Who’s a Doula?

By AzPHA Member Prashanthinie (Prashi) Mohan, MBA

Over the last few years, there has been more and more focus on the triple aim – improving patient experience, reducing costs, and improving population health. Accomplishing these goals requires the system to be creative and actively look for new approaches to lowering costs while improving outcomes.

Doulas are increasingly being recognized as a professional that can do just that. 

Several studies have shown that moms who have doula services during their pregnancy and delivery have fewer cesarean sections and epidurals, reduced premature births, higher rates and a longer duration of breastfeeding. In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal medicine issued a consensus statement which explicitly stated that published data has indicated better labor and delivery outcomes when continuous support personnel such as doulas are used.

So, we’ve got better outcomes covered, what about lower costs?

Recent evidence on the return on investment for doulas is encouraging. In addition to improving birth outcomes, doula coverage can also be cost effective (if not cost saving) to Medicaid programs. Doula coverage can help reduce costs by lowering the rate of pre-term and cesarean deliveries. One study conducted across 10 states computed an average savings of $986 per doula supported birth.

Despite the evidence on doula-supported births, only 6% of U.S. women who give birth are estimated to have doula support. Low income women and women of color, who are the most likely groups to want doula services, may not be able to afford doula services, which can cost $500 to $750 per birth in Arizona.  Because few health plans currently reimburse for doula services, most women are unable to take advantage of the improved outcomes and enhanced birth experience that doulas provide.

Licensed and culturally trained doulas who are from the minority communities can not only provide emotional support during the prenatal period and the delivery process, but can also help facilitate key communication between the mother and her care providers.

The question is, what are we waiting for? Doulas have proven to be effective in improving birth outcomes cost effectively in other states in the U.S. It’s time Arizonans start looking into how doula services can be efficiently reimbursed for the mothers in our state.

Take Your Understanding of Health Policy Beyond the Classroom

ASU’s College of Nursing and Health Innovation is excited to announce our new  Health Policy Academy.  It’s a 4-week program designed for new and transitioning professionals interested in the policy, politics and advocacy affecting public health today.  There is 3 weeks of intensive online training and three days of in-person experience at the Arizona State Capitol, and participants will receive practical tools to better navigate and impact the world of health policy.  This inaugural cohort will take place from September 10 – October 4, 2018. 

The Health Policy Academy is now accepting applications and the deadline for applying is Friday, August 31, 2018. Come join this talented group and develop the skills and connections to effect meaningful change!   Learn More about the Health Policy Academy

Program Particulars:

  • September 10-30, 2018 – Online Self-Guided Modules
  • October 2-4, 2018 – In-person Workshop at Arizona State Capitol
  • Price: $550  Apply Here

Federal Policy Decisions Eroding Health Insurance Stability

It’s been a few weeks since I’ve written about what’s happening with the Affordable Care Act- and there’s been some recent action- so here goes.

First of all, there’s good evidence that stable health insurance coverage helps people get preventive and primary care services that improve outcomes and downstream healthcare spending.  The Affordable Care Act included several provisions that helps people get these kinds of preventive services.  One of the primary goals of the ACA was to create broad access to robust health insurance coverage through: 

  • Employer mandated coverage for large employers;
  • An mandate to be insured or face a tax penalty to encourage full participation;
  • Subsidies and out-of-pocket protections for purchasing in the individual federal marketplaces;
  • Guaranteed issue and community rating of premiums;
  • Expansion of Medicaid to low-income adults; and
  • Ten essential health benefits for all marketplace insurance sold on the individual federal marketplaces, which includes requirements to cover services for mental health, substance abuse, and reproductive health.

It’s been working.  In the last several years the percentage of uninsured working-age adults decreased from 20% in 2013 to 12% by 2016 (nationally).  It would have been an even bigger decrease if all states had expanded Medicaid.  This  coverage expansion has led to increased access to preventive services, higher rates of having a usual source of primary care and increased affordability of care. 

