HealthLawProf Blog

As Budgets Tighten, More People Decide Medical Care Can Wait

The Washington Post reports that the global economic crunch is forcing a growing number of Americans to scale back on medical care as they push off seemingly less urgent services in the hope their financial health will improve.  Ceci Connolly and Kendra Marr write,

To monitor the multiple sclerosis attacking Ann Pietrangelo's central nervous system, her doctor recommends an annual MRI. Last year, the 49-year-old Winchester, Va., woman had to pay a $3,000 co-payment to get the imaging done.

This year, she's skipping the test. Even with insurance, it's more than her budget can tolerate, especially with the roller coaster on Wall Street devouring her retirement savings.

"I'm doing everything I can to avoid going to the doctor," she said.

From Park Avenue dental offices to the Arlington Free Clinic, the global economic crunch is forcing a growing number of Americans to scale back on medical care. Consumers are attempting their own form of triage, pushing off seemingly less-urgent services in the hope that their financial health will improve. But the danger, say physicians, is that the short-term savings may translate into more severe long-term health implications.

At the extreme are cases such as the Texas woman who went to the hospital complaining of back pain. Physician Doug Curran immediately spotted cancer on the X-ray.

"She'd had a lump in her breast for a while, but things were tight and she said she couldn't get it looked at," he recalled. "We're going to see more of that."

Nationwide, the number of consumers who went without a prescription, tapped into retirement savings to pay for health care or skipped a doctor visit for themselves or a child has risen since last year, according to a survey released this summer by the Rockefeller Foundation and Time magazine. One-quarter of the 2,000 respondents, for example, said they had decided not to see a doctor because of cost in 2008, up from 18 percent the year before. Ten percent said they did not take a child to the doctor for the same reason.

"When the economy is in the situation we have today, people make tough choices," said Kansas Insurance Commissioner Sandy Praeger, who is head of the National Association of Insurance Commissioners. "Things are just not going to get done."

After nearly a decade of steady -- often double-digit -- increases in drug spending, the research company IMS Health this summer recorded the first actual decline. And a survey by the Center for Studying Health System Change found that nearly 20 percent of Americans report having difficulty paying medical bills.

Layoffs, shrinking bank accounts, rising medical prices and widespread anxiety that the economy is likely to worsen are prompting people to split pills, forgo screening tests such as colonoscopies, delay elective procedures such as laser eye surgery and turn to home remedies as cheaper alternatives. Hospitals report that unpaid medical bills are on the rise, pharmacists see a spike in cheaper generics, and demand for low-cost care is climbing.

Falls Church music teacher Lisa Emrich is coping with a dwindling number of piano students by cutting back on physician visits.

"I have too many doctors and specialists who all wish to see me twice a year," said Emrich, who is being treated for multiple sclerosis and arthritis. "Sometimes I might skip one if I'm doing well in that area. . . . When I see my neurologist, I'll ask about my arthritis, which doesn't make much sense. But I try to get as much as possible out of my doctor visits."

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States Ask Baby Product Companies to Avoid BPA

The Washington Post reports that attorneys general from Connecticut, New Jersey and Delaware sent letters Friday to eleven companies that make baby bottles and baby formula containers, asking that they no longer use the chemical bisphenol A (BPA) in their manufacturing despite the FDA's tentative conclusion that BPA is safe.  Larry Smith writes,

The Food & Drug Administration has tentatively concluded that BPA is safe based on a review of research, and some manufacturers have already said they would make BPA-free baby bottles.

But Connecticut Attorney General Richard Blumenthal criticized the FDA for declining to take action after a preliminary study last month drew a possible connection to BPA and risks of heart disease and diabetes.

"Unfortunately the federal agency, the Federal Food and Drug Administration, has been asleep at the switch, in fact resistant to respecting the scientific evidence that grave harm can result in use of this product," Blumenthal said.

Scientists are at odds about the risks of BPA. A preliminary study released last month by the Journal of the American Medical Association suggested that adults exposed to higher amounts of the chemical were more likely to report having heart disease and diabetes. The study doesn't provide proof, although its authors said the results deserve scientific follow-up.

Michael Herndon, an FDA spokesman, said Monday that the agency is continuing to evaluate its risk assessment.

More than 90 percent of Americans have traces of BPA in their bodies, but the FDA says the levels of exposure are too low to pose a health risk, even for infants and children. Other scientists, however, say BPA has been shown to affect the human body even at low levels.

