“Ya Down With OCP?” “Yeah, you know me!”

“Nothing is as expensive as it is when it is free,” or so goes the adage.

Obamacare rears its ugly head again, obscured in the news by the debt ceiling debate and the like. Part of Obamacare is that the department of Health and Human Services (HHS) has the power to regulate what health insurance must cover. One of the ideas behind Obamacare is that preventative services will ‘bend the cost curve.’ It’s an idea that has met with some controversy because some cost analyses have shown that an ounce of prevention may not be worth a pound of cure in some settings.

So, last month, the Institute of Medicine, an independent not-for-profit think-tank that is a member of the National Academies (National Academy of Science, etc) issued it’s recommendation regarding recommended services for women’s preventative services.

HHS this week announced what it’s going to mandate covered FOR FREE to the patient. This is a rather progressively biased but otherwise informative article from our ‘friends’ at the AP.

Begin Parenthetical. Now before Dr. J. gets to the punchlines, the National Academy are the ‘go to’ guys for the Federal Government when they have questions regarding science (and medicine) when they are trying to inform their policies. The IoM is made up largely of academic physicians of various stripes. In the academy, becoming a member of the IoM is a big deal, because you are seen as someone who is a sufficient expert in your field for these guys to care about your opinion. Because it is a who’s who of the academy, there are a lot of liberal types that are members. The IoM has caused Dr. J. great headaches because they were the ‘go to guys’ for the ACGME with regard to workhour restriction recommendations for residents which have already significantly affected their learning, and from what Dr. J.’s minions (residents and fellows) have told him, their morale as well. The IoM’s recommendations were not founded in reality and probably have made graduate medical education worse. End parenthetical.

So, this is what the IoM recommended should be covered at no cost to patients under OBAMACARE with regard to women’s health:

· screening for gestational diabetes

· human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30

· counseling on sexually transmitted infections

· counseling and screening for HIV

· contraceptive methods and counseling to prevent unintended pregnancies

· lactation counseling and equipment to promote breast-feeding

· screening and counseling to detect and prevent interpersonal and domestic violence

· yearly well-woman preventive care visits to obtain recommended preventive services

Now most folk have insurance that covers the bulk of these services. These services come with nominal co-pay’s. That way, at present, the patient has a modest amount of skin in the game. When Mrs. Dr. J. was great with lil resident, our United Healthcare Policy covered the whole pregnancy for $15 out of pocket. When she was carrying the lil med student, our BC&BS policy had $15 co-pays per visit and some minor complications put us on the hook for $100 here and there. Mrs. Dr. J. has an annual visit with her Ob/Gyn covered for $30 because he is ‘out of network’ since he changed groups, but that’s fine. When Mrs. Dr. J. took oral contraceptives back in the day, they cost her $30-45 a month, as insurance didn’t cover OCP’s. That’s about the same as a typical ‘Tier II’ drug on most insurance plans.

Here are where the added costs come in:

1) HPV DNA testing in addition to a standard Pap-smear. It’s sensitive, it doesn’t cover all of the cancer causing forms of HPV, but it adds information. Probably valuable.

2) Screening for HIV annually. Hopefully doctors will only test appropriate candidates. Not all women need a HIV test. Some doc’s will do it because it’s now free to the patient (resulting in an increased rate of false positive tests because of Bayes’s theorem), other docs will only test appropriate patients. Honestly, HIV is freaking rare in women, testing free of charge is wasteful if it is done with impunity.

3) Comprehensive lactation support…this is largely covered by insurance. With regard to equipment, that can add up if its free.

4) Annual visit(s) – there may be more than one visit if it takes that many visits to get things straightened out. There is NO CO-PAY. Thus this increases cost.

5) All counseling costs time. Doctors will be a fixed cost more and more as they become salaried with less productivity incentives in the future, their time will become scarce.

6) The biggie – The full range of FDA approved contraceptive methods, sterilization, education and counseling. This is HUGE. Oral contraceptives, one of, if not the, most commonly prescribed class of medication in the USA will now be free. If OCP’s are not the method of choice, then IUD’s, depo-provera shots and those patches will be free. This is a huge cost that’s being shifted from the patient to society. OCP’s can run from $9-90 depending on the brand. Many women through trial and error find they tolerate one agent poorly and then move on to a more expensive brand. Contraceptives treat physiology, not pathology, and frankly, they’re not that expensive, but a few million prescriptions per year, will add up. The vast majority of people can, do, and should pay for them themselves. Those that can’t afford them can get contraception, along with all other medications through a combination of industry, charity and government means.

It makes no sense to Dr. J. that the most able bodied among us (young people who are physically well enough to have sex) aren’t responsible enough to pay for their own their own contraceptive needs. Contrast that with folks with hypertension, high cholesterol, and plenty of other maladies fork over a whopping $4 or more per prescription for their medication that prevents, heart attack, stroke, and death for Pete’s sake.

By making these services free, will not necessarily avail individuals to take advantage of them. Paradoxically, folks will be more lacksidasical with regard to taking care of themselves. In addition if anyone were to pay for these services, or medications out of pocket, those costs will rise.

What’s worse, because of Obamacare approved plans will be subsidized for those of less means, means that Dr. J. and others will be on the hook via tax dollars for therapies that we may find objectionable, such as RU-486 which can terminate a pregnancy prior to implantation of the fertilized egg by causing shedding of the uterine lining (aka causing a period), or an IUD, many of which prevent implantation of a fertilized egg. The argument that progressives make about RU-486 and IUD’s not ‘causing abortions’ is that if one does not know if a) they’ve ovulated, b) they’ve conceived, and c) that a pregnancy ended due to the use of either agent for contraception then it’s not an abortion. It’s the progressive’s version of , “if a tree falls in the woods and no one hears it, does it make a sound?”

Dr. J. has been repeatedly troubled by the Obama administration’s lack of respect for disagreements of conscience, especially surrounding issues of life. Since Dr. J. has gone on enough, he will link to Kathryn Lopez’s piece from the Corner today. She discusses this aspect of the regulations with some input from Cardinal DiNardo of Houston Texas. Go and read that, and this fine piece by Greg Pfundstein at the Corner as well, if you want some juicy medical ethics reading. That’s just too much to do in one post by Dr. J., even as long winded as he is.

About Dr. J.

Dr. J. was born the son of a New Atlantean sharecropper who cornered the market on notoriously delicious seaweed Himanthalia elongata (popularly known as Thongweed). With his newly minted seaweed fortune, Mr. J. the Elder sent his son to attend the Academy of Sorcery, Alchemy and Surgery where the good doctor apprenticed with the finest sorcerer surgeons in New Atlantis. Dr. J.'s areas of expertise grew to include bleeding, cutting for stone, trephination, medical divination with outstanding spatial and temporal resolution, cybernetic sorcery and medicinal alchemy. When King Orin of Atlantis fell ill with the Ick, Dr. J. stepped in with an elixir he devised from a combination of minerals, herbs and saps. Curing the king, Dr. J. gained significant notoriety which afforded him the luxury of time to devote himself to his side hobbies which include porpoise racing, the study of supply-side economics, cooking and raising his lovely merchildren alongside his lovely bride the archconservative Mrs. Dr. J.