PCR's on the Gold Question

[vinoveri]

Re: PCR's on the Gold Question

The question is why does the U.S. have so much gold, 8171 tons to be exact, far more than any other country, and more than Germany, Italy, and France combined, with a market value of $322 billion?

The combined market value of the 15 largest national and institutional gold holdings, including the IMF and BIS, has a market value of over $1 trillion.

For what?

The answer to that question is the reason to own gold.

And they won't repatriate to Germany a paltry 300 tons .... a goldbug say this is b/c there is no gold to give back, but perhaps "safekeeping" for contingencies is a better explanation

[shiny!]

Re: PCR's on the Gold Question

The USA has the most expensive health care in the world- by far. Insurance companies aren't the only villians, turns out. Price gouging is happening at every level, from manufacturers of medical devices to middlemen to hospitals to insurance companies. Doctors aren't all getting rich on this. When I had the right side of my thyroid removed, the doctor in the hospital who did my 20 minute biopsy got paid twice as much ($1600) as the surgeon who performed my 4-hour surgery ($800).

Elizabeth Rosenthal of the NY Times has been doing an excellent series of articles about the cost of healthcare in the U.S. highlighting colonoscopies, pregnancy, prescriptions and ER visits. Here are excerpts from the one about joint replacements. This is what happens when there is no requirement for price transparency or rules to prevent price gouging.

In Need of a New Hip, but Priced Out of the U.S.
— Elisabeth Rosenthal, Reporter

WARSAW, Ind. — Michael Shopenn’s artificial hip was made by a company based in this remote town, a global center of joint manufacturing. But he had to fly to Europe to have it installed.

Mr. Shopenn, 67, an architectural photographer and avid snowboarder, had been in such pain from arthritis that he could not stand long enough to make coffee, let alone work. He had health insurance, but it would not cover a joint replacement because his degenerative disease was related to an old sports injury, thus considered a pre-existing condition.

Desperate to find an affordable solution, he reached out to a sailing buddy with friends at a medical device manufacturer, which arranged to provide his local hospital with an implant at what was described as the “list price” of $13,000, with no markup. But when the hospital’s finance office estimated that the hospital charges would run another $65,000, not including the surgeon’s fee, he knew he had to think outside the box, and outside the country.

“That was a third of my savings at the time,” Mr. Shopenn said recently from the living room of his condo in Boulder, Colo. “It wasn’t happening.”

“Very leery” of going to a developing country like India or Thailand, which both draw so-called medical tourists, he ultimately chose to have his hip replaced in 2007 at a private hospital outside Brussels for $13,660. That price included not only a hip joint, made by Warsaw-based Zimmer Holdings, but also all doctors’ fees, operating room charges, crutches, medicine, a hospital room for five days, a week in rehab and a round-trip ticket from America.

“We have the most expensive health care in the world, but it doesn’t necessarily mean it’s the best,” Mr. Shopenn said. “I’m kind of the poster child for that.”

... An artificial hip, however, costs only about $350 to manufacture in the United States...

... So why are implant list prices so high, and rising by more than 5 percent a year? In the United States, nearly all hip and knee implants — sterilized pieces of tooled metal, plastic or ceramics — are made by five companies, which some economists describe as a cartel. Manufacturers tweak old models and patent the changes as new products, with ever-bigger price tags...

... Generic or foreign-made joint implants have been kept out of the United States by trade policy, patents and an expensive Food and Drug Administration approval process...

... device makers typically require doctors’ groups and hospitals to sign nondisclosure agreements about prices, which means institutions do not know what their competitors are paying. This secrecy erodes bargaining power and has allowed a small industry of profit-taking middlemen to flourish: joint implant purchasing consultants, implant billing companies, joint brokers. There are as many as 13 layers of vendors between the physician and the patient for a hip replacement...

... Hospitals and orthopedic clinics typically pay $4,500 to $7,500 for an artificial hip... But those numbers balloon with the cost of installation equipment and all the intermediaries’ fees, including an often hefty hospital markup...

... The list price of a total hip implant increased nearly 300 percent from 1998 to 2011, according to Orthopedic Network News, a newsletter about the industry. That is a result, economists say, of how American medicine generally sets charges: without government regulation or genuine marketplace competition.

... Like many other countries, Belgium oversees major medical purchases, approving dozens of different types of implants from a selection of manufacturers, and determining the allowed wholesale price for each of them, for example. That price, which is published, currently averages about $3,000, depending on the model, and can be marked up by about $180 per implant. (The Belgian hospital paid about $4,000 for Mr. Shopenn’s high-end Zimmer implant at a time when American hospitals were paying an average of over $8,000 for the same model.)

More...

[don]

Re: PCR's on the Gold Question

Patients’ Costs Skyrocket; Specialists’ Incomes Soar


CONWAY, Ark. — Kim Little had not thought much about the tiny white spot on the side of her cheek until a physician’s assistant at her dermatologist’s office warned that it might be cancerous. He took a biopsy, returning 15 minutes later to confirm the diagnosis and schedule her for an outpatient procedure at the Arkansas Skin Cancer Center in Little Rock, 30 miles away.