The scientific debate about the chemical could last for years.

In the letters, Blumenthal cites studies that indicate BPA can attach to food in heated containers. "The preventable release of a toxic chemical directly into the food we eat is unconscionable and intolerable," he wrote.

Letters were sent Friday to baby bottle manufacturers Avent America Inc., Disney First Years, Gerber, Handicraft Co., Playtex Products Inc. and Evenflo Co., and formula makers Abbott, Mead Johnson, PBM Products, Nature's One and Wyeth.

"Unfortunately the FDA has refused to do anything about it," Blumenthal said Monday. "We're asking the 11 manufacturers to do so voluntarily."

Jay Highman, president and CEO of Nature's One, who said his company doesn't sell its products in containers that have the chemical, hadn't received the letter by Monday.

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Infant Deaths Drop in U.S., but Rate Is Still High

The New York Times reports that according to government researchers, infant deaths in the United States declined 2 percent in 2006, but the rate still remains well above that of most other industrialized countries and is one of many indicators suggesting that Americans pay more but get less from their health care system.  Gardiner Harris writes,

Infant mortality has long been considered one of the most important indicators of the health of a nation and the quality of its medical system. In 1960, the United States ranked 12th lowest in the world, but by 2004, the latest year for which comparisons were issued by the Centers for Disease Control and Prevention, that ranking had dropped to 29th lowest.

This international gap has widened even though the United States devotes a far greater share of its national wealth to health care than other countries. In 2006, Americans spent $6,714 per capita on health — more than twice the average of other industrialized countries.

Some blame cultural issues like obesity and drug use. Others say that the nation’s decentralized health care system is failing, and some researchers point to troubling trends in preterm births and Caesarean deliveries.

Many agree, however, that the data are a major national concern. More than 28,000 infants under the age of 1 die each year in the United States.

“Infant mortality and our comparison with the rest of the world continue to be an embarrassment to the United States,” said Grace-Marie Turner, president of the Galen Institute, a conservative research organization. “How can we get better outcomes?”

The data, collected by the Centers for Disease Control and Prevention, indicate that the nation’s infant mortality rate has been static for years despite enormous advances in the care given to preterm infants. Two-thirds of the infant deaths are in preterm babies.

In 2006, 6.71 infants died in the United States for every 1,000 live births, a rate little different from the 6.89 rate reported in 2000 or the 6.86 rate of 2005. Twenty-two countries had infant mortality rates in 2004 below 5.0 infant deaths per 1,000 live births, with many Scandinavian and East Asian countries posting rates below 3.5. While there are some differences in the way countries collect these data, those differences cannot explain the relatively low international ranking of the United States, according to researchers at the disease control agency.

Preterm birth is a significant risk factor for infant death. From 2000 to 2005, the percentage of preterm births in the United States jumped 9 percent, to 12.7 percent of all births. The most rapid increase has been among late preterm births, or babies born at 34 to 36 weeks of gestation. Some 92 percent of these increased premature births are by Caesarean section, according to a recent study.

Dr. Alan Fleischman, medical director of the March of Dimes Foundation, said that a growing number of these late preterm births might be induced for reasons of convenience. “Women have always been concerned about the last few weeks of pregnancy as being onerous,” Dr. Fleischman said, “but what we hadn’t realized before is that the risks to the babies of early induction are quite substantial.”

Dr. Mary D’Alton, chairwoman of the department of obstetrics and gynecology at Columbia University, said doctors should not induce labor before 39 weeks of gestation unless there was an urgent medical or obstetrical need. For unknown reasons, the number of preterm births is far higher among African-American women even when those women have access to good medical care, Dr. D’Alton said.

There is some evidence, she said, that steroids given to mothers at risk of giving birth early may help. A trial to test this theory is about to start.

Some economists argue that the disappointing infant mortality figure is one of many health indicators demonstrating that the health care system in the United States, despite its enormous cost, is failing.

Although the United States has relatively good numbers for cancer screening and survival, the nation compares poorly with other countries in many other statistical categories, including life expectancy and preventable deaths from diseases like diabetes, circulatory problems and respiratory issues like asthma.

Ms. Turner blamed socioeconomic factors like obesity, high drug use, violence with guns and car accidents — factors that she said could not be addressed by health reform. Karen Davis, president of the Commonwealth Fund, a nonprofit research organization, agreed that socioeconomic factors played a role but said that the nation’s heavy reliance on the private delivery of care was also to blame.

