Changes in Healthcare Laws and a New Device may Increase the Appeal of the IUD

Even though they’re more effective at preventing pregnancy than most other forms of contraception, long-acting birth-control methods such as intrauterine devices and hormonal implants have been a tough sell for women, especially younger ones. But changes in health-care laws and the introduction of the first new IUD in 12 years may make these methods more attractive. Increased interest in the devices could benefit younger women because of their high rates of unintended pregnancy, according to experts in women’s reproductive health.

IUDs and the hormonal implant — a matchstick-sized rod that is inserted under the skin of the arm that releases pregnancy-preventing hormones for up to three years — generally cost between $400 and $1,000. The steep upfront cost has deterred many women from trying them, women’s health advocates say, even though they are cost-effective in the long run compared with other methods, because they last far longer.

Under the Affordable Care Act, new plans or those that lose their grandfathered status are required to provide a range of preventive benefits, including birth control, without patient cost-sharing. Yet even when insurance is covering the cost of the device and insertion, some plans may require women to pick up related expenses, such as lab charges.

Long-acting reversible contraceptives (LARCs) require no effort once they’re put into place, so they can be an appealing birth-control option for teens and young women, whose rates of unintended pregnancy are highest, experts say.

Across all age groups, nearly half of pregnancies are unintended, but younger women’s rates are significantly higher, according to a 2011 study from the Guttmacher Institute, a reproductive health research organization. Eighty-two percent of pregnancies among 15- to 19-year-olds were unintended in 2006, and 64 percent of those among young women age 20 to 24 were unintended, the study found.

Although the use of LARCs has more than doubled in recent years, it is a small part of the contraceptive market. Among women who use birth control, 8.5 percent of women used one of those methods in 2009, according to the Guttmacher Institute. The use of LARCs by teenagers was significantly lower at 4.5 percent, while 8.3 percent of 20- to 24-year-olds chose this type of contraception.

In October, the American College of Obstetricians and Gynecologistsreiterated its strong support for the use of LARCs in young women.

Yet many young women are unaware that long-acting methods could be good options for them, in part because their doctors may be reluctant to prescribe them, experts say. That is partly the legacy of the Dalkon Shield, an IUD that was introduced in the 1970s whose serious defects caused pain, bleeding, perforations in the uterus and sterility among some users. The problemsled to litigation that resulted in nearly $3 billion in payments to more than 200,000 women.

In addition, providers may hesitate because there’s a slightly higher risk that younger women will expel the device, experts say.

But expulsion is a problem more likely associated with the size of the uterus, which is not necessarily related to a patient’s age, says Tina Raine-Bennett, research director at the Women’s Health Research Institute at Kaiser Permanente Northern California and chairwoman of the ACOG committee that released the revised opinion on LARCs. “Expulsion is only a problem if it goes unrecognized.” (Kaiser Health News is not affiliated with Kaiser Permanente.)

The new IUD Skyla became available in this month. It is made by Bayer, the same company that makes Mirena, another IUD sold in the United States. Unlike Mirena, which is recommended for women who have had a child, Skyla has no such restrictions (nor does ParaGard, the third type of IUD sold here). Mirena is currently the subject of numerous lawsuits alleging some complications, such as device dislocation and expulsion.

Skyla is slightly smaller than the other two IUDs on the market and is designed to protect against pregnancy for up to three years, a shorter time frame than the others.

This shorter time frame may make Skyla more attractive to younger women who think they may want to get pregnant relatively soon, some experts say, although any IUD can be removed at any time.

“More providers are spreading the word that it’s okay, and more young women are demanding it,” says Eve Espey, a professor of obstetrics and gynecology at the University of New Mexico.

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Health Technology's 'Essential Critic' Warns of Medical Mistakes

Computer mistakes like the one that produced incorrect prescriptions for thousands of Rhode Island patients are probably far more common and dangerous than the Obama administration wants you to believe, says Drexel University’s Dr. Scot Silverstein.

Flawed software at Lifespan hospital group printed orders for low-dose, short-acting pills when patients should have been taking stronger, time-release ones, the Providence-based system disclosed in 2011. Lifespan says nobody was harmed.

But Silverstein, a physician and adjunct professor of healthcare informatics who is making a name for himself as a strident critic of electronic health records, says the Lifespan breakdown is part of a much larger problem.

[See also: Medical errors continue to dog healthcare.]

“We’re in the midst of a mania right now” as traditional patient charts are switched to computers, he said in an interview in his Lansdale home. “We know it causes harm, and we don’t even know the level of magnitude. That statement alone should be the basis for the greatest of caution and slowing down.”

Use of electronic medical records is speeding up, thanks to $10-billion-and-counting in bounties the federal government is paying to caregivers who adopt them. The consensus among government officials and researchers is that computers will cut mistakes and promote efficiency. So some 4,000 hospitals have or are installing digital records, the Department of Health and Human Services said last month.

Seventy percent of doctors surveyed in September  by research firm CapSite said they had switched to digital data.