That was the prelude to a daylong medical odyssey several weeks later, through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an anesthesiologist and an ophthalmologist who practices plastic surgery. It generated bills of more than $25,000.

“I felt like I was a hostage,” said Ms. Little, a professor of history at the University of Central Arkansas, who had been told beforehand that she would need just a couple of stitches. “I didn’t have any clue how much they were going to bill. I had no idea it would be so much.”

Ms. Little’s seemingly minor medical problem — she had the least dangerous form of skin cancer — racked up big bills because it involved three doctors from specialties that are among the highest compensated in medicine, and it was done on the grounds of a hospital. Many specialists have become particularly adept at the business of medicine by becoming more entrepreneurial, protecting their turf through aggressive lobbying by their medical societies, and most of all, increasing revenues by offering new procedures — or doing more of lucrative ones.

It does not matter if the procedure is big or small, learned in a decade of training or a weeklong course. In fact, minor procedures typically offer the best return on investment: A cardiac surgeon can perform only a couple of bypass operations a day, but other specialists can perform a dozen procedures in that time span.

That math explains why the incomes of dermatologists, gastroenterologists and oncologists rose 50 percent or more between 1995 and 2012, even when adjusted for inflation, while those for primary care physicians rose only 10 percent and lag far behind, since insurers pay far less for traditional doctoring tasks like listening for a heart murmur or prescribing the right antibiotic.

By 2012, dermatologists — whose incomes were more or less on par with internists in 1985 — had become the fourth-highest earners in American medicine in some surveys, bringing in an average of $471,555, according to the Medical Group Management Association, which tracks doctors’ income, though their workload is one of the lightest.

In addition, salary figures often understate physician earning power since they often do not include revenue from business activities: fees for blood or pathology tests at a lab that the doctor owns or “facility” charges at an ambulatory surgery center where the physician is an investor, for example.

“The high earning in many fields relates mostly to how well they’ve managed to monetize treatment — if you freeze off 18 lesions and bill separately for surgery for each, it can be very lucrative,” said Dr. Steven Schroeder, a professor at the University of California and the chairman of the National Commission on Physician Payment Reform, an initiative funded in part by the Robert Wood Johnson Foundation.

Doctors’ charges — and the incentives they reflect — are a major factor in the nation’s $2.7 trillion medical bill. Payments to doctors in the United States, who make far more than their counterparts in other developed countries, account for 20 percent of American health care expenses, second only to hospital costs.

Specialists earn an average of two and often four times as much as primary care physicians in the United States, a differential that far surpasses that in all other developed countries, according to Miriam Laugesen, a professor at Columbia University’s Mailman School of Public Health. That earnings gap has deleterious effects: Only an estimated 25 percent of new physicians end up in primary care, at the very time that health policy experts say front-line doctors are badly needed, according to Dr. Christine Sinsky, an Iowa internist who studies physician satisfaction. In fact, many pediatricians and general doctors in private practice say they are struggling to survive.

Studies show that more specialists mean more tests and more expensive care. “It may be better to wait and see, but waiting doesn’t make you money,” said Jean Mitchell, a professor of health economics at Georgetown University. “It’s ‘Let me do a little snip of tissue’ and then they get professional, lab and facility fees. Each patient is like an ATM machine.”

For example, the procedure performed on Ms. Little, called Mohs surgery, involves slicing off a skin cancer in layers under local anesthesia, with microscopic pathology performed between each “stage” until the growth has been removed. While it offers clear advantages in certain cases, it is more expensive than simply cutting or freezing off a lesion. (Hospitals seeking to hire a staff dermatologist for Mohs surgery had to offer an average of $586,083 in 2010, even more than for a cardiac surgeon, according to Becker’s Hospital Review.)

Use of the surgery has skyrocketed in the United States — over 400 percent in a little over a decade — to the point that last summer Medicare put it at the top of its “potentially misvalued” list of overused or overpriced procedures. Even the American Academy of Dermatology agrees that the surgery is sometimes used inappropriately. Dr. Brett Coldiron, president-elect of the academy, defended skin doctors as “very cost-efficient” specialists who deal in thousands of diagnoses and called Mohs “a wonderful tool.” He said that his specialty was being unfairly targeted by insurers because of general frustration with medical prices. “Health care reform is a subsidized buffet and if it’s too expensive, you go to the kitchen and shoot one of the cooks,” he said. “Now they’re shooting dermatologists.”

The specialists point to an epidemic, noting there are two million to four million skin cancers diagnosed in the United States each year, with a huge increase in basal cell carcinomas, the type Ms. Little had, which usually do not metastasize. (A small fraction of the cancers are melanomas, a far more serious condition.) But, said Dr. Cary Gross, a cancer epidemiologist at Yale University Medical School, “The real question is: Is there a true epidemic or is there an epidemic of biopsies and treatments that are not needed? I think the answer is both.”

