Dr. Nelson reports that she receives grant or research support from Bayer HealthCare, Medicines 360, Pfizer, and Teva. She serves as a speaker for Bayer, Merck, Pfizer, and Teva, and as a consultant or advisor for Bayer, Pfizer, Ortho-McNeil, and Teva.
CHALLENGE 5: Providing targeted care to adolescents
Daniel M. Avery, MD
Dr. Avery is Associate Professor and Chair in the Department of Obstetrics and Gynecology at the University of Alabama School of Medicine in Tuscaloosa, Ala. He serves on the OBG Management Virtual Board of Editors.
Among the challenges of providing quality ObGyn care to adolescents are 1) preventing, identifying, and treating sexually transmitted infection (STI) and 2) screening for cervical cancer. The Centers for Disease Control and Prevention estimates that there are approximately 19 million new cases of STI each year in the United States—almost half of them in people 15 to 24 years old.3 Chlamydia and gonorrhea are the two most prevalent STIs.3 In my practice, where roughly 20% of my patients are adolescent, chlamydia is a major concern. I test patients annually for this STI.
As for Pap testing, what we tell adolescents next year may be different from what we tell them this year. Guidelines have changed regularly enough that ObGyns must make an effort to stay on the cutting edge. For example, late last year the recommended age for the initial Pap test moved to 21 years, regardless of the patient’s age at sexual debut.2
We have also learned to manage Pap tests less aggressively in adolescents. We perform fewer colposcopies, biopsies, and loop electrosurgical excision procedures (LEEP) than ever before because data indicate that many cervical changes spontaneously regress in these patients; moreover, unnecessary treatment can lead to incompetent, fibrotic, and scarred cervixes. The risk of invasive cervical cancer in women younger than 20 years is 1 in 40,000.
Nevertheless, our medical school referral practice has seen two women younger than 20 years who had invasive cervical cancer. One year after I vaccinated a 16-year-old virgin against HPV, she became sexually active and got pregnant. Her initial Pap test— during prenatal care—showed low-grade squamous intraepithelial lesions, and her postpartum Pap test was classified as atypical squamous cells of undetermined significance; a postpartum HPV test was negative for high-risk strains. This patient did not see me again for 1 year, at which time a repeat Pap smear showed atypical squamous cells with a high risk of neoplasia. Colposcopically directed biopsies were suspicious for invasive cervical cancer, which was confirmed by LEEP. The patient underwent a radical hysterectomy with pelvic and peri-aortic lymph node dissection when she was only 19 years old.
In my practice, I emphasize education, vaccination against HPV, chlamydia detection and prevention, abstinence, and barrier contraception.
I am candid with adolescent patients about the risks they face and I view education as paramount to their health and well-being.
Dr. Avery reports no financial relationships relevant to this article.
CHALLENGE 6: Dealing with the insurance beast
Ed Cohen, MD
Dr. Cohen practices obstetrics and gynecology in Los Altos, Calif. He serves on the OBG Management Virtual Board of Editors.
The letter from the insurance company began promisingly enough:
- The approved services listed above are medically necessary.
Then it turned ugly:
- However, prior authorization was not obtained in a timely manner. Benefits will be reduced by $500.
This particular letter was dated Feb. 17, 2010, but it is not the first—or even the latest—unfriendly communiqué one of my patients has received from an insurer. Over the 30 years that I have practiced ObGyn, hundreds of tearful patients have asked for my help in resolving insurance-related issues. It has been my experience that the insurers rarely relent and do the right thing—even after appeal. They only tighten the thumbscrews.
In counseling patients, I try to help them understand that insurance companies are in business only to make money. No matter how welcoming and sincere their commercial enticements may appear, they are not on the side of the patient.
If insurers were acting in good faith and on the patient’s behalf, would they erect so many obstacles?
I invite any insurer to adequately and honestly explain why it makes any difference whether they are notified of a procedure on Tuesday instead of Wednesday. If the services are approved and covered and deemed to be necessary, why should reimbursement be reduced?
This is the main problem I’ve had with insurers, whose employees receive substantial “incentive pay” as long as the company remains profitable. Their real incentive should be to serve their customers, the insured. Instead, they make every effort to pay out less and put the difference in their own pockets.