One California cardiology group has confronted steep Medicare cuts with a tactic that may irk patients who already face soaring health costs in that state: Beginning April 1, Pacific Heart Institute, in Santa Monica, will charge some patients annual fees ranging from $500 to $7,500, in addition to the regular fees paid by patients and insurers.

Cardiologists don't ♥ Medicare cuts. (iStockphoto.com)

This steep fees provide an unusually vivid example of a phenomenon called "cost-shifting," one of the many reasons economists say your health insurance costs so much.

The premise is that doctors and hospitals charge privately-insured patients higher rates to make up for the lower fees paid by Medicare and other public programs, as well as uncompensated care for uninsured people. One report refers to cost-shifting as a "Hidden Health Tax."

Physicians are not usually allowed to charge Medicare patients fees in addition to the set Medicare rate for covered services -- such as "new patient evaluations" -- but they may charge separate fees for things Medicare does not cover. The annual fees described in the letter are said to pay for "ancillary" services above and beyond what insurers and Medicare finance.

The doctors of Pacific Heart Institute aren't the only cardiologists in panic mode right now. The American College of Cardiology sued the federal government in December to block 40-percent pay cuts for costly nuclear scans and other tests. Doctors also faced a 21-percent overall pay cut this year, but that cut has been delayed by Congress. "What they've done is basically killed the private practice of cardiology," Jack Lewin, the college's CEO, told USA Today when the suit was filed.

Neither Pacific Heart Institute nor the college returned phone calls. The letter from the Pacific doctors indicates that patients who don't agree to pay annual fees will still be able to see doctors at the clinic, but will face certain restrictions. For instance, "[t]elephone availability will only be offered for medical necessity and emergencies," but not checking on lab results. Medicare and many insurers do not pay for phone conversations.

"I wanted to go back to [Pacific Heart Institute], and now I don't think I can," said Jeff Goodman, a former patient who has recently regained insurance coverage that the clinic accepts. Goodman, who forwarded the letter to us, says he already pays $686 a month for his insurance plan because of preexisting conditions, and can't afford Pacific Heart Institutes new annual fees on top of that.

"If I need to make an appointment simply to get a blood result so he can bill, that's not good," Goodman added. "It creates stress, something most heart patients don't need."

For more, listen to NPR's Joanne Silberner report on changes in cardiology for Monday's All Things Considered.

Weaver is a reporter for Kaiser Health News, a nonprofit news service.

Democrats' maneuvers to pass health overhaul are getting curiouser and curiouser.

House Speaker Nancy Pelosi has a plan for making it easier for Democrats to vote for health overhaul. (TIM SLOAN/AFP/Getty Images)

If you thought budget reconciliation was a strange way to make a law that would recast the nation's health system, then wrap your mind around "deeming."

It now looks as though the House Democrats may tackle overhaul by formally voting on fixes to the Senate bill, and by passing them deem the underlying Senate bill also approved. The approach, also called a "self-executing rule," is used fairly frequently on Capitol Hill, but not on anything as big as health overhaul.

Why would she like that? Well, as NPR's Andrea Seabrook explained on Tuesday's Morning Edition, the House just hates the Senate bill. Some members don't like the way it handles abortion, others bristle at its effect on immigrants and the stalwart liberals are still upset that it doesn't offer a government-run public option.

The bill also would give some cover to vulnerable freshman representatives come Election Day.

The Wall Street Journal's editorial page slammed the self-executing rule as an "amazing procedural ruse." And the paper crystallized the view of Republican opposition like so: "This two-votes-in-one gambit is a brazen affront to the plain language of the Constitution, which is intended to require democratic accountability."

If you can't get enough on the self-executing rule, check out this rundown prepared by the Congressional Research Service in 2006. We found out, for instance, that a self-executing rule made it illegal to smoke on airplane flights less than two hours long way back in 1989.

This may not come as a complete shocker, but Republicans and Democrats not only disagree on what health overhaul should look like, they also hold dramatically different views on the effect of being uninsured.

How much of a headache is it to be uninsured? (iStockphoto.com)

That fundamental difference in viewpoint says a lot about what the two parties think is the right remedy for those without health coverage. "If you think that everyone can already get good care, regardless of insurance status, you might not think that comprehensive reform is really necessary," says Tara Sussman Oakman, the lead author of a study published Thursday in Health Affairs.

