Health News 4 Men

The staying power of Christian medical bill-sharing plans has judges, legislators and regulators asking a philosophical question: Does a plan count as insurance if it doesn't charge premiums or pay claims, yet allows people to contribute to a pool of money they can draw upon to pay medical bills?

The answer to that question might depend upon a reading of state insurance law, whether a state has passed exemptions for religious organizations that pay for medical bills, or even the religious sensibilities of the parties involved.

Backers of these plans say they provide a low-cost alternative to insurance for people who otherwise couldn't get it or afford it. Their detractors say these plans are insurers in sheep's clothing, trying to find a way to shimmy out of state insurance financial and coverage regulations.

Either way, doctors might not know their patients might be participating in these bill-sharing plans, because often the plans are constructed so a physician is paid in cash first, after which the patient's bill is published in a plan's newsletter, with a request for reimbursement. However, sometimes physicians face the same wait for payment as they do for any health plan.

Christian bill-sharing plans aren't new, but have attracted more attention lately because of regulatory and legislative activity, and because the plans are being pitched as an alternative to not being insured -- though they say they're not insurance.

The Cover Florida health reform plan Gov. Charlie Crist signed in May included an amendment exempting faith-based health care programs from state insurance regulation, as long as the group qualifies under federal guidelines as a nonprofit religious organization.

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Bad debt levels fell among for-profit hospitals in the first quarter of 2008, says a report by the international credit-rating agency Fitch Ratings.

Still, these hospitals continue to have a higher percentage of unpaid medical bills than physicians and nonprofit hospitals.

For-profit hospitals saw bad debt levels as a percentage of revenues fall from 18.4% in the fourth quarter of 2007 to 17.7% in the following quarter, said Fitch Ratings' recently released "For-Profit Hospital Industry Quarterly Diagnosis" report.

Past surveys by the Medical Group Management Assn. estimated physician practices' bad debt level in the 5% to 10% range. For nonprofit hospitals, Fitch said the percentage in 2006, the latest data available, was 5.5%. Bad debt is generally defined as payments that are written off as uncollectable.

Fitch analyst Lauren Coste attributes the decline in bad debt among for-profit hospitals in part to decreases in the number of uninsured patients at those facilities.

In addition, hospitals have been more aggressive in collecting co-payments up front and have improved efforts externally and internally to collect debt, she said.

This has balanced a change in for-profit hospitals' accounting techniques, Coste said. They have become more conservative in their assumptions concerning how many of their patients would pay for their services, which results in more debt being written off as uncollectable. Before, their accounting figures reflected a more hopeful collection amount.

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After several years of mostly striking out with consumers, personal health record vendors are adopting a business-to-business marketing model, courting employers and insurers in hopes of expanding PHR adoption.

A recent study by Cambridge, Mass.-based industry analyst Chilmark Research found that of the more than 200 PHRs on the market, only 20% are Internet-hosted, which is what the study focused on.

Of those, 40% are thriving, 35% are treading water "and the remaining 25% are walking zombies, not quite dead, but not very alive, either," the study said.

Study author John Moore said PHR vendors, until recently, were marketing to consumers. But with the exception of those with a chronic disease or their caregivers, consumers had expressed very little interest.

Now employers and health plans are starting to see the potential for PHRs to reduce health care costs, Moore said, and are offering incentives for their use. So vendors are focusing on strategic alliances.

Moore said privacy and security hurdles still need to be cleared before consumers can be sold on offering personal information for any PHR.

"What really surprised me [in doing the survey] is what a terrible job the PHR vendors have done addressing privacy and security as an industry," he said.

Moore believes the entrance of Google and Microsoft into the market could help raise the bar on what consumers will expect.

But the American Medical Association and others aren't waiting for vendors to respond, but would like to see legislation mandating security standards. The AMA is advocating that HIPAA be extended to all entities that have contact with health data, including PHR vendors.

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The cases of 11 infants who contracted pertussis from a health care worker have renewed calls to get adolescents and adults vaccinated against the infection, particularly if they work in a hospital or other medical setting.

