Adding HIV Tests to Routine Medical Care

Pregnant women in New Jersey will get routine HIV tests under a law signed Wednesday. Because the virus is transmitted largely through sexual activity and intravenous drug use, the move may take some of the stigma out of HIV testing by integrating it into mainstream care.

The law allows women to opt out of an HIV test if they don’t want one. State officials say the law is designed to reduce the number of infants born with HIV; when doctors know a woman carries the virus, which causes AIDS, they can take steps that drastically reduce the risk she will pass it to her newborn baby.

About 5,700 women in New Jersey have AIDS, according to the AP. Seven of roughly 115,000 babies born there in 2005 were born with HIV.

Meanwhile, according to the CDC, some 25% of people with HIV are unaware that they are infected. Last year, the agency recommended that everyone between the ages of 13 and 64 be offered an HIV test as part of routine medical care. The New Jersey law is a step in this direction.

Four states (Michigan, Arkansas, Texas and Tennessee) have laws similar to New Jersey’s policy of testing pregnant women. And three (New York, Connecticut and Illinois) have mandatory testing for newborn babies. The New Jersey law will require testing of newborns when the mother is HIV positive or when her HIV status is unknown.

The American Civil Liberties Union and some women’s groups have argued that the New Jersey law deprives women of authority to make medical decisions, according to the AP.

Specialists Scarce in Hospital ERs

As visits to hospital emergency rooms rise, the shortage of medical specialists to treat the patients who show up there is growing, the Washington Post reports.

The dearth of specialists taking on-call duty for emergencies is delaying treatment as patients wait longer for a specialist to show up or are transferred to other hospitals. “It can mean death,” Linda Lawrence, president of the American College of Emergency Physicians told the Post. “Patients have died in transport, or waiting to find a neurosurgeon, or getting to a heart center for a cardiologist.”

Specialists often agree to take on-call duty in exchange for admitting privileges to the hospital and use of the facilities. But the growth of specialty hospitals and outpatient surgery centers have decreased their interest in general hospitals, the Post says. Fear of lawsuits, the flood of uninsured patients and an unwillingness to compromise one’s personal life may also be factors.

Some hospitals are addressing the problem by employing full-time specialists or paying doctors extra for taking ER call.

Unions Cash In on California Health Plan

The juicy details behind California’s effort to expand health-care coverage are starting to be squeezed out.

Assembly Speaker Fabian Nuñez added last-minute provisions that benefited members of two major unions, the Service Employees International Union and American Federation of State, County and Municipal Employees, the Los Angeles Times reports. The changes gave “millions of dollars for better benefits and worker training” for workers who provide home care for the elderly, blind and disabled and were an effort to garner the support of two unions, the story says.

The unions recently increased their financial backing of a Nuñez initiative that would extend the terms of many lawmakers, Nuñez included. The American Federation has given $610,633 and SEIU has given $1.1 million but Jeanine Meyer Rodriguez, an SEIU spokeswoman, denied that donations had anything to do with the added provisions.

“We have been working on healthcare reform really, really hard all year long,” Rodriguez told the LAT. “And there is this perception that suddenly all these amendments happen and then we’re on board, which is just wrong.”

Still others were skeptical.

“We were waiting for the payoff to show up,” Jerry Flanagan, healthcare policy director for theFoundation for Taxpayer and Consumer Rights, a Santa Monica-based nonprofit, told the LAT. His group believes the Nuñez plan will be too expensive for some consumers. “It’s really remarkable, in terms of the express aiming of this money toward two particular unions.”

The bill passed the Assembly on Monday and is headed for the Senate.

Medicare Stinginess Casts Pall Over Primary Care

Benjamin Brewer, who writes the Doctor’s Office column for WSJ.com, checks in with an update to his most recent piece, about the proposed cuts in Medicare’s payments to doctors.

His column contemplated that a planned 10.1% cut, on average, might be averted, as previous proposed cuts had been. And, in fact, last week a deal was reached that would give docs a tiny raise, but it may not last long. The fix is really a six-month postponement until Congress takes up the matter again.

Brewer says the economic pressure on primary care remains. The core problem is that the lack of meaningful increases in Medicare payments to primary care doctors amounts to a cut anyway in the face of steadily rising costs for providing care.

Here’s the rest of the dispatch from Brewer, who practices in rural Illinois.

Reaction to the 0.5% increase and six-month Medicare reprieve has been filtering back — mostly reflecting disappointment.

Docs have until Jan. 1 to opt in or out of Medicare for next year, and they only know what half the year will bring. Primary care docs feel that Medicare has no intention of even keeping up with the inflation in their practice expenses let alone a pay raise of some kind. Morale is pretty low from the docs in private practice. Those that are in big institutions, where primary care is but a loss leader for the hospital, won’t feel much of the effect because they’re on salary for the most part.

One doctor I talked to told me that he’s mulling a career change out of medicine. Though his practice seems to be growing in size, profitability isn’t. I can see that the clash of ideals between what good medicine should be and the economics of what he’s going to have do to survive are tearing him up. Being more efficient will only take him so far. He doesn’t want to run a patient mill, but he fears that’s the only choice he’s got for the long haul.

That is a big part of what is wrong with our health care “system.” It causes thoughtful care by engaged, compassionate people to go by the wayside in favor of churning people through. It turns the office into an impersonal assembly line. It burns out those with the natural inclination to care for others. The docs that remain have the capacity to see a patient every six minutes all day long, but not much time or capacity to care. The medical students who I teach are running from primary care. When the money gets tight, a lot of hard choices have to be made. The solution is to pay doctors on quality of care, not quantity of visits.