She and her colleagues note that previous studies have documented that people who are uninsured receive poorer quality of care and have more unmet medical needs than those who have insurance. Nonetheless, only one-quarter of Republicans believe that being uninsured would bar a person from getting necessary health care, in comparison to more than 40 percent of Democrats who believe so, the research finds.

Harvard health policy professor Robert Blendon, a co-author of the study, told Shots, "It gives a picture of another reason why when they have a [health care] summit, one group is talking about covering 31 million people, and the other is talking about covering 3 million."

Maybe the more surprising finding in the paper is that the same type of division exists between seniors and younger people. Just 19 percent of seniors think that the uninsured can't get the medical care they need, versus 42 percent of people under 30. The study authors say maybe the difference in perception has to do with personal experience with the uninsured, something seniors don't have to worry about when they're safely nestled under the blanket of Medicare.

The result in the study that could spell trouble for health overhaul advocates down the road, though, is that even when Republicans and Democrats who were surveyed did agree on the problem of the uninsured, they still didn't agree on reform. This may be due to a Republican "ideological opposition to national health insurance," says Sussman Oakman.

The researchers suggest that the political divide could complicate the future of any program passed by Congress this year. "If one party really thinks the issue is less serious, and there's a big shift back to Republicans in the government, we shouldn't be surprised if they decide not to put as much government money toward that problem," said Blendon.

Mertens is a reporter for Kaiser Health News, a nonprofit news service.

Kids who behave badly may wind up feeling the pain as adults.

Researchers who checked up on 45-year-olds whose parents and teachers said they were naughty as children were more likely to have chronic pain as adults.

"We found that we could identify children who were about twice as likely to report chronic widespread pain as adults, based on whatever their parents and teachers had said about their behavior when they were 7, 11 and 16," says Gary Macfarlane, an epidemiologist at the University of Aberdeen in Scotland.

The adult group that was twice as likely report pain had high "bad behavior" scores at all three checks. The research findings appear in the journal Rheumatology.

In their work Macfarlane and colleagues mined a rich database from a study of all people born in the United Kingdom in a single week in 1958. When the children were 7, 11, and 16 years old, their parents and teachers filled out questionnaires about the children. Did they lie, cheat or steal? Were they withdrawn, or anxious? Did they bully other children? About 8,500 subjects were available for followup at age 45. They were asked if they had recently had any aches or pains that lasted a month or more.

Macfarlane says there are many possible reasons for the association between childhood behavior and chronic adult pain. Naughty kids may be more likely to grow up to have health conditions such as arthritis, for example. But he suspects a disruption in something called the hypothalamic-pituitary-adrenal axis.

The hypothalamus, pituitary and adrenal gland are three parts of the body that produce hormones in response to stress and pain. Other studies have shown that the axis works differently in some adults with psychological conditions such as depression. Macfarlane and his colleagues are now studying the axis in children who've been exposed to stressful situations, such as severe illness, or loss of a parent.

Researchers who study the mind-body connection say the new study adds to the evidence from other, smaller studies. And Charles Raison, clinical director of the Mind-Body Program at the Emory University School of Medicine, says finding a way to deal with really bad behavior may prevent some chronic pain in adults. But that study, he says, would be very hard to do, since you'd have to leave some children untreated, and you'd have to wait 30 or 40 years for the result.

Some kids seem to have near-constant ear infections. Even after the pain is gone, a parent's got to wonder: Are there lasting effects from all that muffling of sound in the formative years?

A child's developing brain needs sound from both ears. (iStockphoto.com)

Research in rats just published in the journal Neuron suggests there might be effects in the brain that, while not permanent, can last for years. Apparently, hearing loss in one ear during critical periods of brain development can rewire the auditory cortex, changing the way it processes sound.

Neurobiologist Dan Polley, who recently moved to Harvard and the Massachusetts Eye and Ear Infirmary in Boston, conducted the research with a colleague, Maria Popescu, while at Vanderbilt University.

"Our ability to hear speech in a noisy background; to hear the wonderful compliments that your date is paying when you've taken her out to dinner; or when you have multiple people talking to you at once, and you try to home in on one speech source -- all these phenomena depend critically upon integrating signals from each ear," he says.

