HPV, Rationing, and Health Ethics

Cervical cancer is a serious problem. In 2007, it is estimated that 11,150 cases will be a reported in the United States, resulting in the death of 3,670. Those affected by cervical cancer are disproportionately women of color and low-income women (not to mention the large problem internationally in the developing world). However, between 1955 and 1992, the number of cervical cancer deaths in the United States dropped by 74%; the main reason for this change is the increased use of the Pap test.

Merck's HPV vacine Gardasil was recently approved by the FDA and is being marketed to young women. I support the vaccine. However, I believe greater consideration is needed when deciding whether or not this should be a mandatory vaccine for school-age girls. Typically, religious fanatics are the ones arguing against universally administering the vaccine. That is not me; I am merely asking for greater contextualization of this vaccine in the health system.

Texas recently mandated that girls in the sixth grade receive the HPV vaccine. This treatment costs $360/person. When taken as a whole, this will cost the state of Texas $60 million dollars. Of course, any sum of money to prevent cervical cancer in women is "worth it." However, is this the best use of 60 million dollars? Texas represents about 8% of the U.S. population. With extrapolating, this means $60 million dollars will be used to prevent around 900 cases of cervical cancer, or around 300 deaths.

I admit, calculations such as these are cold and heartless. They make me uncomfortable. I don't like to make such statements. I want to to say that any vaccine to prevent a terrible disease is well worth it. But it some ways, not thinking about the alternatives is heartless. Tradeoffs should be considered. What could $60 million dollars do to provide sexual education? How far could $60 million dollars go to covering health insurance/programs to low-income people without access? What other affects could this $60 million have on the health system?

I don't like bringing up questions like this because it is easy for me not to. It is easy for me to jump on the 'eliminate cervical cancer' bandwagon, without thinking about how those limited resources are spent. Considering state Medicaid resources are budget constrained, this money could be draining programs for the Medicaid population as a whole, which is most likely the disabled population.

The avoidance of these discussions, I believe, is a central problem of the American health care system. Line-item decisions are made by the legislature on coverage decisions, such as mandating the HPV vaccine. These decisions are not contextualized within the larger system. Questions above are not asked; alternatives not weighed, because the decision making process is made item by item, rather than contextualized with alternatives being weighed. Instead, decisions are made one-by-one on an up or down basis, largely influenced by special interests groups - both corporate and consumer.

Is this argument too utilitarian? Maybe.

I don't know what the answer is. Oregon's health care rationing program was not successful. But was it a step in the right direction? I don't know. All I am saying, is dialogue to these decisions needs to be open. By not taking about these ethical tradeoffs- we are ignoring the problems and making simple decisions that may make us feel we are doing the right thing-- when that in fact, that may not be the case. Not talking about the trade-offs is an ethical decision in and of itself.

We need to recognize complexity. As a nation, we need to stop being afraid of complexity and difficult, ethically challenged decisions. Only such a recognition and acknowledgment will result in better decisions we make as a public.

Health Wonk Review is up

Check out the latest edition of health wonk review. Health wonk review is a bi-weekly compendium of the best of the health policy blogs.

New website that reviews quality of health articles in the popular press

Check it out: http://www.healthnewsreview.org/

This website reviews the quality of health articles published by newspapers and magazine. The website was started out of University of Minnesota and uses 20 reviews from universities and health clinics to examine newspapers, magazines, and other media outlets - and provides critical ratings on the quality of the studies/article. This is a great - I just looked at the website and it seemed a bit complicated for the average reader (i.e. how study design is described), but it is certainly a step in getting more critical about health news articles. Perhaps it will help reporters present information to the public in a more critical light.

Enrollment Problems in Public Health Insurance Programs

I found this article on a wonderful blog, Healthy Policy. This article was published in the LA Times and serves as an educational peice for the uninsured and discusses different programs that people may qualify depending on their income. Such options (in California) include:

• Medi-Cal: for low-income children, pregnant mothers and disabled adults who are U.S. citizens.
• Healthy Families: for low-income children who are U.S. citizens
• Healthy Kids: A county-run program for low-income undocumented children, if the county has the program and if there are spots available in the program
• Kaiser Child Health Plan: A program available to low-income undocumented children, if Kaiser has available slots open.
• CaliforniaKids: A program for undocumented children, which is currently full and not open to new enrollees.
• AIM: A program for pregnant mothers
  

Susan Brink, the author frames the article in her first sentence: "No one doubts that there are ample holes, but America's, and California's, healthcare safety net might be a little more tightly knit than many expect." The message is clear: people (i.e. kids) have options, if only parents would get off their butts and sign them up. The common cited statistic was quoted: "About two-thirds of the uninsured children in California could, if only they'd apply, qualify for Medi-Cal or Healthy Families, according to the UCLA Center for Health Policy Research." Yes, programs exist and people aren't enrolled. There are many reasons: not knowing about programs, stigma, poor past experience with medical providers, difficult family situations, etc. However, this glosses over a huge issue: the large number who apply but are denied because of the bureacratic enrollment process.

