The American College of Obstetricians and Gynecologists has loosened up its recommendations regarding women who've previously given birth via ceserean section but want to deliver vaginally the next time around.

As the WSJ reports, now women who have already had two C-sections and those who are pregnant with twins following a C-section delivery are candidates for so-called VBACs, so long as their operations included a low-on-the-abdomen, horizontal incision.

While ACOG still recommends that women attempt vaginal delivery only if they're in a facility that has "staff immediately available to provide emergency care," the group says that if those resources aren't available the woman should "be allowed to accept increased levels of risk" if they are informed about the potential dangers and availability of facilities and staff. There are risks associated with all variations of childbirth, including vaginal birth and C-section.

Will the guidelines do anything to budge the C-section rate, which stood at more than 31% in 2007, according to ACOG? After the last set of guidelines were released, that same "immediately available" language led some hospitals to refuse to allow women with a history of C-section to make an attempt at delivering vaginally by allowing labor to progress.

William Grobman, a co-author of the guidelines and an associate professor of obstetrics and gynecology at Northwestern University's medical school, says that's the wrong question to ask. "We are culturally very focused on outcomes -- the C-section rate, the VBAC rate," he tells the Health Blog. "But we aren't trying to achieve arbitrary rates. There's as much focus on process as there is on outcomes," he says, which is why the guidelines emphasize "autonomy, shared decisionmaking and the provision of information."

If there were a metric to track, says Grobman, it would be the percentage of medical charts that show "there was a clear discussion about the risks and benefits" of an attempt at labor by women with a history of C-section.

He says it's not clear how many women have wanted a VBAC but have been unable to get it due to hospital or physician policy, but that there were enough people speaking out at a recent NIH consensus conference on the topic to suggest "it's a problem of some importance."

Grobman says the new clinical guidelines won't be "the start and finish" of a shift in physician behavior and hospital policies, since those things are also shaped by personal experience and professional liability concerns. "That being said, there's no doubt the guidelines are an important foundation," he says.

The Obama administration unveiled new rules, today, specifying which preventive health services will be free to consumers under the new health law after Sept. 23. Mandated preventive care seeks to correct the problem of under utilization of preventive care services because of out-of-pocket expenses for consumers. Americans use preventive services at about 50% the recommended rate, according to research cited by the White House. Chronic diseases, which are often preventable, are responsible for 7 of 10 deaths among Americans each year and account for 75 percent of the nation's health spending.

Free preventive services are among the health insurance benefits that the White House is touting as it tries to show consumers that the health care overhaul has tangible benefits. The list of services likely to spark intense debate within the health industry over what's included and what gets left out.

• Children will get more than two dozen services, including vaccinations for influenza, diphtheria and tetanus, and screenings for hearing and vision impairment and autism.
• Women over 40 will still be able to get a mammogram screening every year or two.
• Colorectal cancer screening for adults over 50.
• Hepatitis B screening
• HIV screening for adults at high risk
• Depression screening for adults and adolescents
• Prenatal services including screenings for iron deficiency.
• Blood pressure screenings.
• Obesity screening and counseling for adults and children.
• Tobacco counseling for pregnant women

New health plans offered after September 23, 2010 must include these preventive services without a copayment or other direct costs for consumers on new health plans. However, these new health insurance plans are expected to be price higher than comparable old plans to cover the mandated services. Consumers who stick with their existing insurance plans won't benefit from the change, but it will become an individual health insurance comparison decision to determine if the new preventive benefits are worth the new health plan rates.

To determine which services qualify as preventive, government officials relied largely on existing recommendations by three groups, including the U.S. Preventive Services Task Force. The preventive services task force drew criticism last year for recommending that women delay annual mammogram services until age 50, instead of age 40. The health care law effectively ignores that recommendation, making mammograms a covered preventive service at age 40 under the law.