“We’re spending twice what other countries do,” Ms. Davis said, “and we’re falling further and further behind them in important measures like infant mortality.”

Hospitals Protest New California Rules on Patient Billing

The Los Angeles Times reports that hospitals are protesting in court new rules that will bar hospitals and physicians from billing patients for the balance of emergency care not covered by insurers.  Lisa Girion writes,

Emergency room patients can no longer be stuck with the bill when hospitals or physicians disagree with insurance companies on their fees.

Under new state rules that take effect today, hospitals and physicians are barred from billing patients for the balance of emergency care not covered by insurers.

But the relief for patients may not last long. Hospitals and physicians are protesting the rules in court. Meanwhile, the state Supreme Court is set to hear another "balance billing" challenge next month.

And another court test may come sooner in a challenge by hospital chain Prime Healthcare Services Inc. of Victorville.

In that case, set for hearing this month, the state Department of Managed Health Care sued Prime. The state is seeking to bar Prime from billing insured patients for unpaid medical bills that the hospital chain contends it is owed from insurers and is seeking from patients as a last resort.

Department director Cindy Ehnes said she was moving forward with the ban on emergency room balance billing in spite of the legal disputes because of the hardship the practice creates for patients.

She called Prime Healthcare a "serial balance biller whose actions have unjustly threatened the credit rating of thousands of Californians." Ehnes said she wanted to take patients out of the middle of billing disputes between insurers, hospitals and physicians.

"No longer will Californians face the possibility that if they have to use an emergency room, they may be stuck with a bill, asking them to pay a second time for emergency care, which they already purchased with their [insurance] policy," she said.

The disputes typically occur when an insured patient ends up in an emergency room that is not in his or her carrier's network.

These hospitals and physicians may send insurers bills that are higher than what the insurance firms usually pay providers in their network. And insurers often balk, sending back less than the full payment.

Insurers accuse hospitals and physicians of taking advantage of the situation and sending out inflated bills. Hospitals and physicians counter that it is the insurers that take advantage by paying far less than reasonable and customary rates.

Patients wind up in the middle of such disputes when a hospital or physician bills them for the balance. "There was very little until now the consumer could do," said Mark Senkel of Tracy, Calif., whose credit was ruined after he refused to pay a balance bill.

"This is a great step in helping us. I'm going to use this now to get the insurance company and hospital to negotiate with each other and leave me alone, and then I have to go and repair my credit."

The department also announced that it would address what Ehnes called "the root cause of balance billing" -- the unfair or late payment of legitimate emergency room claims by insurers. She said the department would add resources to speed up the resolution of hospital and physician complaints over such practices.

Ehnes said she was confident the rules would pass legal muster in pending court tests.

"We believe our legal authority to protect consumers from balance billing is clear, and we believe our moral authority is even more clear," Ehnes said.

But several physician and hospital organizations have sued the department to block its enforcement of the ban on balance billing.

"The root cause of balance billing is HMOs underpaying providers," said Ned Wigglesworth, a spokesman for the California Medical Assn., which represents physicians.

The role of the state agency "is to regulate HMOs. Yet, instead of addressing balance billing by addressing the misfeasance of the industry it is supposed to regulate, the DMHC went after doctors and hospitals," he said. "The question is why."

Wigglesworth said the department had a poor record of enforcing physician payment complaints. Its current system, he said, is "like the old cartoon with a trash can below a bottomless complaints box."

Prime Healthcare lawyer Michael Sarrao said the new rules favored insurers and hurt doctors and hospitals.

"The HMOs are going to pay ridiculously low rates; the DMHC doesn't do anything, and so the hospitals are going to have to sue HMOs to get paid anything," he said.

Sarrao said hospitals had no idea what they would get paid by insurers with which they had no contracts. One of Prime's hospitals in Chino, for example, treated two children for coyote bites within three months. In the first case, the insurer paid about 90% of billed charges. In the second, the same insurer paid less than 40%.

The new rules should make it easier for consumers to avoid problems with their credit ratings and repair those damaged in billing skirmishes, said Elizabeth Landsberg, a lawyer with the Western Center for Law and Poverty.

"Balance billing has real consequences for consumers," she said. "Some pay their bill not knowing they shouldn't have to. And those who don't pay the bill risk credit ruin."

