The Incidental Economist has some good news on the prevalence of HPV originated cancers in New Mexico after vaccination started:
From 2007 to 2014, more than 20,000 lesions were diagnosed in females age 15-29 years old. After adjusting for changes in screening over time, they found that reductions in the incidence of all neoplasias over time were significant. Grade 1 lesions in this group dropped, on average, 9% each year. Grade 2 lesions dropped 10.5%, and Grade 3 lesions dropped a whopping 41.3%.
The number of grade three lesions in females age 15 to 29 years dropped from 240.2 in 2007 to 0 (yes, zero) in 2014.
There’s good news here all over. The first is that the HPV vaccine seems to be working. We’re picking up less and less cancer in women who are screened. This means that we should also consider raising the age for screening even higher.
And this is with the uptake of HPV vaccine being about 40% in this population. If we could get the rate of HPV vaccination up high enough, we might see even better results.
That is very good news. It is also a new problem for us to solve as the vaccination rate is still too low to either severely diminish the number of cancerous lesions or provide herd immunity. The ACA has helped on this measure as the HPV vaccine is a no cost-share service. If the patient or the parent of the patient asks for the HPV vaccine, there is no cost barrier to care.
But while the ACA requires that insurers pay for prevention, there is no requirement that insurers push for prevention efforts that usually don’t pay off for years or decades. We looked at this last spring:
the HPV vaccine has a very different profile. It’s main cost saving function is avoiding cancers a decade or more after the administration of the vaccine. There is massive churn in a decade, especially among teenagers who become young adults. Two payment schemes could be created. The first would be the vaccine avoidance payment of a few dollars per month until an individual is 18. Then a decade later a second payment stream would be created. This stream would be a small monthly sum for cancer treatments avoided.
Why do I think something like this should be implemented?
Right now the ACA gives insurers an incentive to push preventative care that has a fairly short pay-off span. It requires payment for all preventative care even if the pay-off in lower claims cost will almost certainly occur when the individual is being covered by someone else. There is an idea that the collective action problem of short term thinking has been eliminated because overall the aggregate pool should be getting healthier as every insurer is required to pay for essential health benefits. This proposal rejiggers the incentives to create a strong push towards universal preventative care.
Once a member from Mayhew Insurance switches to Big Blue, we have no interest in their long term health. If anything we have an active interest in not making it easy for the member to incur more claims that costs us money but saves Big Blue money. We can’t deny but we can avoid pushing good long term investments in health. Phone calls won’t be made, letters won’t be sent and health coaches will have those members whose employer group is not renewing with us at the bottom of the priority list.
If instead, preventative care was at least a break even proposition even if the member received that service on their last day of enrollment with Mayhew Insurance, there is a much stronger incentive for Mayhew Insurance to push preventative care services. From a revenue point of view, Mayhew Insurance would need to push preventative services to minimize the net outflow of long run transfer payments even if they can not be maximized as positive cash inflow. Every insurer, including Medicaid and CHIP would be under the same pressure to help get appropriate preventative care to as many people as clinically appropriate.
Re-aligning incentives so that everyone benefits from pushing vaccinations to the target population would increase vaccination uptake rate. If insurers don’t lose money on vaccinations and have a chance to capture gains, they will push it. If providers through pay for performance and gain sharing arrangements can improve their bonuses, they will push harder. And if incentives can be given for vaccinations, patients will ask for it. I know for flu shots and a few other common preventative care measures, my company will send $25 or $50 gift cards to members because their participation produces clear wins of better health and lower costs through avoiding an acute care episode.
Cermet
Maybe a universal tax deduction for each child give their full range of vaccinations for a given year? We would all save big time in lower health care costs.
Hildebrand
You can thank puritanical assholes for the too slow embrace of the vaccine. In Texas, they were masterful in spreading grotesque scare-mongering knavery about HPV vaccination.
Tara the Antisocial Social Worker
The right-wing crusade against HPV vaccination was truly mind-pretzeling. People seriously arguing that little teenage Susie was going to run out and have sex because she’d been vaccinated against a kind of cancer she’s never heard of, that might strike her decades from now.
Or as Katha Pollitt called it, “Virginity or death!”
daveNYC
What level of vaccination would you need to get something like herd immunity when you’re talking about an STD that stays resident in anyone who has had it? It’s a different sort of critter than say measles.
MomSense
@Cermet:
One that doesn’t require itemization.
EthylEster
Could someone translate/explain this for me?
Ignoring the awkward phase “raising the age for screening even higher”….
1. Is this an error and it’s supposed to read “lowering the age for screening”?
2. If no, then what does “raising the age for screening” accomplish?
Argiope
@daveNYC: Actually HPV doesn’t stay resident forever; immune systems (particularly of young people) can and do kick it out without further intervention about 85% of the time. Herpes is different; that does stick around forever.
Argiope
@EthylEster: Screening always has both a negative and a positive set of possible effects. We are always trying to balance the benefits of screening against the costs. In this case, the benefits include earlier detection that can save lives, but in some cases can also lead to unnecessary interventions for a condition that often solves itself. Many HPV infections are tackled and conquered by the immune system, but some are not. Interventions for oncogenic HPV involve procedures that change the architecture of the cervix–increasing later risk for preterm birth in the process. Unfortunately, we can’t tell which high grade infections will resolve on their own, and thus we can’t watch and wait because of the cancer risk. The costs of too much screening– beyond unnecessary intervention– include speculum exams (not physically risky, but for some women not psychologically safe), money, and worry from false positives. If we can find the sweet spot, screening mostly women in whom HPV has persisted for a longer time (those are the infections that lead to cancer), we reduce the overall costs of a screening program while still accomplishing the benefits. Widespread adoption of HPV vaccination could raise the screening age upward because the sweet spot moves to an older age range.
Richard Mayhew
@Argiope: Thank you for a great explanation!