A few weeks ago, I stumbled across the Facebook group “Chicken Pox Parties—New York Metro Area.” It has 143 members, all of whom, I’m guessing, are parents who have chosen not to vaccinate their kids against chickenpox and instead hope to build their kids’ immunity the old-fashioned way, by directly exposing them to the germs of a poxinfected child. They are not alone: Facebook has 14 other
chickenpox party groups organized by geographical region, and if you can’t get to one in person, you can always ask to be sent a lollipop with an infected child’s spit on it. Perhaps these parents go this route because they’re distrustful of the vaccine or they think that inoculating against chickenpox is dumb. For those of us who endured chickenpox as kids and emerged relatively unscathed, the
varicella vaccine, as it’s called, does at first seem kind of dumb—another unnecessary medical intervention being thrust upon us and another box to check off on the neverending paperwork that is raising a child. So should we say no to our pediatricians and bring a pox on all our houses instead?
After evaluating the medical evidence, my answer is an emphatic no. The shot is by far the better way to go. That’s because although we might recall chickenpox as a small but annoying blip on our childhood radar it can be dangerous. True, before the vaccine was licensed in 1995, only about 100 to 150 American kids died of chickenpox every year, and most of these children had underlying immune system issues. But every year, chickenpox landed about 11,000 kids in the hospital. It’s not that they couldn’t handle all the itching; one
study from Europe (where many countries do not vaccinate against chickenpox) has found that one-fifth of all otherwise healthy kids who are hospitalized for chickenpox suffer neurological problems such as strokes, meningitis, convulsions, and encephalitis. Chickenpox can also cause septic shock, pneumonia, necrotizing fasciitis (that’s flesheating bacteria), and other bacterial infections.
All in all, before the vaccine was available, about one in 400 kids who caught the chickenpox ended up in the hospital. (For comparison, your child also has a one in 400 chance of developing diabetes.) But the vaccine prevents these complications. According to one University of Michigan study, after the varicella vaccine was licensed, hospitalizations related to the infection dropped by 75
percent within six years. Clinical trials suggest that after kids receive the first dose of the varicella vaccine between the ages of 12 and 15 months, they are between 80 and 94 percent less likely to catch the infection compared with unvaccinated children (the range I’ve provided here is large because it reflects findings from studies conducted in different ways). After receiving the second dose between
ages 4 and 6, kids are 98 percent protected. And even when vaccinated kids do get sick, their bouts are usually very mild because the vaccine still helps them fight the infection more effectively. (Kids are more likely to suffer these “breakthrough” infections if they have asthma or if they receive the MMR vaccine within 28 days of the varicella vaccine.)
There’s also evidence to suggest that the vaccine staves off shingles. Chickenpox is a herpes virus, which, like the kind that affects your lips and nether regions, sits latent inside your cells after an initial infection until something causes it to flare up again. Seniors are at a high risk for suffering these chickenpox-related flare-ups, called shingles, which can cause terrible, long-lasting pain. (About half of all 85-yearolds have had it.) Kids and adolescents can get shingles too, though it’s rare. And a 14-year-long study found that kids
vaccinated against varicella were 39 percent less likely to get shingles as youth than were unvaccinated kids who had naturally caught the infection. No one yet knows, however, whether this extra shingles protection will last until old age because the chickenpox vaccine hasn’t been around long enough—its earliest recipients are still pretty young.
Does the vaccine pose risks, too? Of course; every edical intervention does. But the risks associated with the vaccine are much lower than the risks associated with infection. The Centers for Disease Control and Prevention and the Food and Drug Administration monitor potential vaccine side effects using the Vaccine Adverse Event Reporting System. VAERS isn’t perfect. For one thing, it doesn’t record problems unless patients or their doctors report them. The complaints about the varicella vaccine that get recorded in VAERS aren’t always caused by the varicella vaccine, either. For instance,
if a person falls ill soon after getting the shot, it’s possible that the timing is simply a coincidence—maybe the child was catching the flu anyway. Moreover, about half of VAERS complaints about the varicella vaccine describe problems people experience after receiving varicella along with other vaccinations, so it’s impossible to know which vaccine caused the reaction.