Researchers Decode the Genome of Two More Malaria Parasites

The New York Times reports that scientists have now sequenced the genome of two more malaria parasites, Plasmodium vivax and Plasmodium knowlesi.  Donald G. McNeil Jr. writes,

Six years after the genome of the most deadly malaria parasite was decoded, scientists have now sequenced two others, opening the way for research into new drugs and vaccines.

Plasmodium falciparum, which is most common in Africa and is responsible for most malaria deaths, was sequenced in 2002; now a team of 40 scientists from around the world, led by a New York University researcher, has untangled Plasmodium vivax, the most common malaria in Asia and Latin America.

While vivax is rarely fatal, it can cause debilitating fevers and shakes for many days and lifelong brain damage. It also has a dormant stage that hides in the liver, causing recurrences months or years later, sometimes long after the victim has left the malarial area.

The parasite seems to have several ways to attack a red blood cell, but it does not cause the cells to twist into clumps, clogging tiny vessels in the brain, as falciparum does.

It has taken longer to sequence vivax because of greater interest in falciparum malaria and because the vivax parasite cannot be kept alive in the laboratory.

A second team sequenced the genome of Plasmodium knowlesi, which is most common in monkeys. It had not been known to infect humans, but scientists suspect that it is the killer in some deaths attributed to other parasites. Both studies were published last week in the journal Nature.

No Carrots for Federal Workers

The Washington Post reports that while health insurance premiums are slated to rise 8 percent on average for federal employees next year, those enrolled in the most popular federal plan, Blue Cross Blue Shield Standard Option, face a 13 percent rate hike.  Christopher J. Gearson writes,

Federal workers and families, meanwhile, will not be offered the financial incentives that the private sector is increasingly using to promote wellness and disease management, said Nancy Kichak, associate director of the Office of Personnel Management.

The federal government has a long history of offering health services on-site through the Federal Occupational Health program, said Bill Hall, a spokesman for the Department of Health and Human Services. In the Washington area, 82 occupational health centers and 19 wellness centers offer immunizations, allergy shots and various preventive and work-related physical exams to federal employees.

Appeals Court Considers Overturning Tobacco Case

The Washington Post reports that a federal appeals court appeared skeptical Tuesday that a landmark tobacco judgment could be supported under racketeering laws, questioning whether cigarette makers had conspired to hide the dangers of smoking and would continue deceiving the public.  Hope Yen writes,

During the three-hour oral argument, all three judges on the appeals panel queried whether the 2006 ruling by U.S. District Judge Gladys Kessler had fully laid out the evidence showing a group conspiracy as required under RICO, a law designed to combat mobsters and other organized criminals.

On several occasions, government attorneys seeking to convince the Court of Appeals for the D.C. Circuit to sign off on billions in financial penalties against the industry allowed that Kessler's 1,653-page ruling might not have spelled out the racketeering violations, or the remedies, as clearly as it should.

"We're asking the judge's order be enforced based on what the court meant," Justice Department lawyer Mark Stern said at one point. He spoke after attorneys for the tobacco industry criticized Kessler's ruling as "cobbling" together statements by cigarette makers that failed to "connect the dots" showing fraud.

"So you want us to enforce the decree not based on what it says but what it 'meant,'" responded a bemused Judge David S. Tatel, a Clinton appointee who has sided with the government in tobacco cases.

Chief Judge David B. Sentelle, a Reagan appointee, was critical of Kessler's finding that the tobacco industry had committed fraud by describing cigarettes as "light," "mild," or "low tar" and by suggesting they were safer than regular cigarettes.

Studies show such cigarettes are not safer because smokers tend to puff harder. Still, cigarette makers were simply following a Federal Trade Commission rule that allowed them to make factual statements about tar and nicotine content based on a specialized test, he said.

"They are basically making factually correct statements," Sentelle said.

Tatel noted that the Supreme Court was reviewing a separate tobacco case that also asks whether advertising of "light" cigarettes might be considered fraud in light of the FTC rule. He suggested the appeals court might want to wait for that decision before acting on at least portions of the current appeal.

The appeal could have wide implications for the tobacco industry, which is facing dozens of lawsuits around the country. A decision to uphold Kessler's landmark judgment could give plaintiffs fresh ammunition and spur new lawsuits by smokers and ex-smokers claiming they were fooled by deceptive marketing.

