OB-GYN-L Messages for October, 1996: Multiple Hormone Testing

Multiple Hormone Testing

From: D. G. Huffman

perinatl@slip.net

Tue Oct 1 07:45:24 1996

1) ACOG addresses the issue of multiple hormone screening in Committee Opinion 141. It states that for women less than 35 years of age (at EDD), the test should be OFFERED [emphasis mine] at 15 - 18 weeks of gestation. It states that screening should be "voluntary and based on informed consent." I do not know whether or not ACOG has a recommended informed consent.

It would seem that ACOG is, by default, setting the standard. I am sure there is not a plaintiff's attorney in this country who is not familiar with ACOG publications and who would not attempt to apply the obstetric publications to anybody practicing obstetrics, whether board certified OB/GYN, other OB/GYN, FP, Nurse Practitioner, etc. (ACOG recently changed the name of their "ACOG Technical Bulletins" to "ACOG Educational Bulletins" -- perhaps they think there is less legal liability induced if they change the name of the publication. I suspect the lawyers will still look to the "ACOG Educational Bulletins" just as they have looked to the "ACOG Technical Bulletins" in the past.)

It is interesting that for women who will be 35 years of age, or older, at the EDD, multiple hormone testing is not recommended in the ACOG publication. I suspect that this is at least part because of the fear that anybody would be able to hire an expert witness to say that not doing (or offering) amniocentesis at age 35 or older is outside the scope of standard of care. (The document gives other reasons for not offering the test to women at or above 35 years of age, which are also valid, but I suspect they are not the real reason.) I offer multiple testing to women at or over 35, but I document that it is offered not as an alternative to amniocentesis, but rather as a test that is available to those who have chosen not to do amniocentesis. I also point out that other chromosome abnormalities, which may also be at increased risk above age of 35, are not detected by the test, such as (but not limited to) sex chromosome abnormalities, trisomy 13 and trisomy 18, although some trisomy 18's are found by hormone tests using estriol.

2) For members of ACOG, there is a web page that has all of the ACOG publications. It can be reached at <http://www.acog.com>. (The reason the address is <http://www.acog.com> rather than <http://www.acog.org> is that the Atlanta Committee for the Olympic Games -- ACOG -- got to acog.org first. Apparently they have told the College that it can have acog.net in 1997.)

3) Finally, there was a US Supreme court decision in 1988 or 1989 that dealt with Medicaid payments to hospitals. The case is Wilder v. Virginia Hospital Association, 496 U.S. 498 (1980). I cannot find that decision the internet. Basically it says that the Medicaid law says Medicaid must pay for care based on a reasonable evaluation of the cost of the care in the area. It increased payments quit a bit in Virginia and I suppose it has been applied elsewhere. On the other hand, the recent welfare "reform" legislation may have completely rendered that decision inoperable. Let me quote from: <http://www.proskauer.com/72125.htm>

"Another conceivable modification to the Boren Amendment (or any substitute standard) could be to restrict providers' access to the courts to enforce the payment standard. Although the United States Supreme Court, in Wilder v. Virginia Hospital Association, 496 U.S. 498 (1980), clearly held that providers have a private right of action through 42 U.S.C. § 1983 to enforce the Boren Amendment, Congress could effectively overrule this decision in structuring a block grant system. For example, Congress could specifically prescribe the circumstances under which providers may seek judicial redress and/or limit the forums in which actions could be brought. Indeed, the National Governor's Association already has proposed a cumbersome and lengthy HCFA administrative process that, if adopted, would make it extremely difficult for providers to seek prompt redress for unreasonable reimbursement systems. "

Dean Huffman

-- ========================== ================ Dean G. Huffman Phone: 217 787-3745 FAX 217 787-0680 (Home) perinatl@slip.net 217 782-9666 217 524-2432 (Office)

Heisenberg might have slept here. H ========================== ================

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