Polley wondered if the kind of periodic, months-long hearing loss experienced by some children with chronic infections and resulting blockage of the middle ear might actually affect the wiring of the brain. So he and his colleague tried a little test in rats of different ages: In each animal, they blocked the sound in one ear for a couple of months, and then unblocked that ear.

The result: In young rats, the ear that had remained open and clear made a sort of real estate grab in the auditory cortex, developing a much richer network of neural connections. The blocked ear lost influence. And even after both ears were once again sending clear signals to the brain, the imbalance in the brain persisted.

It's the sort of thing, Polley says, that could make triangulating the source of a sound harder, he says, and create subtle, but important deficits in hearing.

"When you don't correctly identify the position of a sound a in space, you may not know it," he says. When you're not able to hear in a noisy background, you may just not go out to dinner as often. You may end up isolating yourself from the environments that really require good hearing."

A child with that sort of problem might withdraw in a noisy classroom, Polley says, or--depending on when the imbalance occurs--might miss milestones in language or learning.Other studies have shown that's just the sort of thing that's been reported among some children with chronic middle ear infections.

Here's some comfort for parents: Though it can take a while, the brain is pretty good at developing workarounds, Polley says. Restore hearing, and the brain will eventually catch up.

Now, finally, the voting is set to begin on federal health legislation that leading Democrats claim could pass the House as soon as this coming weekend.

Democrats are still wrangling support in the House, where the action begins this afternoon when the House Budget Committee meets to start the process.

On Wednesday, the House Rules Committee will get down to business on the reconciliation bill. When its work is done, which could take a couple of days, the full House will get its crack at a vote.

But the House must still pass the existing Senate health bill, approved at the end of last year. Can the Democrats do it?

House Majority Whip House James Clyburn of South Carolina acknowledged Sunday that the Democrats didn't have the votes lined up just yet. But, Clyburn said on NBC's Meet the Press: "We've been working this thing all weekend and we will be working it going into the week. I am also very confident that we will get this done."

Then, assuming the Democrats get their way, the action will shift to the Senate, which would have to follow through on changes the House Democrats want. Senate deliberations and voting would take another week.

Republicans in both chambers remain opposed to the overhaul plan and vow to try to stop it. On CNN Sunday, House Minority Leader John Boehner of Ohio said, ""I'm doing everything I can to prevent this bill from becoming law. Plain and simple."

As a reminder of what's at stake, the Robert Wood Johnson Foundation put out an estimate that 10 million more people in the next five years would be without health insurance if nothing happens on overhaul.

The middle class would get hit hard by a lack of action, the report says, with the proportion of those families without coverage increasing to 28 percent in a decade from about 19 percent today.

The nation's "vaccine court" has once again concluded that vaccines don't cause autism.

The U.S. Court of Federal Claims has rejected claims in three test cases that tried to show that vaccines preserved with thimerosal contributed to the development of autism.

The ruling comes a year after the same court rejected the claims of three other test cases. In those cases, experts failed to convince the court that the combined effects of the MMR vaccine and thimerosal caused autism.

The court's decision got a warm welcome from groups that support childhood vaccination, as well as some autism groups.

"We all feel for the families," said Alison Singer, president of the Autism Science Foundation. "But we can't lose sight of the science."

It's time to stop trying to blame vaccines for autism and invest in research that could lead to the real cause, Singer said.

If the court's decision holds up, it will mean that children with autism are not eligible for payments from the National Vaccine Injury Compensation Program.

Currently there are claims to the program on behalf of thousands of children.

But the court battle isn't over yet. The petitioners to the so-called vaccine court can still ask for a review of the decision and appeal it to higher courts.

And they can still sue vaccine makers directly.

One in six Americans has genital herpes. And among African-Americans and women, the odds are even higher, according to results from a national survey released by the Centers for Disease Control and Prevention on Tuesday.

Still, the fact that half of African-American women are infected, according to CDC, took us aback. We turned to Dr. Adaora Adimora, a professor at the University of North Carolina's Center for Infectious Diseases, who told Shots "the racial disparity for herpes is actually less than for HIV and other STDs."