Patient Given No Choice

A fair-skinned redhead who teaches history at the University of Central Arkansas, Ms. Little had gone to a private dermatology practice in Heber Springs, Ark., to check some moles on her arms when the physician’s assistant on duty noticed a whitish bump — like a “tiny fragment of thread” — on her face, she said. Her family practitioner had told her it was just a clogged pore.

A diligent medical consumer, Ms. Little had read up on the Mohs technique (invented by Dr. Frederic Mohs in 1938) before she and her husband arrived for her surgery in November 2012 in a doctors’ office building at Baptist Health Medical Center here. Pressed for time as the end of the semester approached, she asked Dr. Randall Breau, the dermatologist, why the tiny growth needed the specialized surgery, as she had asked the physician’s assistant earlier. They both answered that it was because it was on her eyelid, a delicate area where Mohs surgery is always required; she repeatedly insisted that it was on her cheekbone below her eye.

After the 30-minute removal, the dermatologist told her that she would have to go across the street to the Arkansas Center for Oculoplastic Surgery, another private doctors’ office on the hospital’s campus, to have the wound closed by a plastic surgeon with “a couple of stitches.”

When Ms. Little protested that she did not want a plastic surgeon and did not care about having a tiny scar, the doctor told her she had no choice, she said. The vast majority of Mohs procedures are sewed up by the dermatologist or just bandaged and left to heal. Yet when Ms. Little arrived at the second practice, nurses took her clothes, put in an IV, and introduced her to an anesthesiologist who would sedate her in an operating room.

Sitting in her cozy office recently, Ms. Little, who has a faint scar under her eye on her right cheek, still fumes at the thought. “It was no bigger than many cuts that heal on their own, and it definitely could have been repaired by one doctor, but at that point what was I going to do?” she recalled. “I have an IV in my arm and a hole in my face that Dr. Breau refused to stitch. And the anesthesiologist is standing there with his mask on.”

Her bills included $1,833 for the Mohs surgery, $14,407 for the plastic surgeon, $1,000 for the anesthesiologist, and $8,774 for the hospital charges.

Mohs surgery is preferable when the removal of a skin cancer is complicated or in a sensitive area, because it typically excises less tissue and leaves less of a scar than other treatments and allows dermatologists to see the borders of a growth and be confident that it is removed entirely. The surgery is generally not used for melanomas, which require more extensive cutting.

Physicians often complain that government and commercial insurance reimbursements for seeing patients are decreasing while their office expenses are going up to deal with mountains of paperwork and demands from insurers. Congress currently is considering a bill that would freeze doctors’ Medicare fees for the next decade. Still, many doctors have found alternative income streams that do not show up on surveys.

Dr. Mitchell of Georgetown University estimates, for example, that many urologists make 50 percent of their income from dealing with patients and the rest from investing in the machines that deliver radiation for prostate cancer or to treat kidney stones. In 2012, urologists had an average income of $416,322, according to Medical Group Management Association data, which often does not include the investment income.

Oncologists benefit from the ability to mark up (and profit from) each dose of chemotherapy they administer in private offices, a practice increased dramatically in the late 1990s. The median compensation for oncologists nearly doubled from 1995 to 2004, to $350,000, according to the M.G.M.A. One study last year attributed 65 percent of the revenue in a typical oncology practice to such payments.

When policy makers reduce one type of payment, some specialists find another. Though orthopedists’ reimbursement from Medicare for performing joint replacements has gone down in the last two decades, the Medscape survey on physician income showed that orthopedists’ average compensation has risen 27 percent since 2011. They are still paid handsomely by many private payers for many minor procedures, and — more important — often own the surgery centers, scanners and physical therapy offices they use.

In a country where top hospital executives typically make more than a million dollars a year, American physicians may feel entitled to high fees, especially because they face costs that their European counterparts do not: Medical school is expensive and new doctors graduate with an average of about $150,000 in debt. Likewise, some specialists face malpractice premiums of over $100,000 a year.

Though medical societies tend to point to the long haul of medical training and the unpredictable hours to justify generous salaries, health economists point out there is often little correlation between compensation and that investment of time. Obstetricians, for example, arguably have the most rigorous schedules but are relatively modest earners. A number of high-income specialties — radiology, ophthalmology, anesthesiology and dermatology — are often called the “lifestyle specialties,” because training is more compatible with a home life than some other disciplines and there are fewer emergencies in these fields. Eighty percent of dermatologists see patients 40 hours or fewer each week, according to a 2013 Medscape report, less than the average doctor.

[Southernguy]

Re: PCR's on the Gold Question

Shiny: you seem to be very informed about health care issues. Perhaps the following would be of interest; to you and to other itulipers.
Low Birth Weight Outcomes: Why Better in Cuba Than Alabama?

• Yasmin Neggers, DrPH, RD and
• Kristi Crowe, PhD, RD, LD

+ Author Affiliations

• From the Department of Human Nutrition, University of Alabama, Tuscaloosa.

• Corresponding author: Kristi Crowe, Department of Nutrition, University of Alabama, Box 870311, Russell Hall 409, Tuscaloosa, AL 35401 (E-mail: kcrowe@ches.ua.edu).