Americans who have been denied coverage because of a preexisting medical condition may begin applying July 1, 2010

The federal government and some state governments will begin accepting applications Thursday, July 1, 2010, for new insurance programs designed to cover people who have been denied health insurance because they have preexisting medical conditions. These so-called high-risk pools were included in the health insurance reform law, the Affordable Care Act. to provide relief for some of the most desperate uninsured Americans until 2014, when insurance companies will be required to cover everyone regardless of medical history.

Who will be eligible for the insurance plan?

American citizens and legal residents who have been without insurance for at least six months and have been denied coverage because they have a preexisting medical condition. Applicants in most states will need a recent copy of a letter from a private insurance company denying coverage altogether or denying coverage of a specific condition.

Which states will have programs and when?

These 21 states have asked the federal government to run the high-risk pool rather than administer it themselves: Alabama, Arizona, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Kentucky, Louisiana, Massachusetts, Minnesota, Mississippi, Nebraska, Nevada, North Dakota, South Carolina, Tennessee, Texas, Virginia, Wyoming. Residents of these states can apply starting July 1. Administration officials said people who apply by July 15 will begin receiving coverage by Aug. 1.

The remaining 29 states and the District of Columbia will run their own programs and begin accepting applications over the next several months. Several of the largest states operating their own plans, including California, Illinois and New York, are not expected to begin enrollment until August. The administration expects that all states will begin enrolling people by the end of the summer.

How much will the insurance cost?

Premiums, as well as benefits, are expected to vary greatly from state to state, with some plans charging as little as $140 a month and some as much as $900 a month, according to administration officials. Premiums could vary by age. And some states may offer a variety of benefit packages.

How do I sign up?

The federal government's new healthcare Web portal at http://www.healthcare.gov, will offer instructions. Residents of states where the federal government will run the high-risk pool will be able to find applications there. The website also contains instructions for residents of states that are running their own pools.

What if my state already has a high-risk pool?

Many states have been operating such pools for years, but some are prohibitively expensive or have been closed to new enrollees. Because the rules for the new plans will be different, administration officials are encouraging people who have been without coverage to consider applying for the new pools.

Will there be enough money to cover to everyone?

Very likely not. The new healthcare law allocated $5 billion for the new high-risk pools, but several independent analyses, including one by the nonpartisan Congressional Budget Office, have estimated that more money would probably be needed because demand will be so high. The Department of Health and Human Services will be able to shift money from states that are not using all their allotted funds to those that need more, but so far administration officials have been reluctant to talk about seeking more funds.

The doctor-patient relationship is moving online. With 68% of American adults now using the Internet to search for healthcare information, it's no surprise that many also want digital access to their doctor. Whether they have that option will depend heavily on doctors' ability to get paid for the service. As of last year, less than 5% of doctors communicating online with their patients were being paid to do so. That's slowly starting to change as big insurance companies, such as Cigna, Aetna, Anthem, and Humana, have begun to reimburse doctors for online clinical consultations.

Privacy Concern is the Primary Obstacle

Patients want to communicate with their doctor via e-mail, but there are security risks. Sending health information to a doctor through a private Gmail or Yahoo account isn't a safe. You have to find a way to ensure you're communicating with the appropriate person on the other end. You need a secure site that requires a log-in with a user name and password. Insurance companies require that online consultations or e-visits as they are called take place through a secure Web portal with high levels of encryption that comply with Health Insurance Portability and Accountability Act (HIPAA) privacy rules.

New Payment Mechanisms are on the Horizon

Currently, 12 states, including California, have laws on the books requiring health plans to pay for online medical services. E-visits generally fall under that umbrella. At the national level, a Center for Medicare and Medicaid Innovation has been formed to help facilitate technology that would let doctors meet with their patients through video chats, telephone checkups and in-home monitoring devices. And most recently, the Department of Health and Human Services issued $220 million in grants to 15 communities around the country for creating three-year pilot programs to test the adoption of healthcare technology, including e-visits.

E-Visit Technology Available Now.

