WASHINGTON -- The American Medical Association came under scrutiny Tuesday from members of a House subcommittee who wondered why the association hasn't been doing more to address the nation's high maternal morbidity and mortality rate, especially when it comes to women of color.
"What is the AMA doing about this [problem]?" Rep. Anna Eshoo (D-Calif.), chairwoman of the House Energy & Commerce Health Subcommittee, asked AMA president Patrice Harris, MD, a witness at the subcommittee's , and herself an African American. "It seems to me you can track the hospitals where women of color [go]. I think the statistics are really very clear. This is not a foggy picture. What was the AMA doing before you came to the witness table? Have you targeted the hospitals? Is it red light and siren to do something?"
Eshoo was particularly interested in whether the AMA was focusing on hospitals that have higher-than-usual rates of maternal mortality -- a topic discussed by another witness at the hearing, Elizabeth Howell, MD, of the Icahn School of Medicine at Mount Sinai in New York City. "There is value in hospitals developing standards, and that would be the recommendation, and that those standards would include metrics for evaluation," replied Harris.
"That hasn't begun yet in terms of the AMA partnering with hospitals?" Eshoo asked. Harris said it had not but noted that the AMA had recently hired its first to work on such matters. Eshoo interrupted Harris, acknowledging that the hiring was a "first step ... For the life of me, I don't understand why doctors aren't trained in this. Where have we gone wrong? Is their training not up to snuff?"
Discrimination Issues
On the other side of the aisle, Rep. Brett Guthrie (R-Ky.) discussed the issue of bias, noting that Howell had testified that in studies that control for education level and insurance status, African Americans and women of color are still treated differently than whites. "We need to make sure this is taken care of," Guthrie said. "What's going on? Is the AMA trying to address this internally? What do you think it is?"
"I think we're trying to find the answers to those questions," said Harris, noting that the association's Center for Health Equity is just getting up and running. "This is one of the areas we want to focus on. For whatever reason -- racism, discrimination, or implicit or unconscious biases -- African-American women are not being heard. We are trying to find solution and spread that to the medical community."
Guthrie did not seem satisfied. "It's disturbing that the healthcare profession is not addressing this better than they are," he said.
Subcommittee members appeared very moved by , whose daughter, Shalon Irving, was an African-American epidemiologist at the CDC who died 3 weeks after her daughter was born, despite repeated attempts to get physicians to take her complaints seriously.
"Imagine the many epidemiology victories Shalon could have generated if only her medical providers had listened to her and addressed her cries for help," Irving said. "Not every maternal mortality is from lack of access [to healthcare or education]. Most pregnancy-related deaths can be prevented."
But the solutions have to be the right ones. "Sending medical folks to implicit bias training is not going to fix this problems without a redesign of medical school curricula," she said. "Preventable death among black women has become a national disgrace."
Looking for Best Practices
Howell gave numbers to further illustrate the point. "Every year, around 700 women [in the U.S.] die from pregnancy-related causes," she said, adding that the leading causes of maternal death include heart conditions, hypertension, and blood clots. In addition, "For every death, over 100 women face a life-threatening [pregnancy] complication ... every hour six new moms will have a tragic event like a stroke, blood clot, or kidney failure ... If we raised the quality of care for pregnant women, we could lower the rates of these tragic events." Howell recommended development and expansion of state perinatal care quality collaboratives, which share data and best practices for perinatal care.
David Nelson, MD, chief of obstetrics at the Parkland Health and Hospital System in Dallas, discussed some of the "best practices" his hospital uses in its 44 labor and delivery rooms. "We have four hemorrhage carts on our unit ... we debrief every time we use [emergency] protocols, to understand if there are opportunities to learn from nurses or physicians. We also perform daily huddles every day for scheduled surgeries," and have dedicated healthcare teams for certain types of cases, Nelson explained.
Rep. Robin Kelly (D-Ill.) talked about legislation she is sponsoring to tackle some of the problems. "Our laws can change the way care is delivered in our hospitals," she said. "Our laws can support the collection of consistent data on who dies on the way to motherhood, and why ... The time has come for action; we've already lost too many mothers." Kelly is sponsoring the , which would provide technical assistance to state morbidity and mortality review committees (MMRCs). Currently, some women are eligible for CHIP or Medicaid coverage 60 days after giving birth; the bill would extend the time period to 1 year.
Rep. John Sarbanes (D-Md.) applauded the idea of extending Medicaid coverage. "It's important to recognize that forcing people to change plans at a very, very critical time can generate negative consequences." He asked Usha Ranji, associate director for women's health policy at the Kaiser Family Foundation, what happens to women who lose their coverage after 2 months.
"It depends on where you live," Ranji said. "Some women are able to continue on Medicaid, some may be able to get subsidies to purchase private insurance, and some may be uninsured. But [this] 'churning' does have an impact ... Churning can negatively affect access to care and result in delays in care and having to switch providers."
Use of Alternative Payment Models?
Rep. Jan Schakowsky (D-Ill.) asked Howell about the idea of using value-based payments to incentivize hospitals to provide better postpartum care. "I think we need more work on alternative payment models ... [but] I do worry about the unintended consequences, specifically, that certain hospitals will be penalized if we don't do this right" because they tend to have sicker panels of patients.
Some subcommittee Republicans complained that none of the bills the subcommittee was considering were sponsored by Republicans. "I'm dismayed at the way this legislative hearing came together," said Rep. Greg Walden (R-Ore.), ranking member of the full Energy & Commerce Committee. He specifically mentioned one bill by Rep. Larry Bucshon, MD (R-La.), the , which had bipartisan sponsorship. "I don't understand why we wouldn't have had that on the docket for consideration as well." He called on the subcommittee to have another hearing to consider Bucshon's measure.
But Eshoo said that many of the measures in the Republican bill were already part of a bill already passed by the Senate Health, Education, Labor & Pensions Committee. "The issues are there; they're being addressed," she told 51˶. "The specific bill they raised -- not that dates make a difference -- but it was just introduced on Sept. 5. This is not something that has been around for years. But the most important thing is content, and the content is there."
"They'll have an opportunity to not only weigh in, but to vote for these issues," she continued. "It matters not to me whose bill it's in. I want to make sure we have the right substance in the bills and pass them on a bipartisan basis, and I believe we can."