Tagged Insuring Your Health

New Vaccine Recommendation Cuts Number Of HPV Shots Children Need

You’d think that a vaccine that protects people against more than a half-dozen types of cancer would have people lining up to get it. But the human papillomavirus (HPV) vaccine, which can prevent roughly 90 percent of all cervical cancers as well as other cancers and sexually transmitted infections caused by the virus, has faced an uphill climb since its introduction more than a decade ago.

Now, with a new dosing schedule that requires fewer shots and a more effective vaccine, clinicians and public health advocates hope they may move the needle on preventing these virus-related cancers.

In December, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommended reducing the number of shots in the HPV vaccine from three to two for girls and boys between the ages of 9 and 14. The recommendation was based on clinical trial data that showed two doses was just as effective as a three-dose regimen for this age group. (Children older than 14 still require three shots.)

Michelle AndrewsInsuring Your Health

The study was conducted using Gardasil 9, a version of the vaccine approved by the Food and Drug Administration in late 2014. It protects against nine types of HPV: seven that are responsible for 90 percent of cervical cancers and two that account for 90 percent of genital warts.

In addition, the new version of Gardasil improved protection against HPV-related cancers in the vagina, vulva, penis, anus, rectum and oropharynx — the tongue and tonsil area at the back of the throat.

An earlier version protected against four types of HPV.

From the start, clinicians have run into some parental and political roadblocks because the vaccine, which is recommended for preteens, protects against genital human papillomavirus — a virus transmitted through sexual contact. Many physicians are also reluctant about discussing the need for the vaccine, and for many parents, the vaccine’s cancer-prevention benefits were overshadowed by concerns about discussing sexual matters with such young kids. Yet for maximum protection, the immunizations should be given before girls and boys become sexually active.

The focus should not have been on sexually transmitted infections, some say. “You only get one chance to make a first impression,” said Dr. H. Cody Meissner, a professor of pediatrics at Tufts University School of Medicine and a member of the American Academy of Pediatrics’ committee on infectious diseases. “This vaccine should have been introduced as a vaccine that will prevent cancer, not sexually transmitted infections.”

The HPV virus is incredibly common. At any given time, nearly 80 million Americans are infected, and most people can expect to contract HPV at some point in their lives. Most never know they’ve been infected and have no symptoms. Some develop genital warts, but the infection generally goes away on its own and many people never have health problems.

However, others may develop problems years later. There are approximately 39,000 HPV-related cancers every year, nearly two-thirds of them in women. In addition to cervical cancer, more than 90 percent of anal cancers and 70 percent of vaginal and vulvar cancers are thought to be caused by the HPV virus. Recent studies show that about 70 percent of cancers in the oropharynx may also be linked to HPV.

A 2015 study published in the Journal of the National Cancer Institute estimated that earlier versions of the HPV vaccine could reduce the number of HPV-related cancers by nearly 25,000 annually, and the new version of the vaccine could further reduce the number of such cancers by about 4,000.

The vaccine is estimated to prevent 5,000 cancer deaths annually, said Dr. Paul Offit, professor of pediatrics and director of the Vaccine Education Center at the Children’s Hospital of Philadelphia.

But compliance is an ongoing problem. “They’re not getting the one vaccine that protects against diseases from which they’re most likely to suffer and die,” Offit said, noting that deaths from pertussis and meningococcal disease, for which adolescents are also vaccinated at that age, are minuscule compared with HPV-related cancers.

In 2015, 87 percent of 13-year-olds were up-to-date with the Tdap vaccine that protects against tetanus, diphtheria and pertussis, and 80 percent had received the meningococcal vaccine, according to the Centers for Disease Control and Prevention. But just 30 percent of girls and 25 percent of boys at that age had received all three doses of the HPV vaccine. In contrast to other vaccines, however, the HPV vaccine is required only in a few states for secondary school.

