Last year, drug maker Bayer introduced the first new IUD in 13 years. And this week, the American Academy of Pediatrics (AAP) updated its guidelines to say long-acting reversible contraceptives, including IUDs, should be the first line of defense to prevent teen pregnancies.
It's been a long road for the IUD. It’s been some 40 years since the Dalkon Shield hit the market. The intrauterine contraceptive device was one of many IUDs at the time, but it is still remembered decades later as a spectacular disaster.
Many women developed pelvic inflammatory disease from the device, which had not been vetted by the FDA. The Shield also had a high failure rate, leading to infections, miscarriages and death.
The Dalkon Shield was pulled off the market, and a federally-funded study in 1981 said IUDs were dangerous.
Some two decades later, when Jenna Sauers, then in her late teens, went to her doctor asking for an IUD as an alternative form of contraception to taking pills with hormones, her doctor would not prescribe it. She tried a second doctor, and then a third who, she recalled, told her: “That’s only an option for women who have completed their families.”
“The damage done was the perception that all IUDs are dangerous,” says Dr. Jill Schwartz, medical director at CONRAD, an organization that focuses on reproductive health research.
Sauers, who is now 28, finally succeeded after visiting yet another doctor.
“I do think that everybody should have the choice. I think they can be a great option, especially for people who, for whatever reason, don’t like taking hormonal birth control,” Sauers says.
Sauers is confident that her IUD poses little risk, because in the last few decades more research has shown that it was the faulty design of the Shield, not IUDs themselves, that was dangerous. Still, it has taken some time to undo the damage done by the Dalkon Shield. In the 1990s, new research came out that called into question the 1981 study condemning all IUDs. In 2012, the New England Journal of Medicine published a study saying IUDs are 20 times more effective than birth-control pills, the patch, or the vaginal ring.
“In the intervening 40 years, there’s been increasing scrutiny and increasing requirements by the FDA and other organizations,” says Dr. Mary Ott, one of the co-authors of the new AAP guidelines for teenage girls. “All the modern devices have at least a decade of safety and effectiveness data in the United States, and 20 years or more, internationally.”
Ott says IUDs are now so safe that teenage girls face more health dangers from complications from pregnancy than they do from the IUDs themselves.
“It’s been not only drug companies, it’s academics, it’s the whole community,” that’s been behind the effort to make IUDs more available, says Schwartz.
World health groups, and non-profits have also been a part of that effort, with Planned Parenthood launching a nationwide educational campaign last year.
John Ajemian was riding his bike on a perfect sunny day in the Boston suburbs in 2006 when he was struck and killed by a car. He was 43.
“After his death, we wanted to plan a memorial service,” says Marianne Ajemian, John’s sister and one of the executors of his estate. “And he kept all his correspondence and records on his email account.”
In addition to his contacts, Marianne wanted the financial records and correspondence it might hold. But the provider refused to give the family access to the account, so she’s suing them. The case is ongoing.
“If you have a diary, if you have letters, your personal representatives are entitled to see that,” she argues.
As people store increasing amounts of information online in email, social media, and cloud storage accounts, what happens to those digital accounts has become a more pressing issue. A recent study by MacAfee found that the average person has $35,000 in digital assets stored online or on their devices.
This summer, the Uniform Law Commission, a group that writes laws for states, drafted legislation that would give executors or other personal representatives access to digital accounts when someone dies. Delaware became the first state to pass a version of it last month, joining only a handful of states that already have more limited laws.
“Essentially, what we’re trying to do is allow the fiduciary to have access, unless the account holder didn’t want a fiduciary to have access,” says Suzanne Walsh, an estate lawyer who helped draft the ULC’s proposed legislation.
“In the old days when I began practicing law, we worked with file cabinets and paper documents,” she explains. “Yesterday’s filing cabinet is now a laptop or a computer or even a phone. Because of that, the nature of our work has changed when we’re administering an estate or assisting an incapable person.”
Balancing access and privacy can be complicated, though.
“There are some times third parties who have communicated with the deceased person who expect those communications to remain private,” says Jim Halpert, the general counsel of the State Privacy and Security Coalition, which represents Facebook, Google, Yahoo, and others on issues like this. “[They] don’t expect somebody that they don’t know and in some cases a person the deceased didn’t even know, to be going through the communications.”
People may not want their family reading their emails, he says, though the law commission’s version provides the option to opt out of access.
Moreover, many service providers worry that state laws granting access are in conflict with existing federal laws.
Currently, companies have varying policies about what happens when an account holder dies. For example, Yahoo says in its terms of service that accounts can’t transfer after death, but a spokesperson says the company will give access if the deceased lays out their explicit permissions in their will. Google lets people chose whether their info should be shared or deleted if they die. Facebook gives family members the option to close the account or "memorialize" it, which preserves the photos and posts already visible on the account, but doesn't give access to private messages.
Halpert says another solution would be to give access to logs that list senders and receivers, but not the contents of emails.
For Marianne Ajemian, that’s not enough.
“John was a writer,” she says. “And so whatever was in that email account could have been very important to us.”
Until she gets into the account, she says she doesn’t know what she might be missing—and how much sentimental or financial value it could hold.
Commercial insurers are ditching or at least tweaking the way they pay medical providers, according to a report out Tuesday from the group Catalyst for Payment Reform.
For years, commercial insurers as well as state and federal governments have paid doctors and hospitals under what’s called fee-for-service. To many in the healthcare world, fee-for-service is seen as one of the key drivers behind the run-up in healthcare costs, because it offers providers a financial incentive to provide extra services that may not be needed.
“I believe fee-for-service generates a lot of waste, and overuse of healthcare services can be not just wasteful, but harmful,” says Harvard Health Economics professor Meredith Rosenthal.
Rosenthal says based on her research, alternatives to fee-for-service can reduce the volume of services by as much as 20 percent. Rosenthal is quick to add there’s not any great evidence yet on the effectiveness of any of the alternatives.
“How to design a payment system to obtain the best value for money and value in healthcare is a very complicated question. And that’s where we are really learning,” she says.
So what options are out there?
Here’s a list of four payment methods starting with the most traditional and with the caveat that these brief descriptions are intended for those of us who aren’t healthcare wonks.
Fee-For-Service: A payment model where providers get paid for specific tests, services, or procedures.
It's the granddaddy of payment models and a scourge for many health reformers.
Pay for Performance: A payment model where on top of the usual fees providers are paid, they can earn extra money for meeting certain healthcare quality goals or other performance targets, like increased efficiency.
In its report, Catalyst for Payment Reform says this is by far the most popular reform this year. You can think of it as healthcare reform with training wheels.
Shared Risk: A payment method where providers accept some financial liability if they spend over a targeted budget. If they go under budget, providers keep a portion of the savings.
A classic intermediate step that carries risk and reward; sort of reform with safety net. It's not very common.
Full Capitation/Global Payment: A fixed payment to providers for care they give over a set time period like one month or a year, no matter how much care the patient utilizes.
This is the most aggressive payment method, where providers keep all the savings and eat all costs that go above the fixed payment. Some see this as medical providers taking on the role of insurer.
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