Walmart offering $9 Birth Control Pills

 (Update – Target and Kroger now sell the same pills Walmart sells for the same $9. In some states, Target’s price is $4 for a month supply.)

The Good News
It’s true. Walmart is selling birth control pills for $9 a pack for a month supply and $8 a pack for a 90 day supply.

That’s the good news, and for women without insurance, its great news. For women who have insurance and a $10 co-pay, it’s not a big savings, and if you can mail away for 3 packs with that co-pay, I’d say “No thanks” to Walmart. But Walmart’s birth control pills are a great deal for women without insurance.

And a huge turn-around from the early days when Walmart refused to carry the morning-after pill, a policy they changed last year. Ah, the power of the almighty profit-dollar. Occasionally, it can be used for good…

The Not Necessarily Bad News

Here’s the not so good, but then again, not necessarily bad news. It’s only 2 pills – Sprintec and Tri-Sprintec, generic versions of Ortho Cyclen and Ortho Tricyclen. Not necessarily my first choice of pills, but not necessarily bad ones, either. For most women, these are fine – in fact, more than fine – pills.

Anecdotally, I seem to get a few more complaints of moodiness on these pills, but it’s not a common side effect. In clinical trials, moodiness was more common among users of Ortho Tri Cyclen than in placebo users, but overall occurred in less than 10% of users. If I had no insurance, and had no problems with mood on pills before, generic Ortho-tricyclen or Ortho Cyclen would be my first choice pill, for sure.

If you have acne, Wal-Mart’s offering a great pill. Ortho-Cyclen was the first pill to receive FDA-approval for acne treatment, primarily because Ortho was the first company to do the clinical trials that proved what we all knew for years – namely, most birth control pills are good for acne. Now, other pill manufacturers have gotten wise. Both Estrastep and Yaz are also FDA-approved for acne treatment.

The Ugly News

The ugly news about Walmart’s birth control pills are the higher generic price tag. Walmart offers all it’s other generics for $4. Why the difference for birth control pills? Wal-Mart claims that the reason for the higher price is that they needed it to be profitable.

I’m not buying it.

Birth control pills are no more expensive than other drugs. In fact, some of the drugs being offered in Wal-Mart’s $4 generic plan are traditionally very expensive – Lamictal and Diflucan to name just two.

No, I figure that Walmart is banking that young women are more likely than Seniors to swallow the $5 difference in price, and also more likely to spend a pretty penny in their stores. And since there is no lobbying group with the power of the AARP behind young women, why not charge them more?

It’s just another example of price discrimination against women. If the dry cleaners and clothing manufacturers can get away with charging women twice the price as they charge men for the same products and services, why shouldn’t Walmart do the same thing?

If I seem particularly sensitive about this subject, it’s because this week, my husband accidentally took one of my “blouses” in for dry cleaning along with his “shirts”, and lo and behold they cleaned the thing for only $1.99 instead of my usual price of $5.99! Lesson learned – send hubby in with your dry cleaning.

Now if it were only that easy for birth control…
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You may also want to read –

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Verizon and Free Speech

From today’s NY Times…

Saying it had the right to block “controversial or unsavory” text messages, Verizon Wireless last week rejected a request from Naral Pro-Choice America, the abortion rights group, to make Verizon’s mobile network available for a text-message program. But the company reversed course this morning, saying it had made a mistake.

Darn right, it was a mistake. And the reversal came just in time. I was about to cancel my phone service…

Darn! I missed it again!

Once again, I let my dream of literary fame slide, and forgot to submit something to the annual Bulwer-Lytton Fiction Contest, which asks its entrants to compose a bad opening sentence to an imaginary work of fiction. And once again, some other writer has claimed the coveted Grand Prize – a pittance.

This year’s contest winner is Jim Gleeson of Madison, Wisconsin, who bowled over the judges with this marvelous opening sentence:

Gerald began–but was interrupted by a piercing whistle which cost him ten percent of his hearing permanently, as it did everyone else in a ten-mile radius of the eruption, not that it mattered much because for them “permanently” meant the next ten minutes or so until buried by searing lava or suffocated by choking ash–to pee.