However, progress is now stalling because of policy changes that have been made by the President like:

Cost Sharing Reduction Payments Stopped

In October 2017, the President announced that he was ending cost-sharing reduction payments (a program that previously reimbursed health insurance companies for the out-of-pocket protections available to some individuals who purchased coverage on the individual marketplaces). This caused higher premium rates in the individual marketplaces this year. 

Short Term Health Plans

The President also issued Executive Order 13813, which expanded “association health plans” and short-term, limited duration insurance. These plans create parallel markets in which healthier individuals move to cheaper plans that offer barebones coverage, destabilizing the marketplace.

Last week HHS and the US Department of Treasury followed through on the EO and issued a final rule that will allow consumers to buy short-term health plans to provide coverage for up to 36 months. These plans don’t need to comply with ACA requirements like covering essential health benefits, pre-existing conditions or the requirement to sell to any consumer regardless of health status.

These plans will likely attract younger, healthier and drive them out of the risk pool, which will increase costs in the ACA compliant plans.  It’s estimated that about 600,000 Americans will enroll in these short-term health plans, increasing federal spending on marketplace subsidies by $200M in 2019 and $28B over ten years.

Individual Mandate Effectively Expiring

As part of the new federal tax law, the individual mandate tax penalties will be $0 starting on January 2019, which will further erode the goal of increasing coverage and stabilizing insurance markets. In July 2018, the Commonwealth Fund predicted that eliminating the tax penalty will result in at least 2.8 million fewer Americans with coverage.  The nonpartisan Congressional Budget Office estimates that the number of people with health insurance will decrease 4M by 2019 and 13M by 2027.   CMS also cut funding for the federally-facilitated Exchange Navigator Program which will also contribute to decreased enrollment rates.

Risk Adjustment Payments

CMS announced in July that it would freeze $10.4B in 2017 risk adjustment payments. Luckily CMS released a final rule a couple of weeks ago to reinstate payments, so that’s an additional destabilizing thing that thankfully won’t happen at least for now.

Everyone benefits from access to primary and preventive services (including behavioral and reproductive health services), specialty care, and culturally appropriate care. If the individual insurance market continues to destabilize or doesn’t include affordable plans that offer comprehensive services, consumers may face expensive and inaccessible healthcare options. 

Many of the decisions that the President has been making make that outcome more likely in my opinion.

Loneliness as a Public Health Threat

I was surprised to learn this week that loneliness raises the risk of premature death by up to 50 percent-that makes loneliness a public health hazard on the scale of smoking and alcohol. Yet many medical and public health professionals haven’t heard about how many risks it poses.

Loneliness means that a person has a small support network and minimal interpersonal contact, and it becomes more common with age.  When a person’s children move or a spouse dies many people find it harder to engage in social activities. Seniors in rural areas are particularly susceptible. Geographic isolation and lack of public transportation combine to keep them alone.

Lack of human contact has serious physiological consequences. Studies show that without human contact our risk of functional decline increases as does our risk of mobility loss. The risk of clinical dementia goes up by 64%.   These health problems further isolate those suffering from social isolation, threatening a vicious cycle of physical, emotional, and psychological decline.

Better support access to existing services is a good start as an intervention.  For example, programs like Meals on Wheels can identify isolated seniors and connect them with resources to reduce loneliness. Other places like churches and city senior centers also serve as important community connectors and potential evaluation and intervention points for lonesome people.

Medicare could prioritize coverage for programs like SilverSneakers which keeps seniors active and creates opportunities for social connections through group exercise.  The Welcome to Medicare and annual Medicare exams could provide opportunities for screening and interventions.  

Medicare Advantage plans could cover benefits to address social isolation.  With an ROI analysis, interventions to reduce isolation could reducing health care costs (the triple aim) while improving outcomes. Developing a reliable tool to screen seniors for social isolation would help as well. 

There’s Hope for More Valley Fever Research Funds

Representatives Kyrsten Sinema and David Schweikert introduced a bill last week that, if it passes, will increase the funding that’s available for valley fever research.  The bill supports new research and incentivizes the development of innovative treatments to fight the disease. The bill would:

  • Provide incentives to researchers working to find new treatments for Valley Fever;
  • Streamline the approval and review process for new treatments of the disease;
  • Direct HHS to conduct research on Valley Fever and sets up a Valley Fever Advisory Committee to oversee the work; and
  • Establish a grant program to facilitate Valley Fever research by universities, hospitals, and non-profits.