Even though the system is imperfect, the numbers suggest that the varicella vaccine is much safer than the infection. VAERS found that between 1995 and 2005, 0.052 percent of people who got the varicella vaccine—that’s 52 out of every 100,000 vaccinees—complained about complications, most of them minor. These included rash (17 out of 100,000), fever (11 out of 100,000), and pain at the injection site (seven out of 100,000). More rarely, the vaccine was associated with diarrhea (1.7 out of 100,000) and convulsions (1.8 out of 100,000 ). And yes, the vaccine was associated with 60 deaths during that decade (one out of every million doses), but most occurred in children who had serious congenital problems or immune-related deficiencies and who should never have gotten the vaccine in the first place. Ten of these deaths were categorized as “crib deaths”—basically, SIDS—so it’s impossible to know whether the vaccine caused them. Comparing the stats more directly, your kid has a one in 400 chance of ending up in the hospital after catching chickenpox at a party or a one in 2,000 chance of suffering a (likely minor) side effect after getting the vaccine. Death, while rare either way, is also far more likely from chickenpox than from the vaccine. And don’t forget that kids who get the vaccine are 39 percent less likely to suffer shingles as a child or teen. Vaccine 3, pox party 0.
Parents who opt for pox parties might end up with a very sick older kid one day.
There are other reasons to give your child the vaccine, too. As more and more kids get vaccinated against varicella, the chances of planning a successful pox party drop: There are simply far fewer kids out there getting—and transmitting— chickenpox. You’ll have to work on that invite list a long time before you find your “patient zero.” And the longer it takes an unvaccinated child to catch the infection, the more dangerous that infection becomes, because more severe cases of chickenpox tend to occur in older kids.
And vaccination may pose a public health risk that, paradoxically, further supports the idea that you should inoculate your kid. Some researchers posit that people who catch chickenpox as kids should be re-exposed to the virus throughout life to boost their immunity; research suggests, for instance, that adults who are frequently exposed to chickenpox are less likely to develop shingles. Since so
many fewer kids are running around with chickenpox now, some researchers worry that this immune-boosting effect is disappearing and that those of us who had the infection as kids are going to experience a “major epidemic” of shingles in the coming years. (This is partly why, in 2006, the CDC began recommending a single dose of shingles vaccine for adults over the age of 60—the idea is that the vaccine will help provide the missing immune boost.) This potential problem—while still unproven—could be a public health drawback to widespread varicella vaccination, but when it comes to deciding what to do for your child, the shot seems the obvious choice, since it seems to substantially reduce shingles risk compared with infection as it is.
As a general rule, you shouldn't be nostalgiac about anything with the word pox in it. So is there any reason not to give your kid the varicella vaccine? Sure. The vaccine is generally not advised for sick kids, those with immune-related conditions such as HIV or cancer, kids who have recently had transfusions, those who have been on immune-quashing steroids for more than two weeks, and children who have had allergic reactions to previous doses of the chickenpox vaccine or have allergies to gelatin or neomycin. (These unvaccinated kids, by the way, rely on herd immunity to keep them safe from infection—so by choosing not to inoculate your child, you’re also putting these already at-risk kids at more risk.) Otherwise, though, the shot is a no-brainer. It is highly effective and poses far fewer risks than the infection does. Plus, it may reduce your child’s risk of shingles. And now that so many kids are being vaccinated against chickenpox, parents who opt for pox parties, or who blithely assume their kid will be infected at school, might end up with a very sick older kid one day. I know that it’s tempting to think, That’s silly; I didn’t have the vaccine, so my kid shouldn’t need it either. But you might
as well be saying that your kid has no right to a healthier, safer world than the one you grew up in—and that sounds far sillier.
Melinda Wenner Moyer is a science writer based in Cold Spring, New York, and is DoubleX’s parenting advice columnist.
Follow her on Twitter. Accessed from www.slate.com on 2/4/15
One of the things that I do a lot here at our practice is talk to parents about their health insurance coverage. The conversation is usually about why they have a balance on their child’s account.