But the notion that electronic charts prevent more mistakes than they cause just isn’t proven, Silverstein says. Government doesn’t require caregivers to report problems, he points out, so many computer-induced mistakes may never surface.

[See also: Medical errors continue to dog healthcare.]

He doesn’t discount the potential of digital records to eliminate duplicate scans and alert doctors to drug interactions and unsuspected dangers.

But the rush to implementation has produced badly designed products that may be more likely to confound doctors than enlighten them, he says. Electronic health records, Silverstein believes, should be rigorously tested under government supervision before being launched into life-and-death situations, much like medical hardware or airplanes.

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Lacks of Doctors For Newly Insured Patients

As the state moves to expand healthcare coverage to millions of Californians under President Obama's healthcare law, it faces a major obstacle: There aren't enough doctors to treat a crush of newly insured patients.

Some lawmakers want to fill the gap by redefining who can provide healthcare.

They are working on proposals that would allow physician assistants to treat more patients and nurse practitioners to set up independent practices. Pharmacists and optometrists could act as primary care providers, diagnosing and managing some chronic illnesses, such as diabetes and high-blood pressure.

"We're going to be mandating that every single person in this state have insurance," said state Sen. Ed Hernandez (D-West Covina), chairman of the Senate Health Committee and leader of the effort to expand professional boundaries. "What good is it if they are going to have a health insurance card but no access to doctors?"

Hernandez's proposed changes, which would dramatically shake up the medical establishment in California, have set off a turf war with physicians that could contribute to the success or failure of the federal Affordable Care Act in California.

Doctors say giving non-physicians more authority and autonomy could jeopardize patient safety. It could also drive up costs, because those workers, who have less medical education and training, tend to order more tests and prescribe more antibiotics, they said.

"Patient safety should always trump access concerns," said Dr. Paul Phinney, president of the California Medical Assn.

Such "scope-of-practice" fights are flaring across the country as states brace for an influx of patients into already strained healthcare systems. About 350 laws altering what health professionals may do have been enacted nationwide in the last two years, according to the National Conference of State Legislatures. Since Jan. 1, more than 50 additional proposals have been launched in 24 states.

As the nation's earliest and most aggressive adopter of the healthcare overhaul, California faces more pressure than many states. Diana Dooley, secretary of the state Health and Human Services Agency, said in an interview that expanding some professionals' roles was among the options policymakers should explore to help meet the expected demand.

At a meeting of healthcare advocates in December, she had offered a more blunt assessment.

"We're going to have to provide care at lower levels," she told the group. "I think a lot of people are trained to do work that our licenses don't allow them to."

Currently, just 16 of California's 58 counties have the federal government's recommended supply of primary care physicians, with the Inland Empire and the San Joaquin Valley facing the worst shortages. In addition, nearly 30% of the state's doctors are nearing retirement age, the highest percentage in the nation, according to the Assn. of American Medical Colleges.

Physician assistants, nurse practitioners, pharmacists and optometrists agree that they have more training than they are allowed to use.

"We don't have enough providers," said Beth Haney, president of the California Assn. for Nurse Practitioners, "...so we should increase access to the ones that we have."

Hernandez, who said he would introduce his legislation and hold a hearing on the issue next month, said his own experience as an optometrist shows the need to empower more practitioners. He said he often sees Medicaid patients who come to his La Puente practice because they have failed their vision test at the DMV. Many complain of constant thirst and frequent urination.

"I know it's diabetes," he said. But he is not allowed to diagnose or treat it and must refer those patients elsewhere. Many of them may face a months-long wait to see a doctor.

The California Medical Assn. says healthcare professionals should not exceed their training. Phinney, a pediatrician, said physician assistants and other mid-level professionals are best deployed in doctor-led teams. They can perform routine exams and prescribe medications in consultation with physicians on the premises or by teleconference.

Allowing certain health workers to set up independent practices would create voids in the clinics, hospitals and offices where they now work, he said. "It's more like moving the deck chairs around rather than solving the problem," Phinney said.

His group proposes a different solution: It wants more funding to expand participation in a loan repayment program for recent medical school graduates. Doctors can now receive up to $105,000 in return for practicing in underserved communities for three years.

Still, it typically takes a decade to train a physician. Health experts say the pool of graduates cannot keep pace.

"We're not going to produce thousands of additional doctors in any kind of short-term time frame," said Assemblyman Roger Dickinson (D-Sacramento). "It makes sense to look at changes that could relieve the pressure that we're going to undoubtedly encounter for access to care."

Administrators of community clinics and public hospitals say nurse practitioners and other non-physician providers already play key roles in caring for patients, a trend they predict will grow as more Californians become insured and enter the healthcare system.

At Kern Medical Center in Kern County, two clinical pharmacists have run the hospital's diabetes clinic, treating about 500 patients a year, since the specialist physician in charge retired. They are licensed to perform physicals, order lab tests, prescribe medicines and counsel patients on lifestyle changes.

"We're going to have to get a whole lot more creative about how care is provided," said Paul Hensler, Kern Medical Center's chief executive.

Source: www.latimes.com

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