Valley fever (Coccidiomycosis) treatment research funds are extremely limited, in part, because it’s a regional illness (unique to the desert southwest).  If the entire country were susceptible to the illness, there would probably be more private research funds invested because there would be a large commercial market for a treatment. 

Basically, that’s why we need an investment of federal funds and policy, because the return on the research investment for valley fever isn’t adequate to recoup costs of developing a treatment because not enough people are susceptible to the illness (because it’s limited to the desert southwest).

Can Medical Marijuana Card Fees Pay for Drug Treatment in AZ?

This week AZ Attorney General Brnovich wrote an Opinion stating that state lawmakers (or presumably the ADHS) can use qualified medical marijuana patient card fees to operate programs to help get people off of other drugs. The Arizona Medical Marijuana Fund (administered by the ADHS) contains more than $44M right now (the fund consists of fees paid by patients for cards, other card fees like dispensary agent cards, and dispensary application fees). 

Here’s a simple Q & A from this week’s Opinion:

Q. Could the Legislature, through the budget process, direct the ADHS Director to appropriate some of the Fund monies to help people addicted to drugs?

A. Yes.  The Legislature may direct the ADHS Director to spend Fund monies for programs to help people addicted to drugs if: (1) the appropriation is passed with a three-fourths vote of each legislative chamber; (2) the appropriation does not deplete the Fund and leave insufficient revenues to cover the immediate and future costs of the initiative; and (3) the appropriation furthers the purpose of the AMMA, i.e., it relates, in some way, to medical marijuana.

The AG Opinion states that:

“The Legislature may direct the ADHS Director to expend monies from the Fund for programs to help people addicted to drugs if: 1) the appropriation is passed with a three-fourths vote of each house; 2) the appropriation does not deplete the Fund and leave insufficient revenues to cover the immediate and future costs of the initiative; and 3) the appropriation furthers the purpose of the AMMA.  

To that end, an appropriation for activities related to distinguishing between medical and nonmedical uses of marijuana, protecting patients and providers from criminal prosecution, or carrying out, implementing, or administering the AMMA would meet this criterion.  If these requirements are met, it is not necessary to submit an appropriation request to Arizona’s voters.

Dr. Bob’s Travelogue 9- “Roots”

Part 9 – Roots

From what I know of my genealogy, I am a true American mongrel – a little bit of everything.  At least, everything northern European, with a little other thrown in.  But Nancy and her family are evidence of pure-bloods, and it became obvious on our most recent two trips.  First, we traveled to Turku, Finland, to hook up with Dawn and Anthony, where he was attending a conference. 

Finland was a joyous and somewhat surreal experience.  Joyous in hanging with our daughter and son-in-law (seeing her come across the main square at the university was one of those pure moments I’ll carry forever).  Surreal in that I was clearly in the land of Nancy’s gene pool.  (For those of you who don’t know, Nancy is 100% Finnish, all four grandparents having immigrated to the US). 

Everywhere I looked, it was chock full of close family resemblances.  The very first day, Dawn, Ant and I were walking behind Nancy on the street, remarking “There’s her long-lost sister.  There’s another.  And another…”

During a medieval street festival, Nan herself spotted the doppelganger of her brother, John.  Here are their pics.  See for yourself.



Nancy's brother

Nancy’s brother

This Finn gentleman was one of a group performing medieval “music” on animal horns.  Think: a kindergarten kazoo band.  It was impossible to hit any actual notes on those things, and the six-part harmony between them was something beyond description.  Yet they persisted.  And it was somehow incredibly entertaining.  Who says the Finns have no sense of humor?