And, she emphasized that though these numbers for herpes are high, they have been pretty much stable since the last national estimate, which looked at the period from 1999 to 2004.

"Its important," she explained, "because of the illness it causes for people with it, and the fact that it can be transmitted from mother to child during childbirth, and the very important fact that it facilitates HIV infection," she said. "So, since it's a lifelong illness, unlike say gonorrhea, it probably contributes to the high rates of HIV -- especially among Blacks in the states."

Adimora said there needs to be better screening processes for genital herpes, which isn't routine. Only a blood test is required, but cost is an issue.

The CDC didn't recommend screening for the general population in its statement this week, but said testing help people "unsure of their status and at high risk for the disease, including those with multiple sex partners, those who are HIV-positive, and gay and bisexual men."

But Adimora would like to see it go a step further. "Given the way the problem is framed and given the high prevalence among everyone in the U.S.," she said, "it would seem completely reasonable to me to screen [everyone] for herpes."

For more on why AfricanAmericans and women -- and especially African-American women -- are particularly vulnerable, check out Friday's All Things Considered for an interview with Dr. Hilda Hutcherson, a professor of obstetrics and gynecology at Columbia University.

The Food and Drug Administration slapped its strongest warning on Plavix, a popular pill to prevent blood clots in people with heart disease.

Plavix is most likely to be ineffective in Asians. (AP Photo/Mark Lennihan) (Mark Lennihan/AP)

The problem: the drug may not work in some people. To be effective, the medicine inside each Plavix pill first has to be activated by the liver. Turns out the enzyme that does the job isn't up to the task in some people, depending on the variation of a gene they carry.

Research in the past few years has show that's problem is present in about 2 percent of Whites, 4 percent of Blacks, and 14 percent of Chinese.

Dr. Louis Teichholz, head of cardiology at Hackensack University Medical Center, told Shots, the warning is important and should be taken into account by doctors and patients, But, he said the testing question remains open. "At this point there isn't enough good scientific data to test everybody." Even among Asians, who have the highest prevalence of the gene, you have to test seven people to find one who might have a problem, he said.

Teichholz prefers a test of platelet aggregation, or stickiness, to the genetic assay. The platelet test is cheaper and may also help flag patients who aren't taking their medicine.

For people who do have trouble metabolizing Plavix, a stronger dose may overcome the problem. A rival drug called Effient may also work.

Last year, the FDA cautioned that patients shouldn't mix Plavix and heartburn pill Prilosec because the combination weakened Plavix's effectiveness.

Correction: The initial version of this post said that Plavix may be ineffective in up to 14 percent of Asians. The 14 percent figure applied to Chinese, not all Asians.

Before Anthem Blue Cross of California got dinged for looking to raise rates by as much 40 percent, the company was put in a harsh political spotlight over cancellation of policies for people in the midst of expensive medical procedures.

(iStockphoto.com)

Last year, Anthem Blue Cross, a unit of WellPoint and the biggest for-profit insurer in the state, agreed to pay a big fine and issue new coverage to the affected people who wanted it. Other insurers also agreed to settle with the state over retroactively canceling policies on technicalities, a practice known as "rescission."

All told California collected almost $14 million from insurers. Around 6,000 people affected by rescissions were eligible to get new policies under the settlements. But did they?

What went wrong? The settlements were too complicated and the state agencies involved in carrying them out didn't do a good enough job reaching out to eligible people.

The report's author is Dr. Bryan Liang, a doctor and lawyer who runs the Institute of Health Law Studies at California Western law school in San Diego. The bottom line, he wrote:

Unfortunately, bluntly put, the settlement agreements have done little to bring justice to those who have had their health insurance policies illegally rescinded and represent limited deterrence against insurer abuses. The numbers speak for themselves: almost no victim took advantage of the settlement agreements to hold insurers accountable.

You can see Liang's recent testimonyhere.

Preteens are far more likely to have huffed cleaning products to get high than to have toked up, government data show.

Kids are more likely to have huffed aerosol products than to have smoked pot. (iStockphoto.com)

Survey results put the lifetime rate of inhalant use by 12-year-olds at 6.9 percent in 2008, just ahead of 5.1 percent for misuse of prescription drugs. Contrary to what you might think, marijuana isn't all that popular, with a lifetime use rate by age 12 of just 1.4 percent.