Public health advocates say they think the shift to a two-dose regimen could make a big difference in the number of adolescents who get all the necessary doses of the HPV vaccine. For one thing, the fewer shots the better, in general, they say.

In addition, because the second HPV shot is supposed to be given anywhere from six months to a year after the first one, “parents can fit it into a routine regimen when people go in for their 12-year-old’s regularly scheduled visit,” said Dr. Joseph Bocchini Jr., chairman of pediatrics at Louisiana State University Health in Shreveport who is president-elect at the National Foundation for Infectious Diseases.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Insurance, Insuring Your Health, Pharmaceuticals, Public Health

Tags: ,

GOP Recycles Controversial 2003 Bill To Boost Small-Business Insurance

In a bid to improve the health insurance purchasing clout of small businesses, Republicans have dusted off a piece of controversial legislation more than a decade old and reintroduced it as part of their effort to remake the market after they throw out the Affordable Care Act.

The earlier bill, which passed the House in 2003 but didn’t advance, was widely panned by groups representing consumers, providers, the health insurance industry and state officials. At the time, they argued that it would do little to enhance the coverage options or control costs of many small businesses, especially those that employ older, sicker workers, while at the same time weakening consumer protections against plan insolvency and fraud.

Health policy experts say there’s no reason to change that assessment now.

“It was a bad idea in 2003, and it’s a worse idea today,” said Timothy Jost, an emeritus professor at Washington and Lee University School of Law in Virginia who is an expert on the health law.

Michelle AndrewsInsuring Your Health

The bill would allow the establishment of nationwide “association health plans” that could be offered by professional or trade groups, chambers of commerce and the like. Small businesses could buy coverage through these associations, in theory gaining strength in numbers to enhance their bargaining leverage with insurers, leading to cheaper, better coverage and lower administrative costs.

The Small Business Health Fairness Act of 2017 is slated to head to the House floor this week. Speaker Paul Ryan (R-Wis.) has expressed enthusiasm for association health plans and said he intends to move the legislation in tandem with the reconciliation bill that would unwind budget-related provisions of Obamacare, another name for the ACA.

Several business groups, including the National Retail Federation and the U.S. Chamber of Commerce, support the bill, hoping that it will encourage more small businesses to offer their employees coverage.

“We don’t think it’s going to be the panacea to solve all our members’ issues, but we view it as a valuable option,” said Kevin Kuhlman, director of government relations for the National Federation of Independent Business, a trade group and supporter of the bill. NFIB members, he said, “want a little more ability to design their own options and less responsibility to conform to federal requirements.”

The idea isn’t new. Association health plans have existed for decades. But they often escaped close supervision because neither states nor the federal government had clear regulatory authority over them. In the 1970s and ’80s, there were cases of fraud and insolvency that raised concerns about the model. Some multiple-employer purchasing groups went belly up and left consumers and providers with millions in unpaid claims.

So Congress amended federal law to allow states to regulate these plans. When the ACA passed in 2010, the Obama administration required that association health plans meet the new small-group standards: They had to cover the 10 essential health benefits, for example, and couldn’t charge older people premiums that were more than three times higher than those of younger people.

The new bill would change all that. It would eliminate most state regulation of association health plans and put oversight in the hands of the federal Department of Labor, which would certify them.

The ACA requirements that apply to all plans, like the prohibition on lifetime and annual coverage limits, would apply to association health plans as well, said Kevin Lucia, a research professor at Georgetown University’s Center on Health Insurance Reforms. But the ACA’s small-group requirements would not. Plans could offer stripped-down coverage and would have more latitude in setting premiums than regular plans in the small-group market. They could operate in multiple states and generally avoid state-mandated benefits and other state insurance rules.

Under the Republican bill, association health plans still couldn’t discriminate against individuals based on their health, but they could charge higher premiums to companies with sicker workers. So association health plans would likely appeal to employers with younger, healthier workers who would qualify for lower rates and not be troubled by skimpier coverage. That could draw those businesses away from state-regulated health plans, which would be left with sicker, costlier enrollees, creating an uneven playing field and a segmented market.