Speaking of breaking ethnic stereotypes, we found the Finns to be incredibly friendly and welcoming, albeit a quiet people, and nearly all we met spoke at least some English.  And their country is incredibly beautiful.  Cafes strewn the length of the river as it ran through the city, historic buildings to include a castle with an amazing tour.  Bucolic forests, rivers and mountains.  And just to fit my night owl personality, even though we were in the southern part of the country, 24 hours of daylight while we were there.

It all left a warm, safe feeling in me as we left for Italy to meet several of Nan’s family for a week-long retreat at Lake Como, in the far north of that country.

Upon our very arrival at the airport, one could tell it was a different place.  Children playfully rode atop rolling suitcases which they aimed smack into travelers, squealing with delight when they could really catch one by surprise.  Moms were right there, ignoring them, perhaps cherishing a moment of peace for themselves.  As we waited at the car rental counter, one man went berserk and laid into the staff for some perceived slight, at a volume and with an exuberance that would make the author of the most stereotypical, bad Hollywood screenplay about Italians blush.

Clearly Toto, we weren’t in Kansas anymore.  Or in Finland.

We had to wait a few hours for an available rental car, so we decided to eat lunch at the airport.  I helpfully pointed to a restaurant listed on an airport map, on the far top level, away from all others, hoping to escape the madding crowd.

As we headed for the escalator, we found ourselves behind a group of slightly older (perhaps 70s) French travelers.  There was one man and several women, each dragging impossibly large pieces of luggage.  They stood at the base of the escalator, looking upward at the ascending staircase, then down at their bags, then furtively about in search of a non-existent elevator, then back down at their bags.

I speak no French, but it was obvious that they were engaged in earnest discussion about whether they should try it.  Finally, one brave woman ventured forth, pushing a bag in each hand, and took the plunge.  Literally.

She went head first over both bags as soon as she stepped onto the moving staircase, but managed to prop herself up on them to right herself, and rode them to the top.  Two others followed without incident, and it seemed that they had found their groove, as we waited patiently in the rear.  I glanced elsewhere.  Then I heard it.

It was a subdued cry, unlike the gentleman at the rental counter who was still at full throttle.  Then her friends began yelling.  The lack of translation made the situation no less understandable.  I turned to see a hapless old lady flat on her back upon the escalator steps, feet flailing above her, her head down below, her massive suitcase on top of her, and a cane several feet behind her.  For some reason it was noticeable that one of her flailing feet had lost its shoe.  She tried in vain to raise her head even an inch above the step upon which it lied to protest her position, and helplessly glided toward a less than glorious arrival at the top.

Nancy dropped everything and ran past her friends, up the steps toward her.  I briefly searched for an emergency stop button for the escalator, but seeing none, followed.  It proved impossible to quickly lift her to her feet.  There we were, seconds from the top, trying to hold her head and body up enough to prevent her hair or clothing from being snagged by the teeth of the contraption.  Suddenly, someone found the stop switch and we came to an abrupt halt with her feet inches from the summit.

Have you ever tried lifting someone to their feet when they are flat on their back, on stairs, head pointing down catawampus, and to begin with, they walk with a cane?

Once the calamity was settled, we schlepped our bags to an actual elevator (at the other end of the building, naturally), searched around, and eventually followed our map to a deserted, narrow hallway lined with airport offices and decidedly uninviting signage, until finally reaching our destination.  As it turned out, it was the employee cafeteria.

Yes, all of this to reach a few tables occupied by persons in uniforms, staring at us.  But thankfully, they let us eat there.

The drive from the airport was uneventful until we inevitably reached the narrow, winding streets of small Italian towns clinging to the hills surrounding Lake Como.  Blind curves and spots that require cars to stop so that oncoming traffic can squeak by.  It was just like British country roads, except decorated with honking and the occasional “have a nice day” hand gesture.  At least they drive on the correct side of the street.

I exaggerate… to some extent.  The villages here are lovely, the villagers are mostly friendly, and the area has been a retreat destination for millennia. 

At one old church, I inspected a plaque upon a wall, dedicated to someone or something I could not decipher, but which by its Roman numerals had been placed there in the 1930s, although the church itself was much older.  I’m sure you’re familiar with historic markers that end with the names of government dignitaries at the time of the monument’s erection.  Lots of public buildings or makers in Arizona will list county supervisors, or a mayor, or the governor at the time.  I confess that in this case, it was a bit startling to see, following other names and as a matter of course, “Benito Mussolini.”