Health insurance is very complicated. At our practice, we deal with health insurance all the time and even for us, it gets to be very complicated sometimes.
Today, I had a conversation with a patient’s parent regarding medical billing issues. After explaining some in-and-outs about why we do certain things, the parent mentioned she had no idea things were the way they were and now understands why doctors’ offices have to do what they have to do.
She also mentioned that we should do something to spread the word. She said, “I think it is important for other parents to know this. Otherwise, how are things going to get better?”
I thought her idea to spread the word was very good. Therefore, I decided to summarize our conversation in an effort to help other parents understand, at the very least, a portion of medical health insurance.
Coding — a lot of what doctors do
At a restaurant, generally you’ll get an itemized check that shows all the things you’ve ordered. Doctors do the same thing, but they do it in the medical chart.
Virtually every doctor who accepts health insurance uses codes (called CPT codes) that are assigned to every task they and their staff performs. Everything from a simple blood draw, to immunizations, to the ear check, to specimen handling — all these things are “coded” separately.
Why do docs do it this way?
These codes are used by the patient’s health insurance company to determine the payment amount that the doctor will receive for his or her services. In other words, the health insurance company (the one actually paying for the services) wants to see what was done during a patient’s appointment. Hence, everything the doctor and the staff does as a code.
For example, if you are coming in for a child’s well visit, the pediatrician will submit a “claim” to the insurance company using the following codes:
- Established Well Visit – 99392
- Developmental Testing – 96110
- Hemoglobin – 85018
- Finger/heel/ear stick – 36416
- Lead Testing -83655
- Hearing Screen – 92587
If the child gets immunizations, those have codes too.
- DTAP-IPV – 90696
- Flu – 90660
Vaccine administration also uses a distinct set of codes. To further complicate things, some vaccines have a single administration code used with them, and others have multiple administration codes for a single vaccine.
- Admin – 90460
- Admin – 90461
Oh, by the way…
Let’s say while you are in the examining room, you ask the doctor, “Ya know doc, little Lisa here has been pulling on her ear lately… she may have an ear infection. Can you check that for me really quick?”
This question requires the doc to perform an entirely different assessment than the well visit the child was getting.
The doctor, in order to show the insurance company that she did a completely different assessment, codes the ear pain diagnosis and adds a 99213 – which is an evaluation and management code that documents in the chart and on the claim to the insurance company that the doctor also checked the patient’s ear.
But we feel like we are being squeezed for every penny
Parents often think when they are looking at the bill that the doctor is nickeland- diming parents, when in reality; it is the insurance company that requires the doc to show their work in this matter.
The health insurance company doesn’t accept the doctor telling them, “I did a well visit — pay me our agreed-upon fee.” They want to know all the things the doctor did during a patient’s visit so they can decide how much they ought to pay the doctor for his/her services.
Since most patients (or in the pediatrician’s case, parents) don’t pay the doctors directly, but rather the health insurance company, they want to know what took place during the visit so they know how much they ought to pay the doctor.
It is the same as going to the restaurant and getting billed for all the side and extra orders. Although the main meal is accompanied by other things, like french fries or a salad, refills, side orders, substitutions and additions to the order are billed as extra.
Health care services are a la carte as well.
Why then do patients have balances if insurance ought to have paid?
The insurance policy that a patient has chosen may not pay for all the services the doctor performed. So when the doc’s billing staff submits a claim for a visit, the health insurance company often comes back and says, “We are not responsible for these codes/services; these are the member’s responsibility per the member’s health insurance policy. ”
For example, the health insurance company may say, the policy your patient chose pays for a vision screen, but not for a hearing screen. Or they may say, we cover the well visit code, but not the ear ache code at the same time as the wellness visit.
Doctors get stuck with the bill
The doctor, already having performed services, now has to go to the patient and say, “Hey, remember that school physical I performed and you asked me about little Lisa’s earache? Well, your insurance says that the policy you have doesn’t cover the earache part, so I’d like to be paid for the work I perform in assessing your child’s earache.”