Next Section
Abstract

Reducing the incidence of low birth weight (LBW), a major predictor of infant mortality and morbidity in developed and developing countries, is an important worldwide goal, yet interventions to reduce this incidence have been disappointingly unsuccessful. Despite its low per capita income, Cuba has managed to significantly reduce the prevalence of LBW in recent decades. To date, minimal research has been conducted to comparatively evaluate risk factors associated with birth weight outcomes between countries with significantly differing rates of LBW. For this reason, we traveled to Havana to study the Cuban model of prenatal care and compare risk factors associated with LBW in Cuba, the United States, and, in particular, Alabama. This article describes the community-based approaches to prenatal care provided within the Cuban healthcare system and their influence on rates of LBW. As a result of these successfully integrated health services, the Cuban healthcare model will be used to evaluate and compare Alabama's current prenatal care system, in particular the implementation of strategies such as community-based clinics and maternity homes for high-risk pregnancies.

• Alabama
• Cuba
• Low Birth Weight
• Prenatal Care
• Risk Factors

Low birth weight (LBW; <2500 g) is the single most important factor affecting neonatal mortality and a significant determinant of postneonatal mortality.¹ Furthermore, LBW babies are at an increased risk for serious health problems, ranging from neurodevelopmental disabilities such as cerebral palsy and mental retardation to respiratory disorders.² In the United States, 65% of all infant deaths result from LBW and preterm birth.¹
The biological importance of LBW is signified by the fact that the World Health Organization and United Nations International Children's Emergency Fund have a Millennium Development Goal for reducing child mortality; this goal includes developing methods to estimate the global percentage of LBW infants born per year despite the fact that >50% of newborns are not weighed at birth.³ As expected, there is considerable variation in the percentage of infants with LBW among countries, yet there is a strong association between LBW percentages and infant mortality rates.² In brief, the rates of LBW are highest in most Asian and African countries, followed by Latin America and Caribbean countries; the lowest rates of LBW are in Oceania and Europe. Among developing countries, Cuba remains an enigma to North America and Europe alike. The percentage of LBW in Cuba is not only much lower than its neighboring developing countries such as Jamaica, Haiti, and the Dominican Republic, but is also lower than far more affluent countries such as England and the United States.⁴ Despite a per capita gross domestic product that places Cuba in the fourth quintile of nations, Cuba's infant mortality rate rivals that of Canada and is lower than the average infant mortality rate in the United States and, in particular, the state of Alabama.⁵ According to the current available statistics, the national average rate of LBW in the United States is 7.7%, and Alabama's rate of LBW is 10.4%.^6,7 Unfortunately, these rates have not significantly declined since the mid-1980s, especially among African-American women and women of low socioeconomic status.⁷ In contrast, in 2009, the rate of LBW for Cuba, as reported by the World Bank World Development Indicators (2011) was only 5.1%, or 50% lower than the LBW rate in Alabama.⁸ Although interventions to reduce the incidence of LBW in both developed and developing countries have been disappointingly unsuccessful, the percentages of LBW and infant mortality rates have consistently declined in Cuba over the past decade, from a rate of 9.0% in 1992 to 5.1% in 2009 (Figure 1).⁸ Such metrics suggest a tailored approach to prenatal care in Cuba that warrants additional investigation.
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Figure 1. Trends in percentage of low birth weight (LBW) for Cuba and USA from 1960–2010. Adapted from Index Mundi⁸ based on data from the World Bank.⁸ Source: UNICEF, State of the World's Children, Child Info, and Demographic and Health Survey by Macro International, 2011.⁸


To date, minimal research has been conducted to comparatively evaluate the established risk factors associated with birth weight outcomes among countries with significantly differing rates of LBW. For this reason, we searched the available literature about Cuba to estimate and compare the prevalence of known risk factors associated with LBW in Cuba and the United States, particularly in Alabama. In addition, we traveled to Cuba in February 2012 to meet with doctors, researchers, and maternal health care professionals at the Institute of Nutrition and Hygiene and the University of Havana for the purpose of discussing these significant differences and the Cuban methods and integrated services used to reduce the incidence of LBW.
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Comparing Risk Factors Associated With LBW in Cuba and Alabama

Although there are numerous factors associated with LBW, the major risk factors include maternal age, race, weight before pregnancy, weight gain during pregnancy, prenatal care, and use of tobacco and alcohol products.⁹ Socioeconomic conditions, nutrition during pregnancy, and anemia are also key factors that have been proven to influence the prevalence of LBW. In comparing the major risk factors between Cuba and the United States, particularly Alabama, prenatal care is the risk factor that is significantly better in Cuba. In contrast, there is a lower prevalence of several major risk factors for LBW, including smoking, anemia, and weight gain during pregnancy, in the United States and Alabama compared with Cuba. Although additional differences may exist in prevalence of risk factors between the countries, these were the only 4 for which there are data available to perform a comparative assessment. As such, the following sections draw contrast to the significant differences in the prevalence of these 4 risk factors in Cuba and Alabama.
Smoking