Various types of technology are used for e-visits, including simple e-mail but also live online visits using Web-based video or phone through companies such as RelayHealth, American Well, MDLiveCare and SwiftMD. Aetna has a proprietary online consult program called webVisit, but only about 1% of their providers use it.

Follow the Money

Although insurers have started to recognize the value of e-visits, most still don't pay for them. Neither does Medicare. That makes e-mail communication just one more daily task that primary-care doctors are saddled with and not paid for. Growing consumer pressure will no doubt force the healthcare industry online, but, ultimately, it's the money that will lead doctors to their computer screens. There is no incentive for doctors to change at the current time.

Nearly a third of people living in the U.S. believe they have a food allergy, according to a recent study published in The Journal of the American Medical Association. But only 8% of children and less than 5% of adults have true food allergies. Experts say food allergies are definitely being over-diagnosed or in many cases erroneously self diagnosed. It's because people don't understand what really constitutes a food allergy and they often misuse the term.

You can't eat cheese, feel sick, and claim you have a food allergy, but then turn around and enjoy ice cream and feel OK. With a true food allergy, the trigger - milk protein in this case - does not change and the trigger will always set off the same immune system response.

A food allergy is a very specific immune system response involving either an immunoglobulin antibody IgE or T-cells. Both are immune system cells that react to a particular food protein, like milk protein. An IgE reaction occurs within minutes to an hour or so of either smelling, touching, or ingesting a particular food. The presence of the food triggers the immune system to over-react and interpret the food as harmful. Histamine is released, causing symptoms that range from mild to severe, including hives, itching, trouble breathing, wheezing, and anaphylaxis. Allergic reactions to food can be serious. About 30,000 Americans per year go to the emergency room due to catastrophic allergic reactions to food, and as many as 200 die every year from food allergies, according to the Food Allergy and Anaphylaxis Network.

Food intolerance is often confused as food allergy.

Food intolerance occurs when the body lacks a particular enzyme to digest that food. Two common examples are lactose intolerance and celiac disease, an autoimmune disorder in which the gastrointestinal tract cannot process gluten, a protein in wheat-based products such as cereal and bread. An intolerant person avoids the foods that trigger a reaction, but these reactions aren't caused by the immune system and they are not life threatening.

Most people who claim food allergies really have food sensitivity.

People with food sensitivity generally have an unpleasant reaction to certain foods - perhaps they develop acid reflux, nausea, or abdominal cramps - but these are not immune system reactions, and these reactions do not always occur in the same way when eating the food.

I think I have a food allergy, so I'll just avoid the offending food.

If you suspect you have a food allergy, just skipping the food that irritates you isn't enough. Unintentional food exposures occur, even in the most cautious individuals with true food allergy. The self-diagnosed individual is unlikely to be properly prepared to manage this potentially life-threatening reaction, such as use of an Epi-Pen." Epi-pen and Twinject are injectable forms of epinephrine.

Proper diagnosis of food allergy is essential.

Blood tests can also help diagnose a true food allergy by measuring IgE levels and determine whether there's a true food allergy. But blood tests can produce false-positives -- results that indicate an allergy when there isn't one -- in patients who have eczema, asthma, or other types of allergies because those people already have higher-than-average IgE levels. One accurate way to find out if you have a true food allergy is to visit your doctor and undergo a food challenge. The food challenge is managed by the doctor and done in a controlled environment at the doctor's office. It involves gradually giving higher doses of a particular food to see how much of that food is needed to trigger an immune system response. Another type of test -- the skin prick test -- can also indicate if the patient has a real food allergy by injecting a small amount of the allergen into the skin and checking whether the skin develops a bump or a rash.

What would happen if patients paid doctors whatever they thought a office visit was worth?

A handful of physicians decided, for one day only, to offer patients the option to pay only as much as they could as an experiment to see how people really value primary care. Physicians chose their own dates for a pay-what-you-can day and got the word out. On the day of the events, no insurance was accepted. Care was provided only to the uninsured, who were asked to pay what they could afford. Laboratory tests were provided at cost, and patients who needed additional services were referred to various public resources. Practices also handed out lists of generic medications available for reduced prices at large, discount pharmacies.