Kessler's ruling found cigarette makers liable for deception but said she lacked the authority to order them to pay financial penalties. The tobacco industry wants the judgment overturned, while the government and health groups such as the Campaign for Tobacco-Free Kids would like to see billions in fines levied against the industry to pay for a smoking cessation program and related efforts.

The ruling bars tobacco companies from labeling cigarettes as "low tar," "light," "ultra light" or "mild"; it also orders the companies to publish in newspapers and on their Web sites "corrective statements" on the adverse health effects and addictiveness of smoking and nicotine. Both those orders have been stayed pending the appeal.

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Lack of Compensation Can Tempt Doctors to Tailor Their Care to a Patient's Coverage

The Washington Post reports that it's not uncommon for patients with no insurance or poor insurance to receive different treatment. A study shows that in nearly one in four encounters, physicians reported adjusting their clinical management based on a patient's insurance status; nearly 90 percent of physicians admitted to making such adjustments.  Manoj Jain writes,

When I walked into the hospital room of a 19-year-old woman, a foul smell all but overwhelmed me. I called a nurse to assist me and saw her, too, catch her breath.

When we examined the young woman we found a chronic infection of her pelvis so painful that she resisted our slightest touch.

How long had she been living like this, I wanted to know. Through tears, my patient hesitantly began an explanation that told me as much about our diseased medical system as about her illness: She'd had diabetes since she was a child, she said. On her 18th birthday, she lost her insurance and had been able to afford insulin only occasionally. She worked two jobs, she said, but neither offered insurance. Uncontrolled, her diabetes had let the infection develop and fester.

As I left her room, I realized I'd already grown accustomed to the rank odor. That, I think, is what happens when we learn that 47 million people in the United States are uninsured. At first, we find it shocking. But over time, most of us learn to ignore it.

What's in Your Wallet?

That experience sparked a conversation with a friend, a primary care physician who told me that about 20 percent of the patients he treats at the hospital are uninsured, and he is not compensated for treating them. (As physicians sometimes say, "No other professionals -- lawyers, plumbers, accountants -- provide uncompensated service to one-fifth of their clients.")

Although the uninsured look like any other patients, it's easy to spot them: Their charts have places for their address, emergency contact and insurance information; an empty insurance box is a telltale sign. Some doctors examine this sheet before examining the patient -- a practice we refer to as a wallet biopsy.

The 1986 Emergency Medical Treatment and Active Labor Act declares that hospitals cannot refuse care to critically ill patients and that the physician on call must treat them. Internists with privileges at a hospital (like my friend) are usually part of the on-call rotation for the emergency room.

"I used to get angry every time the emergency room admitted an uninsured patient," he said. "I would try to spend less time with them -- 20 minutes instead of 30 -- and try to get them out of the hospital quickly and hope they would not come to my clinic."

It's not uncommon for patients with no insurance or poor insurance to receive different treatment. A 2006 study of 25 primary care private practices in the Washington area showed that in nearly one in four encounters, physicians reported adjusting their clinical management based on a patient's insurance status; nearly 90 percent of physicians admitted to making such adjustments. For patients with no insurance, alterations occurred 43 percent of the time; and for the privately insured, just 19 percent.

Some of these adjustments make little difference: Uninsured patients received more generic drugs and multiple drugs. A doctor might prescribe two generic pills for high blood pressure -- an ACE inhibitor and a diuretic, which together would cost $20 for a given period -- instead of a combined brand-name pill, which would cost $241.

The impact of other decisions is more worrying. A heart surgeon told me he operates on uninsured patients but schedules them for the end of the day; if other cases take longer than expected, the uninsured get bumped. Some gastroenterologists are quick to perform endoscopies or colonoscopies on insured patients; not so for the uninsured.

Some uninsured patients forgo tests or treatment. According to a 2003 study, participation in screening tests for breast cancer, prostate cancer or high cholesterol was 30 percentage points higher in some instances among people with insurance than among those without. Once the uninsured become eligible for Medicare, that gap shrinks.

Although the uninsured can be guaranteed care by coming to an emergency room, not all care is available there. Nor should it be. Estimates suggest that an ER visit is six times more expensive than a clinic visit.

Take the story I heard of an uninsured 31-year-old man who came to the emergency room complaining of pain in his groin. A CT scan revealed enlarged lymph nodes and what looked like a tumor above his left kidney. This was not the kind of problem that the ER would take care of; nor was the patient so ill that he required admission. So the ER doctor referred the patient to the urologist on call for a follow-up office visit.