Smoking during pregnancy is among the leading preventable causes of adverse fetal outcomes such as LBW, small for gestational age, stillbirth, and sudden infant death syndrome.¹⁰ Because only a minority of women of childbearing age manages to quit smoking when they become pregnant, smoking among young women is the primary determinant of the prevalence of smoking during pregnancy.¹¹ During the past several decades, smoking among women of reproductive age has decreased in the United States. In 1965, 44% of women aged 25 to 44 years smoked. In 2000, these rates decreased to 23%.¹¹ In Alabama in 2009, 11.3% of 20- to 34-year-old women and 7.5% of women aged 35 and older reported smoking during pregnancy.⁷ Among Cuban women, the latest statistics available reported a smoking prevalence of 26.3% for women aged ≥15 years, according to the Pan American Health Organization^12,13; furthermore, results of a descriptive population-based study using smoking prevalence and mortality data in Cuba from 1995 and 2007 indicated that 15% and 16% of preventable deaths, respectively, were attributed to smoking.¹⁴

Anemia

Anemia is a global public health problem affecting both developed and developing countries. The resulting effect of anemia on pregnancy outcomes includes increased risk of maternal mortality, infant mortality, and poor fetal growth resulting in LBW.¹⁵ According to the World Health Organization Global Database on Anemia published in 2008, the estimate of anemia among pregnant women the United States was 5.7% (95% confidence interval [CI], 3.6–8.9).¹⁶ As a public health problem in the United States, anemia was rated as mild.¹⁶ According to the same database, the prevalence of anemia in pregnant women in Cuba was 39.1% (95% CI, 14.0–71.5). As a public health problem in Cuba, anemia was rated as moderate. Overall, iron deficiency anemia is the most common nutritional problem in Cuba.¹³ The updated dietary reference intake for Cuba (published in 2008) recommends an intake of 30 mg iron/day for pregnant women, which is higher than 27 mg/day recommended for pregnant women in the United States.¹⁷

Weight Gain During Pregnancy

Weight gain during pregnancy is a significant predictor of infant birth weight; furthermore, weight gain below recommended ranges correlates with increased infant mortality and LBW.¹⁸ The United States currently uses recommendations by the Institute of Medicine that are based on prepregnancy body mass index (BMI) categories and data on gains associated with the birth of healthy-sized newborns (approximately 3500–4500 g, or 7 lb 13 oz to 10 lb).¹⁹ For all gravidas except those deemed obese according to BMI (BMI >30 to 40 kg/m²), women who gain weight within these recommended ranges are half as likely to deliver newborns with LBW or who are small for gestational age compared with women who gain less.²⁰ Pregnancy weight gain below the recommended ranges is associated with increased infant mortality and LBW. According to the data, approximately 40% of U.S. women gain within the recommended weight ranges during pregnancy.²¹ Studies conducted in Cuba indicate that a total weight gain of <8 kg during pregnancy increases the risk of LBW.^21,22 For example, Escobar et al²¹ reported an adjusted odds ratio (RPO) of 3.27 (95% CI, 2.52–4.24) for LBW among women who gained <8 kg during pregnancy compared with those women who gained >8 kg during pregnancy. During the years spanning 1984 to 1990, the nutrition surveillance indicators used to guide the maternal care process in Cuba included (1) low weight/height at the beginning of pregnancy (below the 10th percentile of Cuban reference values), (2) insufficient weight gain (<8 kg at the end of pregnancy) and, (3) anemia (hemoglobin levels <11g/dL) during the third trimester.²³ The percentages of pregnant women at risk according to these 3 indicators were 8.7%, 5.5%, and 11.4%, respectively.

Prenatal Care

In the United States, the efficacy of prenatal care to lower infant LBW and infant mortality is controversial, and some researchers believe that it is difficult to evaluate the association between quality of prenatal care and birth outcomes.²⁴ With regard to adequate prenatal care (care initiated by the fourth month of pregnancy with 80% of recommended prenatal visits made), maternal and child health statistics in Alabama in 2009 indicated that only 72% of women received adequate prenatal care; several counties in Alabama reported that less than half (47.5%) of pregnant women receive adequate prenatal care.^7,25
In Cuba, the centralized Maternal-Child Program (Programa Nacional de Atencion Materno-infantil, or PAM) was established in 1970. PAM has the main responsibility of assuring the health of women of childbearing age. The success of PAM's efforts is documented by one of the most rapid declines in infant mortality ever recorded.²⁶ Under the leadership of this program, governmental sectors as well as community organizations collaborate to provide prenatal care and other health services to women and their children. Such services include free screening and diagnostic testing as well as the availability of maternity homes in every municipality to provide medical assistance and nutritionally balanced, calorically dense meals 24 hours/day to women with high-risk pregnancies.^26,27 According to World Bank data, 100% of pregnant Cuban women receive prenatal care, defined as medical and nursing care recommended for women before and during pregnancy.^3,6,28 Likewise, in Cuba the average number of prenatal visits per woman increased from 17.2 in 1992 to 23.6 in 1996.¹³
Although in most countries interventions to reduce the incidence of LBW are largely unsuccessful, implementation of universal health care with a strong focus on community-based services for prenatal care in Cuba has significantly reduced the prevalence of LBW over the past 20 years.⁵ For example, the MEDICC Review Cuba Health Report for Havana City indicates that the infant mortality rate, which was oscillating between 6.6 and 7.1 per 1000 live births since 2001, dropped to 4.9 in 2006, and the prevalence of LBW decreased from 5.6 to 5.4²⁹ As quoted within the report, the vice director of Havana's Health Department, in charge of the city's medical services, attributed most of this decline to well-integrated universal primary and secondary health care, particularly specialized prenatal care for high-risk pregnant women.
After reviewing the available research, we came to the conclusion that a strong emphasis on prenatal care, including integrated health services such as community-based clinics and maternity homes, particularly in disadvantaged communities in Alabama, may reduce the prevalence of LBW infants. With a modest investment in infrastructure combined with extensive public health strategy, education, and effective communication, Alabamians would be expected to benefit from a modified Cuban approach. With this hypothesis in mind, we traveled to Cuba to study the community-based approaches to prenatal care provided within the Cuban health care system, which has significantly reduced the rate of LBW and infant mortality in that country.