Overall, participating physicians said they learned that although patients valued the physician visit enough to pay something, the payments were below actual cost. Still, most valued it enough to pay something. Some patients were unemployed and paid nothing; some paid $100. Visits were as short as 10 minutes or as long as an hour. Some people scraped up $20, some paid $60 to $80. One patient, a waitress and college student, paid $80, mostly in singles. The doctor gave her $20 back.

None of the participating physicians collected enough money to make the concept financially viable over the long term, mainly because payments didn't match a typical day's collections from insurance and co-pays. Yet most say they want to do it again and enjoyed having one day free from insurance paperwork. Doctors found it was satisfying to be of service to people who have a need, even just for one day.

Physicians discovered an unanticipated and unintended benefit: Pay-what-you-can days can help build a practice. Local media coverage may increase a practice's profile, and patients from pay-what-you-can days might return when they do have insurance.
Pay-what-you-can days also brought an unexpected amount of goodwill to medical practices and produced public recognition within their communities, physicians said. Participating physicians say they have been stopped on the streets and in grocery stores by people thanking them for their efforts.

When a local newspaper ran a story about Will Conner, MD, a family physician in Matthews, N.C., holding a pay-what-you-can day at his Conner Family Health Clinic, one of his patients who was a nurse volunteered to help. Someone else dropped off a flower with a card that said Dr. Conner was "receiving this because you have done something nice. "The pay-what-you-can day "definitely got recognized. We know we did the right thing," Dr. Conner said. "It's not very practical to do every day, but it is good for the community, and good for patient care."

When your doctor bills your insurance company, she begins a complex, expensive, and inefficient process during which she will spend an average of 12% of her patient revenue as well as wasting a considerable amount her own time. A recent study, Saving Billions of Dollars--and Physicians' Time--by Streamlining Billing Practices published on April 29, 2010 in the Journal: Health Affairs, estimates that on a national scale that translates to $7 billion wasted.

The study points out that billions of dollars could be saved each year by a uniform system of provider payments - uniform to all insurance companies. Medicare already has such a system of transparent payment requirements in place. Perhaps not ideal, but using them insures fair and accurate payment of providers. We've all heard the horror stories of fraud and waste in the Medicare system. But the FBI estimates that the the fraud and abuse in Medicare compares to private insurance companies - 3-10 percent.

The Patient Protection and Affordable Care Act includes broad requirements to streamline medical billing, but like many aspects of the law, many details are left to be worked out in the next few years. Given the amount of money that could be listed under the "money saved" side of the equation, perhaps we'll see a uniform, transparent payment system take shape.

For years, private Medicare Advantage plans have enjoyed generous payments from the government, currently averaging 9 percent more than the cost of care in traditional Medicare. The government's benevolence enabled Medicare Advantage plans to offer lower out-of-pocket costs and extra insurance benefits compared with traditional Medicare - like dental, vision, and prescription drug coverage. About 11 million seniors are signed up, nearly one-fourth of Medicare recipients.

That's about to change under the health care overhaul. Payments are being trimmed back starting next year for all plans, to correct what Obama says is wasteful overspending. However, beginning in 2012, the law directs Medicare to award bonuses to high performing plans - plans that score four stars or better on a 5-star rating system. The payment shift means that high-quality plans will find it a lot easier to keep offering extra benefits, while others will struggle. Indeed, Medicare's own analysts predict an exodus from Medicare Advantage back to the traditional program after the cutbacks begin.

The government's rating system evaluates health plans according to several measures, including customer service, prevention and medical care for people with chronic health problems. The ratings, already available on medicare.gov, assign one to five stars for quality, with one signifying poor performance and five excellent.