The patient never went. A year and a half later, he showed up in the ER, with worse pain. The tumor had spread to his testicles, which were surgically removed a couple of months ago. A new urologist discovered that the patient had an endocrine tumor, which could have been managed with medication.

That patient's experience is reflected in research. A 2007 study by the American Cancer Society showed that patients with no insurance have lower survival rates for breast and colorectal cancer than insured patients. Similarly, a 2004 report in Health Affairs showed that people ages 51 to 61 with diabetes, hypertension or heart disease had a mortality rate of 12.5 percent over eight years if they had insurance and 18.8 percent if they had no insurance.

There may be a few among the uninsured who prefer to buy $149.99 sneakers than health insurance. Far more common are stories of preexisting conditions that make insurance unaffordable or jobs that offer none. My primary care friend told me about a patient who had left a boil untreated until it needed surgical drainage and intravenous antibiotics. When asked why didn't have insurance, the man said he had lost his job and was recently divorced. Stories like that helped my friend realize what injustices the uninsured face.

Makeshift Solutions

At the hospital, I avoid looking upfront at the patient's insurance status. In my office, my receptionist asks uninsured patients to bring a deposit of $50 to $75 and offers a payment plan. Some surgeons expect a $500 down payment before an operation.

I do not discriminate at an individual level, but many doctors, including myself, discriminate more broadly by moving our clinics to wealthier parts of the city, for example. To compensate for the cost of treating uninsured patients (about 10 percent of my practice), I inflate my charges for all patients, thus increasing my income from commercial insurance. According to a Kaiser Commission report, uncompensated care for the uninsured cost $41 billion in 2004 , the majority of which was paid by the government.

In my city, Memphis, as in many other cities, doctors are applying their own makeshift bandages to our hemorrhaging system often in collaboration with faith-based institutions. One Memphis doctor -- who is also a Methodist minister -- founded the Church Health Center, which cares for more than 50,000 patients. The city's Muslim community has a clinic alongside the mosque where my partner volunteers. At the Hindu temple clinic where my wife and I volunteer, I counsel patients on vaccines and infections.

And as that foul odor wafts through my consciousness, I advise them on how they should try to get health insurance.

AIDS Vaccine Focus Shifts After Disappointments

The Washington Post reports that a global AIDS vaccine conference this week will seek fresh strategies against the HIV virus, with experts weighing the value of basic laboratory research against large-scale human clinical trials after a string of disappointments.  Andrew Quinn writes,

Approaches focusing on "neutralizing antibodies" that would allow the human immune system to block infection completely, are likely to take precedence over existing models that seek to manage infection after it occurs, experts said.

"There's a real redirection and rethinking," said Lynn Morris, co-chair of a world AIDS vaccine conference that starts in Cape Town, South Africa, on Monday.

"Fundamentally we don't understand enough about the human immune system and we don't know how the immune system deals with HIV."

The conference -- a gathering of many of the top names in HIV research -- follows a year that saw scientists drop plans for widespread human testing of the two most promising vaccine prototypes due to safety concerns.

The AIDS virus infects an estimated 33 million people globally and has killed 25 million since it was identified in the 1980s. Cocktails of drugs can control the virus but there is no cure.

The two stalled vaccines, one developed by drug giant Merck and the other by U.S. government researchers, both aimed to fight AIDS by encouraging so-called cell-mediated immunity, jump-starting T-cells to tackle the virus and stop or slow the progress of HIV-related disease.

But early results from a large human trial of the Merck product were discouraging and data showed the vaccine may have left some people more prone to HIV infection -- halting the tests and prompting some scientists to reconsider the model.

'A REAL SWING BACK'

Morris, the head of the AIDS unit at South Africa's National Institute for Communicable Diseases, said the focus was now on another approach to fighting HIV: lab work to discover how to help the body produce antibodies to prevent infection altogether.

"Neutralizing antibodies are a major component of almost all other vaccines," Morris said. "I think there is going to be a real swing back to thinking about them."

The International AIDS Vaccine Initiative last month announced it was launching a $30 million joint venture research lab in California dedicated to accelerating work on neutralizing antibodies.