Previous SectionNext Section
The Cuban Approach to Monitoring Pregnancy Outcomes

In recent years, several articles have documented the Cuban primary health care system; to date, however, no research has been conducted to document the methodology and measurements used within the Cuban Health System for evaluating the nutritional status of pregnant women. Given the historical landscape of Cuba and its influence on population dynamics, including nutrition and food security, anthropometric charts developed outside of Cuba would not be expected to accurately reflect the Cuban population. For this reason, nutrition scientists at the Institute of Food and Hygiene with the support of United Nations International Children's Emergency Fund developed pregnancy weight gain guidelines and measurements for use within community-based clinics and maternity homes in Cuba. During our visit to Havana, we met with the developers of these guidelines and with researchers at the College of San Geronimo and the University of Havana. From these meetings, we focused our attention on 3 primary features unique to the Cuban health care system that differ from prenatal care approaches in the United States and Alabama. These include population-specific pregnancy weight gain guidelines, frequency of maternal clinic visits and screenings throughout pregnancy, and routine provision of free vitamin supplements to pregnant women.
Development of Cuban Weight Gain Guidelines

Data collected for the development of pregnancy weight gain guidelines for Cuban women was conducted over a 3-year period, during which nurses and dietitians in 15 municipalities around Havana were trained to accurately collect anthropometric data at the first prenatal care visit and subsequent visits throughout gravida.³⁰ The sample population from which data were collected to develop these nutritional assessment materials consisted of 6750 pregnant women between the ages of 20 and 39 years. Hierarchical linear models were applied to collected data to carry out predictions necessary to build charts of attained weight recommendations for gestational age according to height. Following multilevel modeling and statistical validation, 12 charts with recommended weight by gestational age for height were developed to assist the primary care team within each municipality and maternity home in evaluating the nutritional status of women during pregnancy. In addition, these charts were used to develop the Cuban Pregnancy Weight Gain Guidelines. These guidelines and measurements are used by health care personnel to classify gravidas as low, moderate, or high risk according to their initial BMI and subsequent weight gain during the second and third trimesters (Table 1).
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Table 1. Cuban Pregnancy Weight Gain Guidelines²⁵


Clinic Visits and Screenings During Pregnancy

Innate to the Cuban health care system, primary care physicians conduct 2 visits per year with each resident within their assigned municipality. The frequency of these visits is mandated by the Cuban government, and all physicians are held accountable for health care outcomes within the community that they serve, such that their employment as a community physician is based on the consistency of appropriate health outcomes and health care goals set by the government. For example, specific outcomes related to pregnancy for which community physicians are held accountable include incidence of LBW and infant mortality.
Upon conception, pregnant women are seen once per month during the first 33 weeks of pregnancy. At the first visit following conception, the level of nutritional risk will be determined using the mother's initial BMI. Additional measures of pre- and postnatal care are provided in Table 2. If the pregnancy is categorized as high risk according to the Cuban Pregnancy Weight Gain Guidelines, women are seen at more frequent intervals or referred to a maternity home for the duration of their pregnancy. In addition, all pregnancies deemed high risk will follow a “partogram” (“delivery gram”) or critical care route outlined for all clinicians attending to these women.²⁹ Under this innovative care plan, the care of each gravida will be transferred early in the pregnancy to the best-suited physicians and hospitals for delivering the newborns based on the individual conditions that place them at high risk. For all normal to moderate-risk pregnancies, twice monthly visits will occur during weeks 34 through 38, after which time weekly visits are initiated. Unique to the “Cuban model” is the fact that if the pregnant woman fails to show up to a clinic visit, the primary care physician will visit the home for the required visit. Also of interest, primary care physicians within each municipality deliver infants unless complications arise that warrant an obstetrician. In keeping with the comprehensive approach to health care in Cuba, the newborn and its mother are seen weekly by their primary care physician through the first 3 months of life, after which time mother and child will transition to monthly visits through the first year of life. Such comprehensive approaches to providing adequate primary care in Cuba have assisted the country in accomplishing an infant mortality rate lower than most other Latin American countries and United States and similar to that of Canada²⁶ (Figure 2).
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Table 2. Prenatal and Postnatal Care, Measurements, and Support Provided Through the Cuban Health Care System

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Figure 2. Trends in infant mortality rate in Cuba and the U.S., 1960–2010. (Data source: World Bank, World Development Indicators.)



