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Organizations advocate for adolescent care
National medical organizations have issued positions on adolescent care will impact your practice. Add the following to the next clinical discussion at your facility:
Clinicians have two HPV vaccines for use in young women: Gardasil, Merck and Co.'s quadrivalent vaccine, and Cervarix, GlaxoSmithKline's bivalent vaccine. Gardasil also has been approved for the prevention of genital warts (condyloma acuminata) due to HPV types 6 and 11 in boys and men, ages 9-26. (When the Advisory Committee on Immunization Practices (ACIP) issued its October 2009 guidance on use of the quadrivalent vaccine in males, it only indicated that the vaccine be given to males ages 9 through 26 years to reduce their likelihood of acquiring genital warts.3 It did not recommend the quadrivalent vaccine for routine use among males.
There are several reasons why it is important that clinicians advocate the benefits of routine HPV vaccination for girls as well as boys, says Jessica Kahn, MD, MPH, assistant chair of academic affairs and faculty development and associate professor of pediatrics in the Division of Adolescent Medicine at Cincinnati Children's Hospital Medical Center. Kahn serves as chairman of the Society for Adolescent Health and Medicine's Vaccination Committee.
First, HPV infection has clinical consequences in males and therefore vaccination might directly benefit males, says Kahn. HPV infection may cause anogenital warts as well as penile, anal, and oropharyngeal cancers in males. Clinical trials have shown that vaccination prevents diseases caused by the HPV types targeted by the vaccine, as long as males are not infected with those HPV types before they are vaccinated, she states.
Second, the sexual partners of men who are vaccinated also might benefit, because they might have less likelihood of acquiring HPV infection from these vaccinated males, notes Kahn. "Vaccination rates among females are relatively low at this point, and vaccination of males may help to decrease overall rates of HPV and HPV-related disease in the population," she observes.
Third, routine vaccination of males, as well as females, is more egalitarian than gender-based vaccination and might increase vaccine acceptability in certain cultures, says Kahn.
Clinicians also need to advocate for insurance coverage of HPV vaccination for males and females, notes Kahn. While ACIP has designated that vaccination of males should be covered under the Vaccines for Children Program, which provides the vaccine free of cost to those through the age of 18 years who are uninsured, have Medicaid, or are underinsured and attend a federally qualified health center or a rural health center, teens who have private insurance might face hurdles in coverage, says Kahn.
"Unfortunately, since allowing the vaccine to be provided via these government programs doesn't guarantee that the private insurance industry will allow the vaccine to be provided to their subscribers, this sets up the possibility that youth who have private health insurance may be denied coverage for HPV vaccine based on the lack of a more definite recommendation for the routine use of the vaccine in males," she notes.
Teens need two visits
Adolescent girls may need two "well-child" visits each year a general preventive visit and a dedicated reproductive health visit and both visits should be covered by insurers, according to an updated ACOG committee opinion.
Current Procedural Terminology (CPT) coding is used to bill office medical procedures. Code 99394 is used for a preventive visit of an established patient ages 12–17. Annual gynecologic visits also may be included in this category.2
Preventive medicine services provided to asymptomatic patients may be used only once a year by any health care provider, according to the committee opinion. "This is problematic because some healthcare providers offer the full range of care from general preventive care to reproductive health care, but many times no one clinician provides all the recommended care an adolescent needs," the opinion states. "Therefore, `well-child' care may require two visits, a general preventive visit and a dedicated reproductive health visit."
Both visits are critical to a teen's health, and each of these visits should be covered, says Diane Merritt, MD, chair of ACOG's Committee on Adolescent Health Care and professor of obstetrics and gynecology at Washington University in St. Louis.
Merritt notes many adolescents may continue to see their pediatrician or family practitioner for care, which includes vaccinations as well as education and counseling on such issues as growth, development, nutrition, obesity, and substance abuse. When a teen comes to see a reproductive health clinician, a visit might cover such topics as puberty, normal menstruation, sexually transmitted diseases and pregnancy prevention, sexual orientation and gender identity, acquaintance rape prevention, substance abuse, and routine gynecologic procedures. Both types of visits are necessary for optimum adolescent health, says Merritt.
Depending on training and experience, gynecologists pediatricians, family medicine physicians, and adolescent medicine specialists may not provide reproductive care and general preventive care to teens. If they do, it might be difficult to provide the full range of general and reproductive care in one office visit.
"In these instances, a team approach is needed in which one physician offers general preventive care and an OB/GYN provides the necessary reproductive preventive health care," says Merritt. "And both annual visits should be covered by insurance to ensure teens are getting comprehensive preventive care."