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Pediatricians Double Vitamin D Recommendations

The Washington Post reports that the nation's leading pediatricians group says children (from newborns to teens) should get double the usually recommended amount of vitamin D because of evidence that it may help prevent serious diseases.  Lindsey Tanner writes,

To meet the new recommendation of 400 units daily, millions of children will need to take daily vitamin D supplements, the American Academy of Pediatrics said. That includes breast-fed infants _ even those who get some formula, too, and many teens who drink little or no milk.

Baby formula contains vitamin D, so infants on formula only generally don't need supplements. However, the academy recommends breast-feeding for at least the first year of life and breast milk is sometimes deficient.

Most commercially available milk is fortified with vitamin D, but most children and teens don't drink enough of it _ four cups daily would be needed _ to meet the new requirement, said Dr. Frank Greer, the report's co-author.

The new advice is based on mounting research about potential benefits from vitamin D besides keeping bones strong, including suggestions that it might reduce risks for cancer, diabetes and heart disease. But the evidence isn't conclusive and there's no consensus on how much of the vitamin would be needed for disease prevention.

The new advice replaces a 2003 academy recommendation for 200 units daily.

That's the amount the government recommends for children and adults up to age 50; 400 units is recommended for adults aged 51 to 70 and 600 units for those aged 71 and up. Vitamin D is sold in drops for young children, capsules and tablets.

The Institute of Medicine, a government advisory group that sets dietary standards, is discussing with federal agencies whether those recommendations should be changed based on emerging research, said spokeswoman Christine Stencel.

The recommendations were prepared for release Monday at an academy conference in Boston. They are to be published in the November issue of the academy's journal, Pediatrics.

Besides milk and some other fortified foods like cereal, vitamin D is found in oily fish including tuna, mackerel and sardines.

But it's hard to get enough through diet; the best source is sunlight because the body makes vitamin D when sunshine hits the skin.

While it is believed that 10 to 15 minutes in the sun without sunscreen a few times weekly is sufficient for many, people with dark skin and those in northern, less sunny climates need more. Because of sunlight's link with skin cancer, "vitamin D supplements during infancy, childhood and adolescence are necessary," the academy's report says.

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Financial Crisis May Hit AIDS Funding

The Washington Post reports that the two French researchers who shared the Nobel Prize in medicine for discovering the AIDS virus are voicing fears that the world financial crisis will hurt funding to fight the disease.  The Washington Post writes,

Luc Montagnier and Francoise Barre-Sinoussi say they told President Nicolas Sarkozy of their concerns that both research and international funding to fight AIDS could be cut in the crisis.

The two met with Sarkozy Wednesday. They told him that medication in Africa is often paid by a global fund for AIDS and distributed for free. Montagnier questioned whether that arrangement will continue.

Barre-Sinoussi and Montagnier discovered HIV in 1983.

They shared the award with Germany's Harald zur Hausen, who discovered viruses causing cervical cancer.

Cost Estimates Vary on Mental Health Parity Law

The Los Angeles Times reports that agencies predict that health insurance costs could increase from 0.2% to 5%, depending on the type of plan.  Tammy Worth writes,

Will the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 increase the cost of health insurance?

Most likely, but estimates vary. According to the Congressional Budget Office, the cost of the legislation could increase group healthcare premiums 0.2% to 0.4% on average.

The (which implemented mental health parity for federal employees' plans back in 2001) estimates the likely average increase as 1.64% for fee-for-service plans (where an insurance company pays the physician or patient directly for each service after a claim has been filed) and 0.3% for HMOs. It estimates that an individual would pay an extra 46 cents per biweekly paycheck and a family would pay $1.02.

Michael Carter, vice president of the benefits consulting firm the Hay Group, predicts increased costs of 2% to 3%, depending upon what type of plan is offered. A 1998 study released by the Substance Abuse and Mental Health Services Administration estimated full parity could increase premiums up to 3.6% and as high as 5% for fee-for-service plans.

Any cost increases would be on the shoulders of the employer, but would likely trickle down to individuals in the form of higher premiums and co-pays for the employees, Carter said. However, studies also show that an increase in what insurance companies pay up front could help them save money over time, he added.

Properly managing mental healthcare can reduce costs overall because people with untreated mental illness are more susceptible to physical illnesses such as heart attacks, said Dr. Nada Stotland, president of the American Psychiatric Assn.

"It is not cost effective" to separate mental and physical healthcare, she said. "We cannot separate the body and the mind."