A sobering reminder that history plays out as merely a string of current events.

We walked cobblestoned hills, took boats about the lake, and took the kids on a “train” that runs upon the street between the towns.

Ah yes, the kids.  Our grand-nephews are here, Matt and Will, ages 3 and 6, respectively.  Naturally, they were the center of attention of the 8 adults there, and are really good little boys.  I was repeatedly  serenaded with “Bobo, the walking talking cat, hoo hoo,” a tune about me (Bobo) written long ago by my then 6 year-old daughter and her friends, which was shamelessly taught to these boys by my brother-in-law, who eggs them on at every opportunity.  Another generation.

Will is quite smart, as demonstrated, among other things, by his ability to outplay me in Rummikub, pronounced “Rummy Cube.”  They are both artists, which of course all children are until society beats the natural creativity out of us.

I mention this because Will presented me with the most accurate portrait I’ve ever seen of myself.  Witness the attention to detail in this work of art.  Note: I believe that the ears were drawn first.

will the kid.jpg

Of all of us, only Nan’s sister, Martha, speaks Italian.  She sounds beautiful in her more-than-passing conversation with the locals, remarkably retained from her college days.  The rest of us, for reasons that are inexplicable, assume that the language is some sort of broken Spanish, and keep trying to insert palabras de Español among our English, making no sense at all to the locals.  Perhaps it’s because the heritage of my brother-in-law, Fred, and thus of his offspring, is Italian.  So it feels incumbent upon us all to at least try.

And try he does, once intoning cheerfully to the befuddled staff of an establishment as he entered, “Buenos Aires!”

Blank stares.

One morning, he took the kids and their parents off walking in this hamlet of perhaps a thousand locals.  Being from Massachusetts, he said they were going off in search of a Dunkin’ Donuts.  Fred has a special kind of determination.  It was a miracle that they ever returned.

Fred’s initial plan for the last day was to hit every one of the “10 best things to do at Lake Como” before we all had to leave the day after.  Thankfully, our slothful selves prevailed, and more reasonable adventures were pursued.

After the final harrowing drive from Lake Como, we dropped Fred and Martha at the airport and settled in to spend a final couple of days in Milan.  Once we’d checked into our hotel that afternoon, we were desperate for food, but nearly everything was closed.  From 2:00 or so until 7:00, perhaps even 8:00 pm, nearly everything closes up shop – stores, restaurants, cafes, even bars were all barred up.

At last, we found a true hole-in-the-wall.  With a small entry and counter, you might dismiss it as some tiny convenience market but for a chalkboard menu on the sidewalk.  But if you walk in and behind the cash register, there’s this huge patio and indoor seating area hidden directly behind.  We sat inside, totally by ourselves, due to the afternoon siesta that nearly the whole city seems to take. 

When we opened our mouths to speak, one of the wait staff, who spoke only Italian, knew enough to say, “Oh, Americans,” and brought us different paper placemats than any of those on the other tables.  They were clearly directed to Americans, alright.  In English, the printed placemats read:  “Guide to mindful eating: Slow the Hell down!  Chew your food!  Put your fork down between bites!”  And then, in one corner it added: “Ignore health advice: Low fat, low carb, blah, blah, blah.”

The food was, predictably enough, good and plentiful.  We had been rescued.

Everything in central Milan seems built to impress.  Really grand structures.  At the plaza Duomo is a magnificent cathedral, begun in the 14th century and not completed until 1805, and is one of the most ornate structures I’ve ever seen.


But immediately next to it is this other incredibly ornately decorated monument, soaring an exaggerated four stories, bearing the dramatic inscription, “A Vittorio Emanuele Il I Milanesi.”  The number of persons passing beneath its arched entry far outnumbered those visiting the cathedral itself.  What could this be, we wondered, A museum?  A palace?  Official government offices?  We searched online, and found this to be a monument to what Milan is truly all about – a shopping mall.

