mazumder, a 27-year-old graphic designer in St. Paul, Minn., was stressed out by the murky legality of the situation when she tried buying birth control pills while in college five years ago. “That was the most difficult part, trying to be an honest citizen but also getting an affordable prescription,” she said. She couldn’t afford to pay $150 a month for her birth control, but found an online Canadian pharmacy that sold her a three-month supply for $60.

Bobby Grant, of Los Angeles, has relied on foreign pharmacies for seven years to get medicine for his partner’s severe asthma. Grant, 38, travels internationally for his job producing live shows. Each time he’s in Mexico or France, he buys 10-packs of inhalers and 20-packs of nebulizer solution for a fraction of what they would cost in the U.S.

His partner’s asthma would require inhalers costing $300 a month if she purchased them here. Grant estimates he saves at least $2,500 a year by buying the drugs overseas.

“I love her to death,” he said. “I’ll do whatever I can to take her stress away.”

This story was originally published by Kaiser Health News, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

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Aetna-Humana antitrust Trial to Have a Different Twist


WASHINGTON —  As the first part of the antitrust trial on a proposed merger of health insurers Anthem and Cigna is wrapping up, a similar challenge to Aetna’s plan to merge with Humana is about to begin.

While both are the result of lawsuits to block the mergers filed by the U.S. Justice Department on the same day in July, the trials will be much different.

The first phase of the Anthem-Cigna trial, expected to wrap up Friday, centers on whether the $54 billion merger of those two insurers would dramatically decrease competition for “national accounts,” or plans for large, multi-state corporations.

The Justice Department also argues the merger would fail because there is friction between the companies’ CEOs and because Cigna in July stopped cooperating with Anthem on various deal-related issues.

“How do you work on integration without talking to the person you’re integrating with?” asked U.S. District Judge Amy Berman Jackson, who is presiding over the trial.

If Jackson does not rule in favor of the Justice Department, the second phase of the Anthem-Cigna trial is scheduled for Dec. 12 and will focus on whether the merger will decrease competition in dozens of local markets.

In another room in the same federal courthouse, the $37 billion Aetna-Humana merger trial is set to begin on Monday.

U.S. District Judge John D. Bates will preside over that trial. The Justice Department will argue that Aetna’s merger with Humana will dry up competition across the nation in the Medicare Advantage market.

The Justice Department says the combined companies would cover 980,000 of the 1.6 million seniors in the nation covered under Medicare Advantage plans. Aetna and Humana will argue that traditional Medicare will provide plenty of competition to their policies.

“The two cases are very different,“ said Deep Banerjee, an insurance analyst with Standard & Poor’s Global Ratings.

Banerjee said Aetna and Humana may have an edge over the other insurers. He agrees with Aetna and Humana that “the Medicare market should be looked at as a whole,” and traditional Medicare considered as competition to Medicare Advantage.

The insurers also have another card they can play, one that Anthem and Cigna do not: They have offered to divest themselves of Medicare Advantage plans in areas of high concentration.

“The divestiture may be a valuable and attractive issue for the judge to use to rule for the insurers,” said Professor Tim Greaney, co-director of the Center for Health Law Studies at Saint Louis University School of Law.

Cigna headquarters in Bloomfield

Cigna Corp.

Cigna headquarters in Bloomfield

Aetna said it has an agreement to sell Medicare Advantage business covering 290,000 people to rival insurer Molina if its planned merger is allowed to be completed.

But Molina specializes in Medicaid, the government insurance for the poor, instead of Medicare Advantage, a type of health plan offered by private companies that contract with Medicare to provide coverage for the elderly.

The Justice Department is expected to argue that it would be difficult for Aetna and Humana to divest themselves of enough Medicare Advantage customers to keep that market competitive, especially in 364 counties across the nation where a merger would result in what it says is an acute lack of competition.

Aetna, meanwhile, is expected to try to knock down another Justice Department complaint – that a merger would hurt competition in Affordable Care Act exchanges – by saying it is quitting most exchanges and leaving many counties in states where it still has a presence in the exchanges.

Failed remedies

The Justice Department argued in the Anthem-Cigna case that a merger would result in higher prices, lower quality, reduced consumer choice and less innovation. It’s expected to make a similar argument in the Aetna-Humana case next week.

“Because of the offer of divestiture, the Aetna-Humana merger may have a better chance,” Greaney said. “But I think the Justice Department has a very strong argument on the merits in both cases.”

Meanwhile, David Balto, a former attorney with the Justice Department’s Antitrust Division who opposes both mergers, said the Aetna-Humana tie-up will result in more concentration than an Anthem-Cigna marriage.

“I think the competitive concerns are even greater,” Balto said. “I think the Justice Department has an even stronger case against Aetna and Humana.”

The reason, Balto said, is that the Justice Department can point to previous cases where insurers made divestitures but premiums rose sharply anyway.

He said divestitures were made in  1999 when Aetna and Prudential merged and in 2008 when United and Sierra merged and prices increased by 7 percent and 13.7 percent, respectively.

Balto said the biggest failure was the 2012 Humana-Arcadian merger, where one of the three companies that acquired business divested as part of the merger “exited the market, another company partially exited the market, and premiums increased by 44 percent.”

First reported in CTMirror, our media partner.

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First Choice Health Offers Classes for Diabetes Month


HARTFORD — November is National Diabetes Awareness Month.

This month, First Choice Health Centers will be hosting a number of events to help educate our community on how healthy lifestyle choices can benefit those with   or without this chronic medical condition.