How the private plans score on the quality rating system set up by the government is about to have a direct impact on insurers' finances -- not to mention seniors' benefits and premiums. President Barack Obama's health care law ties what the plans get paid by the government to the quality they provide, for the first time. These ratings are about to become much more important. When you start linking quality to payment, you can bet the plans are going to be very motivated to bring the scores up.

Millions of seniors signed up for popular Medicare Advantage insurance plans don't get the best quality, an independent study found. There seems to be plenty of room for improvement. The study being released in April 2010 by looked at the health plans that seniors pick, according to the plans' scores on a government rating system designed for consumers. Overall, senior have proven to be poor shoppers of Medicare Advantage plans. The analysis found that 47 percent of Medicare beneficiaries are in plans that rate three stars or two -- medium to fair quality. Just 23 percent were signed up in plans that rate four or five stars -- very good to excellent quality. Many of the rest were in plans not yet rated.

If the new system of rewarding the best plans and culling out the poor performers works, seniors will be more likely to be gravitate to the better plans.

Experiments designed to charge a predetermined fee for common surgical procedures offer a glimpse into the future of healthcare spending.

Wildly different prices for the same medical procedures often leave consumers bewildered and financially ruined. Charges are all over the map. Here in Southern California, the hospital cost alone for hip-replacement surgery typically runs from about $103,000 at UC Irvine Medical Center to $41,000 at Hemet Valley Medical Center. The variation is influenced by myriad factors. Facilities that offer expensive specialty services such as trauma centers, burn units or transplant programs tend to charge more for care. Meanwhile, hospitals often charge privately insured patients more to make up for what they lose on uninsured patients and relatively low reimbursement rates from Medicare. Caregivers and hospitals point out that they receive only a fraction of charges they submit, whether to insurance companies or the federal government. Like the patients they serve, they, too, welcome more predictability. Many providers and insurers say they are now ready to experiment with new ways to cut unpredictable healthcare spending.

In one closely watched test beginning in August, several of California's best-known healthcare providers -- including Cedars-Sinai Medical Center, the UCLA Health System, and Hoag Memorial Hospital Presbyterian in Newport Beach -- will begin charging lump-sum fees for hip and knee replacements. Doctor bills, X-rays, artificial joints, tests and hospital care are among the fees that will be wrapped together for commercially insured patients who would otherwise be charged for each service. The single charge will vary from hospital to hospital based on the fee each negotiates.

The lumped charges for hospitals and doctors will cover most aspects of medical treatment from surgery through 90 days of recovery. That's a radical departure from the traditional practice of hospitals and doctors charging separately for their services, a fragmented system that drives up costs while leaving no one to coordinate decisions about patient care. Hospitals and doctors say they expect to share in savings when patients recover promptly, while bearing the risk of additional expenses when complications arise.

The federal government already is testing similar "bundled" payments for its Medicare program in Colorado, Texas, New Mexico and Oklahoma. And President Obama's new healthcare law calls for exploring additional arrangements for surgical services for the elderly and the poor.

Congressional Democrats have begun pushing legislation giving government regulators greater authority to block big increases in health insurance premiums. The move, which comes less than a month after President Obama signed the healthcare legislation, is aimed at giving all states the power to stop premium hikes deemed excessive and allowing the federal government to step in if the states don't act.

While politically astute, these efforts will not result in lower health insurance premiums. Health plan premiums are a symptom, not a cause of the problem. The cause of high health insurance premiums is high health care costs. State insurance regulators have no control over that, nor over the administrative costs of the insurers. If insurance company profits are abusive, then regulators can pare back profits to a reasonable level. The problem is that insurance company profits are an almost undetectable portion of our $2.5 trillion national health expenditures. Dramatically reducing insurer profits will not even appear as a footnote in the report of our health care spending.

Unfortunately, the medical insurance industry has been and will continue to be ineffective in controlling rising costs. The government must provide the solutions to rising costs, but under the reform model approved by Congress and the President, there are no effective solutions.