Maternal Vitamin Supplementation

Within the Cuban health care system, all women who achieve menarche are provided iron, vitamin C, folic acid, and vitamin A supplements at no cost (personal communication, Dr. Maria Elena Diaz, professor and Chair of the Institute of Nutrition and Hygiene, Havana, Cuba, February 7, 2011). In addition, increased amounts of these same nutrients are provided routinely as maternal vitamin supplements at conception through the infant's first year of life as a feature of the prenatal care services provided at no cost to pregnant women. In addition to the free provision of maternal supplements, the Cuban population must consume a daily multivitamin at a minimal cost assumed by each individual. This government directive on multivitamin supplementation is tracked and reported by individual pharmacies selling the supplements, is supervised by the community physician at yearly visits, and is reported by the physician. Although the multivitamin must currently be purchased by individuals, the government dispensed the multivitamins door-to-door free of charge during preceding decades when the health of the Cuban population was suboptimal. The exact mechanism of tracking and reproach for not taking government-sponsored vitamins is not information that was divulged. Table 3 contrasts the Institute of Medicine's prenatal supplement recommendations for women at risk of deficiency with those nutrients provided by the Cuban multivitamin and maternal supplements.³¹ Regardless of the difference between recommendations and intake of supplements or the potential for patriotic reporting bias over the current health care system, Cuban birth weight outcomes are significantly better than most Western countries, and the provision of free maternal supplements is a remarkable feature of the Cuban approach to prenatal care.
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Table 3. Comparison of Prenatal Supplement Provision Through the Cuban Healthcare System and the Prenatal Supplement Guidelines for Women at Risk of Deficiency According to the Institute of Medicine



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Examples of Potential Programs to Change Prenatal Care Consistent With the Cuban Approach

There are several examples outlined below for implementing community-based prenatal care in the United States that will be considered for adaptation on a pilot scale.^32,33 In Alabama, efforts to develop outcome-based, community-oriented maternity clinics/homes are feasible in light of a major impetus from the Patient Protection and Affordable Care Act, which emphasizes preventive- and outcome-based medicine.
North Carolina, which is culturally similar to Alabama, recently (March 2012) started The Pregnancy Medical Home (PMH) program through cooperation between the North Carolina Division of Medical Assistance and the NC Division of Public Health and Community Care of North Carolina.³² The PMH program provides comprehensive, coordinated maternity care to pregnant Medicaid patients within 14 local networks of Community Care of North Carolina. Within each network, an obstetrician and an obstetric nurse coordinator are responsible for recruiting pregnant women and supporting practices adopted as part of the PMH program to reduce the incidence of LBW.
Another attractive approach for implementing community-based prenatal care in Alabama is a pilot program in cooperation with family practice physicians in the College of Community Health Sciences at the University of Alabama. In this program, local midwives, nurse practitioners, and social workers would work in conjunction with family physicians to provide comprehensive, coordinated, and integrated prenatal care within a single institutional setting. Recruitment assistance for this pilot program would be made possible through the Obstetrics and Gynecology Clinic at the College of Community Health Science's Family Practice Center, which currently serves mostly low-income, uninsured, or Medicaid patients. Since patient information and results of medical tests conducted at the Family Practice Clinic are fully computerized in one location, data collection as part of the pilot program could be accomplished through existing protocols.
Last, local churches may provide a practical vehicle for implementation of community-based prenatal care approaches. For example, a church-affiliated maternity home recently was opened in the small community of Fosters, Alabama, to house and provide prenatal care for up to 12 pregnant women.³⁴ The long-term effects of programs such as these are yet to be determined and would need to be followed and improved on for further implementation throughout rural and urban areas of Alabama.

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Conclusions

Although country-specific guidelines such as these are unique, the well-integrated Cuban approach to adequate primary care during pregnancy coupled with significantly lower rates of LBW and infant mortality warrant additional investigation as to the broader significance of population-specific guidelines and approaches across a broad range of economically challenged countries. With regard to the state of Alabama, the Cuban health care model represents a model system for evaluation and comparison with the state's current prenatal care system and policies. Implementation of strategies such as community-based clinics and maternity homes for high-risk pregnancies, similar to those implemented in Cuba, along with routine vitamin/mineral supplementation at no cost to pregnant women have the potential to significantly improve birth weight outcomes among Alabamians and the United States as a whole. Modifying existing prenatal care practice in the United States to a more flexible model, with frequency, content, and timing designed to meet maternal and fetal risk, may improve poor birth outcomes such as LBW. Given the challenges of providing affordable health care, sincere investigations and discussions of these strategies must occur at both the medical and governmental levels to effectively impact the health of future generations.