"We think it's very important that people do everything to prevent pertussis in infants, and this means immunizing teens, adults, parents of infants and people who are taking care of infants. It means immunizing health care workers," said Don Murphey, MD, lead author of the paper outlining the incident published in the June 6 Morbidity and Mortality Weekly Report. He is also the medical director of occupational health at Cook Children's Medical Center in Ft. Worth, Texas. The infants were infected at another hospital in the community.

The outbreak occurred a year before the Food and Drug Administration's 2005 approval of Tdap -- the vaccine that includes the pertussis immunization -- for adults and adolescents. This step was followed by recommendations from the Advisory Committee on Immunization Practices urging that all adolescents and adults receive the preventive, with those working for a medical institution viewed as especially high-priority targets. The American Medical Association encourages health care workers to be immunized for their own protection and to reduce transmission to others. But most experts suspect that many health care professionals remain unimmunized and that the risk that outbreaks will continue remains high.

"Patients should have the right and every expectation that they're not going to get diseases that they didn't have when they went into the exam room or hospital," said Greg Poland, MD, professor of medicine and director of the vaccine research group at Mayo Clinic in Rochester, Minn.

No data have been collected on how many health care workers have received the Tdap vaccine, although numbers pertaining to the general adult population are not encouraging. According to statistics released in January from the Centers for Disease Control and Prevention's National Immunization Survey, 2.1% of 18- to 64-year-olds had received it. Also, a study published in the November 2007 issue of the journal Infection Control and Hospital Epidemiology found that 87% of health care workers were not planning to receive it.

Experts are concerned because health care workers are more likely to get pertussis in the course of their job. They also are more likely to transmit it to those most likely to experience complications.

A 2007 study said 87% of health care workers didn't plan to get vaccinated against pertussis.

"[Pertussis] is clearly a hundred-day cough in adolescents and adults," said Grace Lee, MD, MPH, assistant professor of pediatric infectious diseases at Harvard Medical School in Boston. "Vaccination protects them and their families. It protects the patients." She has published several papers on the cost effectiveness of this vaccine.

Some medical institutions are piggybacking pertussis vaccination efforts onto those for influenza. In some ways, pertussis vaccination is easier because it doesn't have to be given annually or during a narrow window in the fall and winter like flu vaccine, but motivating health care workers to get the shot is challenging. It's fairly new -- some people are not aware of it or that protection from childhood pertussis immunization likely has waned. Also, even though cases of pertussis have increased among adults, it's still viewed as a childhood disease. So the vaccine may not be viewed as vital for adults.

"This does require a whole new kind of paradigm, and we need to educate both the professional staff and others in the hospital about why we're talking about whooping cough," said William Schaffner, MD, president-elect of the National Foundation for Infectious Diseases and chair of the Dept. of Preventive Medicine at Vanderbilt University School of Medicine in Nashville, Tenn.

The price of the vaccine also may be a barrier, although studies have shown that vaccination saves money by reducing disruption and the need for prophylactic antibiotics caused by outbreaks.

Washington -- Vaccines have long been considered one of public health's greatest and most life-saving achievements, yet they continue to spark controversy. In recent weeks, protesters in Washington, D.C., claimed that childhood vaccines are unsafe, while in Albany, N.Y., others rallied against a mandatory vaccine bill in that state.

Parents attempting to do the right thing for their children are often caught in the cross fire.

Now along comes a new book, Do Vaccines Cause That?! A Guide for Evaluating Vaccine Safety Concerns. It summarizes the research findings on vaccines and presents a method for analyzing that research. The book is by Martin Myers, MD, a pediatrician and executive director of the nonprofit National Network for Immunization Information, based at the University of Texas Medical Branch in Galveston, and NNii science writer Diego Pineda. NNii provides information about vaccines on its Web site (www.immunizationinfo.org). Affiliates include the AMA, the Infectious Diseases Society of America, the American Academy of Pediatrics and the American Academy of Family Physicians, which support its work. NNii does not accept pharmaceutical company funding, Dr. Myers said.

The authors evaluate the long-running controversy linking vaccines with rising rates of autism as well as claims suggesting vaccines' possible association with asthma. The book also delves into the effects of multiple vaccines on a child's immune system.