The numbers are being thrust into the spotlight by the federal Substance Abuse and Mental Health Services Administration to draw attention to the problem.

The high is cheap and it's easy to get the stuff. The dangers aren't always so clear, and kids underestimate them.

Inhaling concentrated toxic vapors can damage the liver and other organs. Huffing can also cause "sudden sniffing death" when a kid's heart stops beating. That fatal problem is most often triggered by sprays containing butane and propane.

For more info, check out this section of the TheAntiDrug.com

]]> <p><a href="http://www.npr.org/blogs/health/2010/03/preteens.html#email">&raquo; E-Mail This</a>&nbsp;&nbsp;&nbsp;&nbsp; <a href="http://del.icio.us/post?url=http://www.npr.org/blogs/health/2010/03/preteens.html">&raquo; Add to Del.icio.us</a> </p> http://www.npr.org/blogs/health/2010/03/preteens.html?ft=1&f=103537970 http://www.npr.org/blogs/health/2010/03/preteens.html?ft=1&f=103537970 Children Public Health Fri, 12 Mar 2010 08:57:05 -0500 By Nadja Popovich Remember when we told you that a little-known but widely-used food flavoring called HVP was causing a mess of recalls because of salmonella contamination? Well, now it turns out that the Las Vegas-based company that produces the stuff knew about the contamination for weeks before the Food and Drug Administration cajoled them to issue a recall. Basic Food Flavors learned that samples taken from their Nevada facility tested positive for salmonella, as early as mid-January, but they kept shipping the flavoring to foodmakers, as the Washington Post explains. The FDA reported that private lab tests came back positive for salmonella on Jan. 21, 2010, but the plant continued to make and distribute HVP products until Feb. 15, under the same processing conditions. The company didn't immediately respond to NPR's request for comment. NYU food guru and author of What to Eat , Marion Nestle, called the situation a "food safety scandal" yesterday on her blog, Food Politics. Luckily, no one seems to have gotten sick yet. Or at least they haven't reported it. This could be because there's very little HPV in most products containing the additive, or the salmonella may have been killed in processessing. But Nestle took this case as further evidence that the FDA's powers need to be increased--currently, they don't have the authority to actually recall foods, but can only pressure companies into making their own "voluntary" recalls. "Do we need more evidence that the FDA needs the authority to order recalls?" Nestle asked. "And when is Congress going to get around to passing the food safety bill?" The food safety bill in question passed in the House months ago, but is stalled in the Senate. You can check out a complete list of recalled products at the FDA's food safety site. And, since the recall also affects Canada, you can find a list of recalled items from our neighbor to the North here. By Nadja Popovich

Remember when we told you that a little-known but widely-used food flavoring called HVP was causing a mess of recalls because of salmonella contamination?

Well, now it turns out that the Las Vegas-based company that produces the stuff knew about the contamination for weeks before the Food and Drug Administration cajoled them to issue a recall.

The FDA reported that private lab tests came back positive for salmonella on Jan. 21, 2010, but the plant continued to make and distribute HVP products until Feb. 15, under the same processing conditions. The company didn't immediately respond to NPR's request for comment.

NYU food guru and author of What to Eat , Marion Nestle, called the situation a "food safety scandal" yesterday on her blog, Food Politics.

Luckily, no one seems to have gotten sick yet. Or at least they haven't reported it. This could be because there's very little HPV in most products containing the additive, or the salmonella may have been killed in processessing.

But Nestle took this case as further evidence that the FDA's powers need to be increased--currently, they don't have the authority to actually recall foods, but can only pressure companies into making their own "voluntary" recalls.

"Do we need more evidence that the FDA needs the authority to order recalls?" Nestle asked. "And when is Congress going to get around to passing the food safety bill?"

The food safety bill in question passed in the House months ago, but is stalled in the Senate.

You can check out a complete list of recalled products at the FDA's food safety site.

And, since the recall also affects Canada, you can find a list of recalled items from our neighbor to the North here.

They may not be the Montagues and Capulets, but fans of low-fat and low-carb diets have been locking horns for quite a while. But now, researchers at Stanford University claim they've found a way to resolve this bitter rivalry: look at your genes.