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Acknowledgments

The authors acknowledge Dr. Maria Elena Diaz, Professor and Chair of the Institute of Nutrition and Hygiene, Havana, Cuba, for her expertise about prenatal care in Cuba.

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Notes

• This article was externally peer reviewed.
  
• Funding: Funding for travel to Cuba was provided by the Alabama-Cuba Initiative, the College of Arts and Sciences, University of Alabama, Tuscaloosa, AL.
  
• Conflict of interest: none declared.

• Received for publication August 29, 2012.
• Revision received November 29, 2012.
• Accepted for publication December 3, 2012.

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[Polish_Silver]

Where the gold is?

I can't speak to the Affordable Car Act but Roberts has been coming across as increasingly off the deep end lately.

How much gold the U.S. Treasury and Fed have is not exactly a mystery. They publish precise data on it to the 1/1000th of an ounce monthly here.
----------------
Status Report of U.S. Treasury-Owned Gold

Return to Gold Report Homepage
Current Report: December 31, 2013

Summary	Fine Troy Ounces	Book Value
Gold Bullion	258,641,878.074	$10,920,429,098.79
Gold Coins, Blanks, Miscellaneous	2,857,048.173	120,630,859.37
Total	261,498,926.247	11,041,059,958.16
Mint-Held Gold - Deep Storage
Denver, CO	43,853,707.279	1,851,599,995.81
Fort Knox, KY	147,341,858.382	6,221,097,412.78
West Point, NY	54,067,331.379	2,282,841,677.17
Subtotal - Deep Storage Gold	245,262,897.040	10,355,539,085.76
Mint-Held Treasury Gold - Working Stock
All locations - Coins, blanks, miscellaneous	2,783,218.656	117,513,614.74
Subtotal - Working Stock Gold	2,783,218.656	117,513,614.74
Grand Total - Mint-Held Gold	248,046,115.696	10,473,052,700.50
Federal Reserve Bank-Held Gold
Gold Bullion:
Federal Reserve Banks - NY Vault	13,376,987.715	564,805,850.63
Federal Reserve Banks - display	1,993.319	84,162.40
Subtotal - Gold Bullion	13,378,981.034	564,890,013.03
Gold Coins:
Federal Reserve Banks - NY Vault	73,452.066	3,101,307.82
Federal Reserve Banks - display	377.451	15,936.81
Subtotal - Gold Coins	73,829.517	3,117.244.63
Total - Federal Reserve Bank-Held Gold	13,452,810.551	568,007,257.66
Total - Treasury-Owned Gold	261,498,926.247	$11,041,059,958.16

Deep Storage: Deep-Storage gold is the portion of the U.S. government-owned Gold Bullion Reserve that the U.S. Mint secures in sealed vaults, which are examined annually by the Department of Treasury's Office of the Inspector General. Deep-Storage gold comprises the vast majority of the Reserve and consists primarily of gold bars. This portion was formerly called "Bullion Reserve" or "Custodial Gold Bullion Reserve."


Working Stock: Working-Stock gold is the portion of the U.S. government-owned Gold Bullion Reserve that the U.S. Mint uses as the raw material for minting congressionally authorized coins. Working-Stock gold comprises only about 1 percent of the Reserve and consists of bars, blanks, unsold coins, and condemned coins. This portion was formerly listed as individual coins and blanks or called "PEF Gold."
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I do not believe that they are lying.

The question is why does the U.S. have so much gold, 8171 tons to be exact, far more than any other country, and more than Germany, Italy, and France combined, with a market value of $322 billion?

The combined market value of the 15 largest national and institutional gold holdings, including the IMF and BIS, has a market value of over $1 trillion.

For what?

The answer to that question is the reason to own gold.

I have read that the gold is not only in Ft. Knox, but also at West Point, the Army academy.

I still think the hoard should be audited by someone outside the government. It's like the fed auditing banks . . .

[jk]

Re: Where the gold is?

the gov't runs the va health system pretty efficiently, and medicare also has low bureaucratic overhead. medicare would be even cheaper, except it was forbidden from negotiating drug prices when medicare part d was written, back when billy tauzin was head of the relevent house committee.

oh yeah, billy is now in the private sector. when he first retired from congress, only a few months after overseeing the creation of part d, he became "the head of the Pharmaceutical Research and Manufacturers of America, or PhRMA, a powerful trade group for pharmaceutical companies." [from wikipedia]

here's more:
"As head of PhRMA, Tauzin was a key player in 2009 health care reform negotiations that produced pharmaceutical industry support for White House and Senate efforts.^[8] Reportedly, proposals for Medicare Part D cost reductions and permitting drug importation from Canada were dropped in favor of $80 billion in other savings.
Tauzin received $11.6 million from PhRMA in 2010, making him the highest-paid health-law lobbyist.^[9]
Tauzin now is on the Board of Directors at Louisiana Healthcare Group."

[BadJuju]

Re: Where the gold is?

I know I'm pretty loopy, so I feel reasonable calling PCR loopy as well. Just look and listen to the guy. He is unhinged. While he may weave some truths into his writings, they are overwhelmingly driven by speculation and spurious accusations.