Of course, doctors don’t actually say that, but when a parent gets a bill for the earache, that is in essence what the doc is trying to say to the parent. And if one looks carefully at the explanation of benefits (that document that the insurance company sends after they process a patient’s claim) one will notice they give an explanation as to why they are not going to pay the doctor for the service.
Funny how things work
Here is an interesting, but crazy fact. In many cases, had the doctor deferred the earache question and told the mom to make another appointment to address that issue during another appointment, the health insurance company would have most likely paid for the office visit.
However, had the doctor done that, the patient would have most likely gotten upset at the doctor. By treating the earache question during the wellness visit, the doctor runs the risk of not being paid despite doing the work. On the other hand, not addressing the ear ache, the doc runs the risk of upsetting the parent, who will probably think the doc is trying to squeeze another $30 copayment, which is clearly not the case.
Cutting cost — not always a good idea
One of the major problems with this is that patients don’t understand what they are financially responsible for. Or, it’s often the case where patients don’t understand what type of health insurance they’ve purchased.
Just like with anything else, you get what you pay for. But patients overlook this issue when purchasing health insurance. They usually look at the monthly premiums and choose the lowest one. But by doing that, they are often reducing the amount of coverage, which means patients will get stuck with larger portions of their medical bills.
Growing trend to save cost
The health insurance company, in an effort to keep their premiums low, have shifted the cost to customers and their doctors. While in the past health insurance companies may have covered 100%, now they are reducing the monthly premiums but only covering 70% of one’s medical expense. Hence all the high deductible plans out there.
Why wasn’t I told they insurance doesn’t cover?
In our practice – which is a small three-provider practice – we see on average 60 to 75 patients daily. Add to that there are virtually thousands and thousands of different health plans. In fact, we have patients whose parents work for the same company, but because they are at different pay grades, have different insurance plans.
The answer is, we don’t have enough manpower or time to sit on the phone verifying every single patient’s healthcare coverage. I know of practices that do, and God bless them. But as a practice we believe it is the patient’s responsibility to find out what is covered and what is not covered. The more time we spend on the phone with a patient’s insurance company, the less time we are able to spend providing health care for our patients.
As a practice, we consider that treating patients based on what the insurance covers and what it doesn’t, instead of treating by what the patient actually needs, is an unethical way to practice medicine.
Although most doctors that I know will take into consideration health insurance stipulations, they will not compromise a child’s health as a result of health insurance restriction and cheap health insurance coverage plans.
I hope this post will give all that read it some insight and perspective on medical billing. If you have a question, or don’t understand why doctors’ office do medical billing, feel free to leave a comment and we will try to address it.
Oh, and thanks for reading…
Brandon Betancourt is a practice administrator for Salud Pediatrics.
You can follow him on Twitter @pediatricinc.
In the largest-ever study of wet wrap therapy—also called soak-and-seal—researchers at National Jewish Health in Denver evaluated the technique in 72 children who had a mean score of 50 (severe) assessed using the Scoring Atopic Dermatitis and AD Quickscore instruments.
The children soaked in a bathtub of warm water for 10 to 20 minutes. While their skin was still damp, topical medications were applied to areas of eczema and creams or ointments to clear skin. To seal in the moisture and medication, the children were either dressed in wet clothing or wraps were applied followed by a layer of dry clothing. After at least 2 hours, the clothing and wrapping were removed. Researchers applied wet wraps 2 or 3 times a day for about 2 weeks, gradually reducing the wrapped area to just the affected skin.
The treated children experienced a 71% decrease in symptoms overall and maintained clinical improvement a month after treatment was discontinued. Mean severity scores declined from roughly 50 to around 15. None of the children needed systemic immunosuppressive therapy to control symptoms during the treatment, and only 31% received oral antibiotics.
Researchers caution parents against trying to use wet wrap therapy on their own because the procedure needs to be followed correctly, and overusing it can do more harm than good.
An estimated 20% of children in the United States have AD, and the incidence is rising. Medications used to control more severe symptoms, such as immunosuppressive drugs and oral corticosteroids, can have long-term effects on bones, blood pressure, and kidneys, leaving parents seeking treatments that reduce the need for these drugs.