At least low-carb and low-fat diet fans both agree that you should stay away from this.(iStockphoto.com)

They say that a simple genetic test may predict which diet works best on a case-by-case basis.

"It's a step closer to realizing personalized nutrition for weight loss," Christopher Gardner, associate professor of medicine at Stanford, told Shots.

Results from the study he helped conduct were presented at an American Heart Association conference last week. The work, which got a lot of attention in the popular press, hasn't been published in a peer-reviewed journal yet.

But we wanted a second opinion, and turned to Nanette Steinle, an endocrinologist at the University of Maryland med school. She agrees that the test shows promise, but says it's far too early to start offering it to the public.

One of the reasons Steinle says she's just not ready to recommend testing is the small sample size of women tested in the Stanford study -- 138, to be precise.

Still, if you've got the money and the curiosity, nobody can stop you from trying it. The test, developed by Interleukin Genetics, requires a swab of the cheek and $149. Interleukin, for what it's worth, also sponsored the study, but you probably guessed that already.

Oh, there's one other thing. This new study isn't completely new. "It's retrospective," Gardner said. Back in 2007, Gardner published a study in the Journal of the American Medical Association on the long-term results of low-carb, high-protein, high-fat diets. At the time NPR's Patti Neighmond took a close look.

According to Neighmond, in that study, 311 women who were 15 to 100 pounds overweight were randomly assigned to one of the diets. After a year, Gardner assessed the women's health and weight.

While the study gave a slight edge to the low-carb diet, Gardner says that weight-loss varied more within each diet than it did between the different approaches. "Within each diet group in our study the range of success was 40 pounds. Some women lost a bunch of weight, some women even gained some," he said.

But last year, Interleukin execs called Gardner up and told him about their new test. The company claimed that it had come up with a classification system for weight-loss genes. They put dieters in three genetic baskets, according to which approach might work best: low-carb, low-fat and balanced. Interleukin wanted to reevaluate the people in Gardner's study based on their criteria.

So Gardner's group contacted them; 141 of those initial 311 women said OK. They swabbed the inside of their cheeks to get DNA samples and sent them in. Turns out that three did it wrong, so the final number of samples was 138.

Gardner agreed that a lot more research needs to go into getting this sort of testing ready for prime time. In fact, he's already planning a larger study.

But, he said it was encouraging that of the women tested in this preliminary study, only five fell in the "balanced" group and the rest were divided 60-40 into the low-carb and low-fat genotypes respectively. "And that actually enriched the story tremendously," Gardner said, because it means that almost half of dieters could respond badly to their diet of choice--if they happened to choose badly. That finding, he said, helped make sense of the huge variations in the study's original results, he said.

Genetics aside, Gardner offered this dieting caveat: "There's more than one way to do low-carb and there's more than one way to do low fat." So make sure a diet is nutritious and that your food choices make sense, regardless of whether you're going low-fat or low-carb. "Sure, [some] cookies say they're 'low-fat,' but they're packed with sugar, that's why people like them," he said.

Just because a woman has given birth by cesarean section, doesn't mean she shouldn't be able to try a vaginal delivery for the next child, a group of experts says.

A nurse prepares the abdomen of a woman before a C-section at Malcolm Grow Medical Center near Washington. (Tech. Sgt. Suzanne M. Day/Wikimedia Commons)

A subsequent vaginal birth is as safe or safer than a C-section, for mothers and infants, according to a National Institutes of Health panel of obstetricians, gynecologists and other medical doctors, as well ethicists, lawyers and scientists who met for three days just outside Washington this week.

Worries about complications have led to a sharp drop in vaginal births after cesarean. "A primary cesarean will begat subsequent cesareans," said Dr. F. Gary Cunningham, chairman of obstetrics and gynecology at University of Texas Southwestern Medical School. Indeed, only about 10 percent of subsequent deliveries are vaginal births.

Shannon Mitchell, who hails from Florida, says she was repeatedly offered more cesareans after her first child, a breech baby, was delivered that way. She argued with an ethicist on the panel over whether she had the right to refuse C-sections.

"This is a human rights issue," Mitchell declared. "I'm being cut open because obstetricians have decided that I need to be," Mitchell shouted back when the ethicist told her there is no absolute rule saying she can refuse the procedure.

