The theory of preventative care, including inoculations, is that we spend a little money now to offset big expenses later in life. But sometimes behavioral friction keeps this from happening, even when the technologies and approaches are proven. We are witnessing such a failure right now with regard to Human Papilloma Virus (HPV).
Here’s the story, from MGH’s James Michaelson, PH.D., arguably one of the most thoughtful, trustworthy, and sensible researchers in the field of analysis of cancer survival. Jim and his team develop sophisticated mathematical methods for predicting the risk of local, regional, and distant recurrence. He says:
There are a couple of good papers about Human Papilloma Virus (HPV), and the coming epidemic (yes, an overused term, but truly applicable here) of head and neck cancer. As Chaturvedi et al say in a recent paper: “If recent incidence trends continue, the annual number of HPV-positive oropharyngeal cancers is expected to surpass the annual number of cervical cancers by the year 2020.”
I get to see this problem from two angles: From my work as the the manager of the MGH/MEEI Head and Neck Cancer Database, and from my experiments in using computer telephone messages to get patients in for preventive health services, such as the fabulous HPV Vaccines: Cervarix (from GlaxoSmithKline) and Gardasil (from Merck). The vaccines are incredibly underutilized. Only about 1% of eligible boys and only 50% of eligible girls get one shot. Only about 25% of girls get all three shots.
Beyond the misplaced reluctance of parents to have their children inoculated–or the lack of understanding of the importance of this for boys as well as girls–I wonder if part of the problem here is that insurance companies see no real payback in helping to promote this. After all, what is the chance that a child I am covering today with insurance is likely to be my subscriber by the time he or she gets cancer? Unlike polio, measles, and mumps, which show up during childhood, the head and neck cancers are not likely to show up until adulthood. While the cost per delivered dosage would be remarkably small, especially measured against the societal savings, there is currently no way to internalize that cost-benefit equation into insurance practice.
Two remedies come to mind:
1) As being explored by Jim, use voice-recognition telephone calls and other media to spread the word to parents. Funding for this could logically come from the pharma companies producing the drugs, or from chains like CVS or Walgreen’s. Maybe, also, some multi-specialty practices will choose out of a sense of responsibility to take it on as part of their regular family medicine practices.
2) Less likely, especially given the sensitive politics, make this inoculation a legal requirement like polio and other vaccines. As an economist would say, this would internalize the externalities by government fiat.
Paul Levy is the former President and CEO Beth Israel Deaconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.