I worked at a Community Health Center last year doing Medi-Cal/Healthy Families applications with parents. The state created an "easy" application form -- to ease enrollment for parents. It is 4 short pages and parents need only include 3 documentation forms (proof of child's citizenship; proof of income; proof of California residence). The application is colorful and appears to be straightforward. However, the process is far from such. I will share one story demonstrating the nightmares of eligibility.

• The mother was paid once a month and I xeroxed her income statement and included it in the application. Her pay-stub said "Feb 2005." Typically it takes 14 working days to process a Healthy Families application. One can check on application status through an automated touchtone system. "Application in Process" is what the automated voice says until an application is accepted or denied. This means if the state takes issue with your application, you cannot find out on the voice system that there is a problem. (The state calls families and sends a letter. However, application assistants cannot easily find out over the phone unless they are persistent to get transfered to speak to an operator and spend around an hour getting transfered.) I went through this game of being transfered from person to person until I found out this application was red-flagged and on the denial pathway. Why? All the information was correct. I was told that the pay stub was "not good enough" because it said "Feb 2005" instead of "Feb 1 - Feb 28 2005". I was told to tell my client to have her employer issue a new paystub with the beginning and ending date of the pay period. In the world of multinational corporations, how are families supposed to have control over how paystubs are made? The kicker? This person worked at the United States Postal Service. Apparently federal employees paystubs don't cut if for the State of California.
  

This is just one story; I have dozens of other similar stories of documentation problems. Over half of my applications would have "issues" that were resolved immediately after spending hours on the telephone trying to get transfered to supervisors and advocate for my clients. The truth is, most clients don't have an advocate. And most advocates and caseworkers don't have the time to follow-up to the degree I did. The result: denied applications. I wonder how many of the well-quoted statistic: "2/3 of California's kids qualify for health insurance, just aren't enrolled" went through the application process to some degree, but were denied.

Public health insurance programs like Medicaid and SCHIP that are intended for low-income folks are not designed for easy enrollment. This serves a stark contrast from Medicare. Both are considered government "entitlement" programs; however, Medicaid is far from an entitlement for those who qualify.

The state of California started a "point-of-entry" program (CHDP) that automatically enrolls uninsured children in Medi-Cal for two months when the child goes in for a well-child visit (immunizations, physical). This is called "presumptive eligibility", i.e Medi-Cal/Healthy Families applications are presumed to eligible until paperwork is processed. Basically, families go in for a well-child visit (immunizations, physical), get on this program, and have between one and two months to complete paperwork. Here are some statistics I found at MRMIB (Managed Risk Medical Insurance Board) who administers Healthy Families, on how eligibility worked for this program that was supposed to improve enrollment in public health insurance programs. Statistics are from July 2003-October 2003:

• 151,000 applications mailed to families whose children entered through CHDP
• 11,410 applications turned in. That is 7.5 percent success rate
• 7,438 applications were for Medi-Cal and 4,864 were for Healthy Families
• Of the Healthy Families applications, only 1,105 children had complete applications. 3,596 were denied due to incomplete applications. The main reason for incomplete applications was "missing documents."
• 31.2% of families had an assistant working on the application with them. 68.7% filled out the application on their own. Of those filling out the application with an assistant, 10.7% of applications were incomplete. Of those filling out applications without an assistant, 89.3% were incomplete.

That enrollment rate is embarassing. Programs not existing is a problem, especially for people who are not documented. However, enrollment difficulties pose just as much of a problem. When considering how to improve the health insurance status of popualtions -- or when considering on how to design health insurance coverage expansions -- policy designers need to pay more attention to enrollment issues.

Ambulatory Service Centers and Physican Owned Hospitals

For the past several weeks I have been reading about "specialty hospitals" and "ambulatory service centers" (ASCs), or what some refer to as "boutique hospitals." These facilities began emerging in the 1990s as 1) a way for physicans to become partial owners, and 2) a way to improve efficiency by specializing in a specific area, mostly orthopedics and cardiology. Regina Herzlinger, professor at Harvard Business School, coined the term "focus factories" for such facilities. She argues that traditional American hospitals have not been patient or consumer focused and instead have been organized to make things easier for providers. Focused factories, she argues, not only improve care because they specialize in a single area and are able to improve efficiency, but they also are designed around the consumer (big rooms, low nurse to patient ratio, etc.).