The major barrier to vaginal births, the panel concluded, is a set of guidelines by the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. Those require "the immediately availability" of surgical and anesthesia personnel before doctors offer a "trial of labor," the medical term for attempting a vaginal birth after a C-section. Those teams are supposed to be on hand in case of serious trouble, such as a rupture of the uterus.

The staffing standard is tough for some hospitals to meet. Recent surveys indicate that, as a consequence, up to 30 percent of hospitals won't allow vaginal births after C-sections. The problem is particularly acute in rural areas where it's especially difficult to provide around-the-clock staff surgical and anesthesiology.

Cunningham says that after looking at the data, the panel found that the guideline hasn't changed outcomes for patients. "It is a crippling rule for many hospitals."

Fear of being sued, however, is a major factor behind the ACOG guidelines. Dr. Michael Socol, of Northwestern University School of Medicine, in talking about the medical claims against the Northwestern Memorial Hospital, explained that the proportion from obstetrician and gynecology -- mostly obstetrics -- represent just 18 percent of all lawsuits filed, but 60 percent of those that were paid out.

Without reform of the legal system, he said, it is going to be very difficult to reverse current trends in the practice of medicine.

The NIH panel encouraged further study of legal obstacles, saying there's not enough evidence to make a recommendation. In very explicit language, however, it urged professional societies and hospitals to reassess policies that create barriers to offering women the opportunity to go through labor in giving birth. "The bottom line," Cunningham conceded, "is we can't make them do anything."

The gold-standard test for heart disease is looking a little tarnished.

Angiograms may be used too often. (Wikimedia Commons)

A big study says most patients without known heart disease who undergo coronary angiography don't have clogged arteries after all.

In such patients angiograms reveal coronary disease only 40 percent of the time. Worse yet, another 40 percent have essentially clear coronaries.

To do an angiogram, or cardiac catheterization, doctors thread a thin tube from the groin up into the coronary arteries. Injecting a dye shows on x-rays whether arteries are gunked-up or clear.

More than a million Americans get angiograms every year. One in five angiograms involves a patient without known heart disease--and often no symptoms.

The new data come from the biggest study of the question so far--encompassing 400,000 patients with unknown coronary-artery status prior to their angiograms. It draws from a database of the American College of Cardiology, which funded the project. The findings were published in the current New England Journal of Medicine.

Duke cardiologist Dr. Manesh Patel, who led the study, says the researchers were "taken aback by the fact that there's an equal percentage of angiogram patients with little or no coronary disease and those with severe disease."

They were also struck by the fact that 83 percent of the angiogram patients had noninvasive "gatekeeper" tests that were positive, suggesting that an angiogram would be likely to find heart disease. Even so, most of the time they didn't. These tests include exercise stress tests, ECGs, echocardiography and scintigraphy, a test that involves injection of a radioactive dye to tell how well the heart's blood supply is functioning.

That leaves doctors with no reliable way to tell in advance which patients without known heart disease really need angiograms. Nobody expects angiography to be perfect--finding heart disease only when it's present, and never when it's not.

But Patel says researchers urgently need to figure out which noninvasive tests--and what other markers, such as family history and diseases like diabetes--are most important to increase the "yield" of angiograms.

Not only are angiograms expensive, but they expose patients to the risk of radiation and rare but sometimes serious side effects.

Dr. David Brenner of Columbia University agrees that doctors need to know which gatekeeper tests work best "to decrease the disturbingly large proportion of invasive coronary angiographic procedures that yield negative results."

Patel thinks that "the entire diagnostic process from start to finish needs reevaluation -- from talking to patients to the threshold for going invasive," meaning angiography.

The best place to start, he says, is with patients without symptoms of heart disease, such as chest pain. Almost 1 in 3 Americans who get angiograms today are symptom-free. Their doctors order angiograms presumably because they suspect "silent" heart disease, perhaps because a patient has a family history of coronary disease, diabetes or other risk factors.

But angioplasty and stenting--procedures commonly done during angiography to widen clogged coronaries and keep them open--have never been shown to lengthen life, Patel says. The reason for doing them is to relieve symptoms. And if a patient doesn't have symptoms, then doctors and patients should ask themselves what's the point of doing the angiogram -- instead of reducing coronary disease risk factors.