“If you’re a healthy small employer and you’re allowed to escape all these rules, you may be able to have lower premiums, until someone in your group gets sick,” said Lucia.

Solvency is a real concern as well, say experts, since the federal standards in the bill are generally less rigorous than state rules.

The flexibility that GOP lawmakers see in the bill might not serve workers well, said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

“Right now there’s a fairly consistent set of rules of what a small group or individual plan has to look like in terms of benefits, costs and coverage,” she said. “If we’re talking about a world where none of that exists anymore or an association health plan is outside of those standards, then as a consumer you’re dealing with a very confusing situation.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Health Industry, Insurance, Insuring Your Health, Repeal And Replace Watch, The Health Law

Tags:

Change In Texas Medicaid Payments Helps Cut Number Of Premature Births

Even though the health risks to babies born before they reach full term at 39 weeks have long been recognized, nearly 1 in 10 babies in the United States is born prematurely. Texas decided to try to change that.

In 2011, the Texas Medicaid program was the first in the country to take steps to curb elective early deliveries by refusing to pay providers who induced early labor or performed a cesarean section that wasn’t medically necessary before 39 weeks. In the first two years after that, Texas reduced the rate of unnecessary early delivery by as much as 14 percent. The state’s efforts also led to an increase in the length of pregnancies by nearly a week, with infants weighing on average nearly half a pound more, a new study found.

Those reimbursement changes were part of a Texas Medicaid payment reform law. Before it took effect, 10.63 percent of Medicaid single births in the state were early elective deliveries, according to the study, which was published in the March issue of Health Affairs.  After the law passed, the percentage of unnecessary early deliveries declined 2.03 percentage points.

Michelle AndrewsInsuring Your Health

About half of the decline was due to the payment reforms, while the rest could be attributed to other efforts to reduce early deliveries, unrelated trends and the economy, said Heather Dahlen, a research associate at Medica Research Institute in Minnetonka, Minn., and the study’s lead author.

Still, “in order for the rate to fall that much, there was a relatively significant effect on the target population,” Dahlen said.

The impact on early elective delivery was greatest for Latinos, whose rate declined 1.77 percentage points to 8.14 percent. The rate for non-Latino blacks declined 1.4 percentage points to 9.57 percent, while non-Latino whites saw a much smaller decline — 0.72 percentage point, to 8.43 percent.

Infants born before 39 weeks are more likely to have a range of health problems, including respiratory disorders, sepsis and feeding issues, and to be admitted to hospital neonatal intensive care units. Doctors and expectant mothers who opt for early delivery may not realize the risk or choose to go ahead for convenience. In some rural areas, women may be encouraged to schedule early deliveries to ensure they’re able to get to the hospital in time.

For the study, researchers analyzed data from 2009 to 2013 on the national Vital Statistics System’s Natality Detail Files, which is derived from information reported on birth certificates.

The federal-state Medicaid program for low-income people pays for roughly half of all births in the United States. After Texas passed its law, five other states passed similar laws in 2013: Georgia, Michigan, New Mexico, New York and South Carolina.

Reducing preterm births generally, and early elective deliveries in particular, is a priority for many groups, including health care providers, hospitals and patient-advocacy organizations. In addition to payment reform, these groups have employed other strategies such as educational programs for health care providers and patients and “hard-stop” policies that prohibit doctors from scheduling early elective deliveries unless they meet medical necessity standards.

“The Medicaid program was paying doctors for doing things that actually harm babies,” said Dr. Paul Jarris, chief medical officer at the March of Dimes, which publishes an annual report card that ranks states based on their preterm birth rates. “These payment changes actually make huge differences if they’re done right.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Insuring Your Health, Medicaid, Public Health, States

Tags: , , ,