Seriously.  This massive, ornate structure was built 150 years ago as a shopping mall, which it still is.  You think America has cornered the market on materialism?  Think again.  At least the “food court” was a clear step up from ours.

‘Best way we found to casually cruise the city was to ride around on any of several historic street cars (San Francisco purchased theirs from Milan).  We set off to do so one day, and should have stuck to that plan.  Instead, we thought we’d hop on and off.  And hop off we did, to see another super-sized structure, Sforza Castle.  Medieval in origin, it had Renaissance and later repairs and additions, but was more massive than anything I’ve yet visited in the UK.  At one point, we sat down at a café in the center of one of its squares.  Nan had her cell phone on the table, planning the rest of our route.

Abruptly a young woman began jabbering away in Italian at us, laid a laminated poster upon our table, which seemed to be something about a lost cat.  One could not help but notice that she was breastfeeding her infant, by simply hiking up her t-shirt to provide the necessary access to her babe in arms.  She had another young friend with her, also breastfeeding.  I tried to avoid eye contact, even as we repeatedly tried to say we spoke only English.  She plaintively continued, seeming to beg for some sort of assistance, then exasperated, scooped up her laminated paper and departed as abruptly as she had arrived.

It took Nancy less than a minute to ask, “Where’s my cell phone?”


She took it!!

I bolted in the direction our pickpocket had exited, and searched desperately, to no avail.  To one side, I noticed a patrol car.

We had already seen numerous officers during our brief time in the city.  “Polizia Locale” officers were plentiful.  They were uniformed, had marked cars, carried guns.  We had actually earlier mused about why they didn’t say “City of Milan” on their uniforms.  I sprinted toward the car and described my plight to the officer who spoke just a little English.

“Oh, I understand.  But I am not a real police officer, I am only a local police officer,” he tried to explain to his incredulous visitor.  He proceeded to give me handwritten directions to a real police station about a mile away, where I could file a report.

He was unable to take a report himself.  Presumably, had I been quicker in my pursuit of our thief, he could have used his gun to shoot her.

In hindsight, it was such an obvious ruse.  The distractions, the use of their infants to cause one to look away rather than stare and get a good look at them, the worn poster placed right on top of the object to be stolen, the sudden departure, rather than going to the next table, and the friend to pass the phone to, before they no doubt departed in opposite directions.

I gotta tell you, we both felt pretty gullible.  Shades of scams to come, preying upon the susceptible elderly, which we apparently have become.

It put a damper on our remaining time there.  We were already dealing with a hotel that didn’t have functioning key-cards, so that each time you wanted to go back to your room, you had to ask for someone to let you in, usually requiring a significant wait. 

On our flight home, our first leg was delayed.  We sprinted through the airport in Brussels, sat frustrated in a Passport Control line, and missed our connection.  After being directed to wait through customs a second time, we finally found what seemed to be the last employee of our airline in the airport, and managed to get booked on a fight ridiculously early the next morning.  We waited with a crowd of similarly hapless travelers for a ride to the hotel they’d assigned us.  When we finally got there, the hotel check-in system was down, with apparently no human intervention possible to override their “improved” automation.  All 20-some stranded passengers waited perhaps two hours, in a hotel lobby which had plenty of empty rooms, before they finally directed us to a different hotel.   

Some four hours after missing our plane, we got into our room at about 1:00 am, and had to rise at 5:00 to catch the bus back for our new flight.  Naturally, when we finally got to London, our bags were missing.  They didn’t find them for another few days.  I’ve never been so grateful to be reunited with underwear.

The travel Gods are telling us that it’s time to go home.  We’ve got one more short trip to Cornwall this week, then Dawn and Ant will be here and we’ll all close up this cottage.  We fly back to the States on July 26, but will stop in Massachusetts to hang with Nancy’s family there for a couple of weeks.  So we’ll be in Phoenix by mid-August.

By the time we get there, I’ll be very ready to be home.  It’s been a wonderful, enlightening experience.  We have new, dear friends.  But I so miss you all.  See y’all soon.