While much can be learned from the design of specialty hospitals that improve patient-satisfaction, there are many concerns about such models of care

-Conflict of interest: Specialty hospitals are unique in that they are owned (partially or wholly) by physicians, unlike community or teaching hospitals. Physicians have been increasingly less satisfied with hospital bureaucracy in traditional hospitals, and such specialty facilities allow physicians to participate in the organization's managment - which they argue makes them more efficient in providing care and more invested in improving the facility. While having ownership in one's workplace likely increases one's committment, there is a potential conflict of interest for health financing when doctor's own hospitals. When doctors are (partial) owners and are paid more when the hospital profits, there is a potential that physicans will over-treat and use more expensive technology that may not be necessary.

-Drain on community hospitals: Community hospitals rely on things like orthopedics and cardiology to pay for other services, such as uncompensated care for the uninsured, burn and trauma units that are expensive to maintain, etc. Many community hospitals fear such specialty hospitals and ASCs opening in their community because their profitable patients will go elsewhere and this will put a further drain on safety-net services. Check out this issue brief at the Center for Studying Health Systems Change.

-Dealing with those with multiple chronic conditions: 83 percent of Medicare beneficiaries have at least one chronic condition; 65 percent have multiple chronic conditions (and these account for 95 percent of all Medicare expenditures). Having specialty hospitals that focus on one aspect of care (i.e. heart hospitals such as Medcath that specialize in angioplasties or coronary artery bypass grafts, CABGs) presents challenges because people who have one chronic condition (i.e. heart disease) are likely to have other chronic conditions (i.e. diabetes, asthma, arthritis, etc.). If care continues to be divided into specialty facilities, this might cause problems for those who manage multiple chronic conditions. Already, those with multiple chronic conditions face difficulty navigating the U.S. health delivery system. Gerard Anderson at Johns Hopkins published article on July 21, 2005 in the New England Journal of Medicine that discussed how the current organizational health system is unprepared to deal with patients with multiple chronic conditions. It is important to consider what a further division of care through "focused factories" might do for this portion of the population.

-Labor issues: It is clear that physicians are satisfied by working in such specialty facilities because of increased salaries, more control over the work environment, etc. However, I wonder about support staff and nurses. Medcath (a specialty hospital that owns many heart hospitals in the U.S.) boasts of high salaries, low patient to staff ratios, etc. in its "employment" section on their website. It seems many support staff like the increased patient contact and more training that such facilities provide staff. However, it does not appear specialty hospitals are unionized, and I doubt they could become "the norm" without support from SEIU or Nurses Unions. Such unions, that are committed not only to labor issues for union employees, but also to maintaining a solid community health system, will resist specialization of care. The role that such unions may play in the future of the a changing health market place has not been investigated, and I think it is interesting to consider. On a personal note, I take comfort knowing that labor still has some power over changes in the health system.


A friend of mine recently had surgery at an orthopedic ASC and was very satisfied with his treatment (I do not believe he understood at the time of surgery the market forces of specialty facilities and threats on the community health system). He sent me this website that his doctor gave him a password and he could log in to see graphics of his specific surgery before the operation. The fact that health education materials are a becoming a profitable industry does not sit well with me, especially because only a certain subset of physicians (who are practicing at specialty facilities) are giving these services to these patients. Such expensive services are probably not accessible to community hospitals. I did some investigation on this company after he sent me this webpage. To make it more upsetting, this company also contracts out to devise manufacturers. So, not only are they profiting off of health education, but they are also marketing new expensive technology to specialty physicians and patients, driving up the cost of care.

Summing up: I will not take a totally negative stand against specialty hospitals; I do believe that hospitals need to be more organized around patients. Specialty hospitals offer a new model of delivering care that seems to improve patient satisfaction and provider satisfaction. While I strongly support community hospitals, I do believe many need to make improvements in the way they deliver care. Nevertheless, I do not feel like outsourcing and dividing care into different sections is necessarily the answer. Specialty hospitals do present a problem for the viability of the community hospitals, a threat for over-treatment, unnecessary cost-drivers because of technology, and a challenge for dealing with those with multiple chronic conditions. Serious efforts need to be invested in re-organizing community hospital care, not outsourcing care to for-profit facilities.

First "Blog"

Because I seem to think about health care an awful lot and my friends are getting sick of listening to me ramble, I thought I would start this blog. This way, I can at least track my thoughts.