Although parents are its intended audience, physicians and others in the health care field can benefit from reading it, according to former Health and Human Services Secretary Louis Sullivan, MD, and Samuel Katz, MD, chairman emeritus of pediatrics at Duke University in Durham, N.C. Together they wrote the book's forward.

"One hopes -- anticipates -- that besides a broad lay audience, health care personnel at every level will take advantage of this book to augment their own perspectives so they can discuss vaccines more comfortably and convincingly with the families for whom they are responsible," write Dr. Sullivan and Dr. Katz.

It remains to be seen whether the new book will answer all queries. "You are going to continue to see parents doing their own research and coming up with a lot of questions," said Barbara Loe Fisher, a frequent critic of vaccines and co-founder of the National Vaccine Information Center, a nonprofit, parent-led organization that seeks to change the mass vaccination process to allow more opt-out flexibility regarding immunizations. She said she looks forward to reading the book but wonders if it will address the issue now being raised about the effect on children's health of recent expansion in the recommended vaccine schedule.

"I've seen the number of vaccines double and the number of doses triple," Fisher said. "No matter what is published in that book, it is still an outstanding question until health authorities give us the answer as to why so many highly vaccinated children are so sick."

AMNews recently talked to Dr. Myers about the book.

AMNews: Why did you write this?

Dr. Myers: For a couple of reasons. The first, and maybe the most important, was that readers of our [NNii] Web site asked us to. They liked the essays on our site and asked us to put them together in a book.

The second was when we went to bookstores to see what was available, we could only find anti-vaccine materials and advocacy books. But we couldn't find a book written to help parents sort their way through conflicting information.

It is meant as a tool to help parents understand what they are hearing and how to evaluate it. We do not advocate. Each section of the book was reviewed by technical experts and parents. We had a panel of parents read the book and tell us whether we were clear or not.

One of my favorite anecdotes concerns a parent who acknowledged that the book was informative but also said it was boring and not the kind of thing a parent is going to read. So we went back and started over.

We hope it's helpful for parents who want more evidence and also to those who need help sorting through the evidence.

AMNews: What's in it for physicians?

Dr. Myers: As Dr. Katz and Dr. Sullivan wrote in the forward to the book, we do review the evidence in some detail. We want to have it all there. They noted that it's something that health professionals should read also, since it's the one place where it is compiled.

A number of physicians at meetings said they were anxious to see the book because they thought it would help them talk to parents.

AMNews: Do physicians and researchers have difficulty communicating clearly to lay people?

Dr. Myers: We use words in a different way. We included a table of words in the book and what they mean to vaccine researchers and what they mean in common English. As we started to compile that table, we kept finding more words.

"Bias" is one of the words. "Plausible" is another. "Significant" to the scientist means it is probably not due to chance, but it could be. But when a parent hears the word significant, it means important.

Then there is the phenomenon of the missing information. If it turns out that a safety concern is caused by the vaccine, like it was with intussusceptions and [the first] rotavirus vaccine [which was withdrawn in 1999], it doesn't take very long to prove it. [Two new rotavirus vaccines were licensed in 2006.] But you can never prove a negative. You have to have lots of studies done by different people, and it might take years until the scientific community says, 'OK, the weight of the evidence is so compelling we think we can reject this.' We used a quote from Einstein that Diego found: 'Many experiments will never prove me right, but one experiment can prove me wrong.'

AMNews: How great is the danger posed by unimmunized children?

Dr. Myers: We have a section in the book called 'community immunity' that addresses how important it is for children to be immunized to protect neighbors. It's an important concept for people to understand that when immunization levels go down, outbreaks can occur.

Attacks of misinformation on vaccine safety can cause that breakthrough. We saw it with whooping cough in the 1970s and 1980s. And we saw it with measles and mumps in the United Kingdom just recently.

AMNews:So are the same vaccine safety debates occurring in other countries?

Dr. Myers: The same discussion on vaccines causing autism was held in England and Europe related to the measles vaccine -- that argument has been discredited now. But as a result, parents became confused and didn't immunize their children, and they had an outbreak of measles and an epidemic of mumps which spread to the United States.