The incredibly vast wonderful matrix of cells, tissues, organs and enzymes that make up the human body is much more complex that would be unraveled in our respective lifetimes. The role tiny elements called trace elements play in ensuring a smooth run of affairs from moment to moment cannot be overstated. Zinc, is one of the elite members in this league of trace elements. Many benefits have been touted to Zinc, and scientific testing has validated many of these. One of the more colloquially perceived strengths of Zinc is under review today, Does Zinc cure the common cold? The common cold is regarded as one of the most widespread illnesses and is a leading cause of visits to the doctor and absenteeism from school and work.
As the argument rages on, researchers pooled a number of randomized controlled trials designed to answer this question with very rigid selection criteria. This meta-analysis meets one of the highest pedigree of medical scrutiny and the study was published in the Cochrane Systemic Database Reviews in June 2013. Researchers, Das and Singh collectively had looked at the effects of Zinc if any and what optimal dosage it is likely to be beneficial in ameliorating symptoms or curing the cold symptoms in about 1900 study participants over a 5 day period.The study findings showed that Zinc when administered within 24 hours of onset of symptoms reduces the duration of common cold symptoms in healthy people but some caution is needed due to the heterogeneity of the data. As the zinc lozenges formulation that has been widely studied show, there is a significant reduction in the duration of cold at a dose of >/= 75 mg/day, for those considering using zinc it would be best to use it at this dose throughout the cold. Regarding prophylactic zinc supplementation, to keep the cold at bay for months at a time, currently no firm recommendation can be made because of insufficient data. When using zinc lozenges (not as syrup or tablets) the likely benefit has to be balanced against side effects, notably a bad taste and nausea.
Excess ingestion of trace elements can have its own problems and always discuss treatment options with your healthcare provider.
Breastfeeding and Risk of Formula Supplementation.
The maxim, “breastfeeding is the way to go!” was drummed in early in my pediatric training and it remains a scientific fact to date. Recently the World Health Organization (WHO) conducted surveys and monitored growth for years on exclusively breast fed newborns in stable home environments from six racial backgrounds in six different geographic regions of the world to get an idea of how a normal human ought to develop in the first 2-years of life. The finding which shows that we all grow in a consistent manner regardless of racial background when exclusively breastfed corroborates the importance of breastfeeding. Baby friendly hospital initiatives gaining traction in some valley newborn nurseries draw their antecedents from these initiatives by the WHO.
There are various reasons why a newborn infant may not handle the transition to establishing normal breastfeeding after birth as well as anticipated. These situations often call for formula supplementation informed by medical reasons. This recommendation frequently meets resistance and understandably so from mothers who want to exclusively breastfeed their newborns. Their concerns are often premised on the fact, that formula supplementation would hamper subsequent establishment of successful breastfeeding.
In the May 2013 of Pediatrics, a publication of the American Academy of Pediatrics, Dr. Flaherman et al set out to address this question for the first time and find out what effects if any the early administration of small formula volumes would have on newborn breastfeeding rates between the first week and the third month of life. 40 exclusively breastfed newborns who had met the medical criteria for early formula supplementation were randomly assigned to a study arm and a control arm. The researchers used a randomized control trial (RCT) model to study the effects of formula supplementation on these newborns. RCT type studies are widely ranked high on the hierarchy of medical evidence and scientific scrutiny. Their findings show that longer term breastfeeding rates were better than anticipated at the first week of life and at 3 month in infants who were allowed early formula supplementation for medical reasons.
This is the first study of its kind to address this concern and indeed shows that our collective fears and concerns about potential adverse effects of early formula supplementation of maternal breastfeeding efforts may be exaggerated and not actually inimical to successful long term breastfeeding rates. There are caveats however, since the infants were supplemented with formula fed by syringe and not a bottle and nipple perhaps to avoid the hobgoblin of nipple confusion is one key outlier not adjusted for in this study. The small size of the study participants also limits the statistical power and applicability to the general population.
We laud the efforts of all mothers and acknowledge the challenge of exclusively breastfeeding a newborn. We champion this cause at our practice and support variations of it. Ultimately the overarching goal must remain optimal nutrition for the newborn to support healthy growth and development.
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