In addition to our events listed below, First Choice Health Centers is proud to offer Care Coordination services to our patients.  The goal of our Care Coordinators is to help our patients navigate the health care system which can often be overwhelming for someone with a chronic disease like Diabetes.  Our Care Coordinators help diabetic patients manage appointments with our Primary Care, Podiatry, Eye Care & Nutrition teams; connect them with outreach services such as SNAP, Medicaid/Medicare enrollment if needed.

They will also communicate with hospital or rehabilitation facilities if the occasion arises.

For more information about our Care Coordinators, please contact Dr. Colleen Rankine, PhD at 860-610-6142 ext. 142

Nov 23rd
Prenatal Yoga @ 4:00-5:30 p.m.
Relieve some of prenatal stress with our experienced yoga instructor with specific stretches to help you and your baby. Call 860-528-1359 ext. 168 to RSVP!

Nov 16th
Diabetes Open House: Learn important information from our guest speaker Anne Lanza a community dietitian with Nova Nordisk about diabetes. Open to public, refreshments will be provided.

Nov 28th
Spanish Speaking Nutrition Class @ 3:00-4:00 p.m.
Basic nutrition class for Spanish-speakers. Topics discussed will be Nutrition labels, basic nutrients, portion sizes, diabetes, and tips for eating healthy on the go.  Got questions about eating healthy?? Bring them to us and we’ll give you answers!

Location for all events:
First Choice Health Centers
110 Connecticut Boulevard, East Hartford CT 06108
2nd floor Conference Room

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Mayor Ganim Swears In New Health Director


BRIDGEPORT —  Mayor Joe Ganim on Tuesday swore in a new Director of Health for the city of Bridgeport.

Maritza Bond brings extensive experience in health administration including nearly a decade with the Eastern Area Health Education Center covering Eastern Connecticut from a base in New London, serving as the organization’s executive director for the last four years.  Bond also has experience managing immunization, medical interpretation  and other programs for diverse populations in the Bridgeport area and the Naugatuck Valley.

Bond’s first official day as Bridgeport Director of Health was on Nov. 1  and according to Connecticut state law, she is now sworn in for a term of four years, to conclude on October 31, 2020.

She is a graduate of Southern Connecticut State University and holds a Master of Public Health Degree from the University of Connecticut Medical School in Farmington.

Bond was nominated for the position by Mayor Ganim after a thorough search and was overwhelmingly approved by the Bridgeport city council on Oct. 17, 2016.

“I am very happy to have Maritza Bond as part of our administration, I am sure she will serve the residents of Bridgeport extremely well,” said Mayor Ganim.  “She clearly has passion and energy for this work and we look forward to years of accomplishments in improving public health in our city that Maritza will lead.”

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CT Resident Diagnosed with Legionnaires Disease


Fran Wilson, Staff Writer

MIDDLETOWN  — First, there’s the Zika virus. Now comes Legionnaires disease to Connecticut.

According to the Centers for Disease Control and Prevention, a Connecticut resident was recently diagnosed with Legionnaires disease.

The resident, a psychiatric patient at Connecticut Valley Hospital in Middletown, was infected with the Legionella bacterium, which is found in soil and in fresh water.

The disease is spread by inhaling a mist or vapor infected with the bacteria. It does not spread from person to person, according to the CDC. When bacteria cause pneumonia, it is called Legionnaires’ disease.

Crews with the health department and the Department of Mental Health and Addiction Services were still investigating the source of the contamination Tuesday evening. The building was not evacuated.

Gov. Dannel P. Malloy said his office is monitoring the cases.

Malloy said residents should not be alarmed.

State officials said that “the bacteria cannot be transmitted from person to person.”

Federal officials said that 8,000 to 18,000 people require hospital care as a result of Legionnaires’ disease. In Connecticut, about 80 cases are diagnosed each year.

Last summer, there was an outbreak of the Legionnaires disease in the South Bronx, which New York Mayor Bill DeBlasio said is the largest outbreak in history. In that outbreak, at least 128 people were sick and 12 died.

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CT Receives More Grant Money to Study Mosquito Virus


EAST HARTFORD — More grant money is coming to Connecticut to fight the onslaught of the Zika virus.

U.S. Sen. Richard Blumenthal, D-Conn., said more grant money will be available “virtually immediately.” That’s because there’s a need for a national research effort to create a Zika vaccine and for public education.

The Centers for Disease Control will give Connecticut $120,000 in federal funding from the Centers for Disease Control to track Zika virus cases in the state and monitor the mosquitoes known to transmit the disease, state health officials said Monday.

So far the state has received $579,055 in grant money, including $479,000 that was awarded.

“What we have here is a potential epidemic,” Blumenthal said. Blumenthal called on GOP leaders to call the Republican-controlled U.S. House and Senate back into session to take action.

He also said that congressional  approval of $1.1 billion is needed to combat the mosquito-transmitted disease.

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Gov. Malloy, Health Chief Announce Zika Detection Protocol


NEW HAVEN — Gov. Dannel Malloy joined the state’s public health chief and a local scientist Thursday in announcing the state will launch a system that will potentially detect new Zika cases as part of its prevention efforts.

State Department of Public Health Commissioner Dr. Raul Pino said Thursday the state has tested 472 people for Zika, confirming 31 cases, three of whom are pregnant women. The disease is especially concerning to pregnant women, as infection during pregnancy could lead to birth defects. Results are pending for several other female patients, Pino said. No child in Connecticut has been born with a birth defect related to a possible infection, Pino added.

“The Department of Public Health has decided to establish a sentinel system in the southern part of the state,” Pino said. “We are basically coordinating with community health centers, hospitals and emergency rooms.”

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