The Bulwer-Lytton Fiction Contest honors the memory of the author who penned, along with memorable lines like “The pen is mightier than the sword”, that famous opening line made infamous by Snoopy, which begins – “It was a dark and stormy night.”

It was a dark and stormy night; the rain fell in torrents–except at occasional intervals, when it was checked by a violent gust of wind which swept up the streets (for it is in London that our scene lies), rattling along the housetops, and fiercely agitating the scanty flame of the lamps that struggled against the darkness.”
– Edward George Bulwer-Lytton, Paul Clifford (1830)

There were multiple category winners and honorable mentions in this year’s contest, but my personal favorite, in the category of Romance, was submitted by Tracy Stapp of Santa Ana, California –

There was a pregnant pause– as pregnant as Judith had just told Darren she was (about seven and a half weeks along), which was why there was a pause in the first place.

Would someone please remind me next year in time for me to submit something?

HPV Vaccine – The Canadian Response

A well-considered position against universal HPV vaccination in Canada has been published in the Canadian Journal of Medicine. The authors, who are part of the Canadian Women’s Health Network, argue the following:

  • Cervical cancer is far from epidemic in their country, with only 400 deaths yearly, a rate that has been steadily declining;
  • Most HPV infections resolve spontaneously;
  • The vaccine was not trialed sufficiently in adolescents, the group being targeted for univeral vaccination;
  • The long-term efficacy of the vaccine against cervical cancer in the population has yet to be proven, in light of the fact that it protects against only two of the subtypes that cause cervical cancer and its duration of effect is not known;
  • The vaccine is too new and the clinical trials were all industry-sponsored;
  • The true costs are not determined.

The Canadian Government apparently had a different opinion on the matter – they recently allocated $300 million for HPV vacination. The Canadian health service is rolling out a mass HPV innoculation campaign with the beginning of this year’s school year, the first such innoculation campaign since the polio vaccine in the 1950’s. (CBC.Canada has a very well-done segment on the vaccine initiative.)

Opponents of universal HPV vaccination in both Canada and the United States are focusing on reports of Guillain Barre syndrome occuring after Gardasil administration, expecially when administered along with the meningococcal vacine Menactra. This is typical of anti-vaccine strategies – to focus on rare adverse events that are unlikely to be caused by a vaccine. Similar publicity around a since-debunked theory that the MMR vaccine causes autism has been blamed for recent outbreaks of measles in Britian.

Here in America, the lawyers are already jumping into the Gardasil fray.

Basically, here is the situation – Merck is frightening women about cervical cancer, then using slick marketing campaigns to sell them their vaccine. The anti-vaccine folks are frightening the public that this vaccine has severe side effects, an approach they basically take with all vaccines.

But well-reasoned and informed views such as those expressed by the Canadian Women’s Health Network deserve attention and discussion. Unfortunately, such views do not lend themselves to catchy slogans or soundbites, and don’t frighten anyone. Which makes it unlikely that anyone will hear them.

My position? (Like I haven’t beat this drum enough already…) I pretty much agree with the position of the Canadian Women’s Health Network. I believe that the HPV vaccine is safe, but not yet appropriate for universal vaccination. Like all new pharmaceuticals, only time will tell if there are rare effects not found in clinical trials. I do offer the vaccine to patients who express interest in it and who understand its limitations, mostly adult women who are having multiple partners over time. I am opposed to universal or mandatory vaccination in young adolescents, and abhor the marketing and lobbying tactics being used to promote this vaccine.

Fig and Plum Tartlets for an Almost Perfect Day

The three couples were first drawn together by our daughters, a treo of 11 year olds who walk together to school every morning. But it’s more than the kids now – it’s a shared love of good food and wine, of different cultures (Greek, Jewish, Christian), of politics and a dream of one day all living in a European city, probably Paris. We are two doctors, a teacher, a psychologist, and a Greek scholar and an actress turned pet store owners. And, oh yes, seven children.

We get our families together for dinner every few months or so. Tonight, I’ve promised to bring dessert.

I sleep late because I have a migraine (I said it was an almost perfect day…), and Mr TBTAM beings me a cup of coffee while I am in the shower waiting for the Imitrex to kick in. It does, and I spend the rest of the morning looking at recipes and cookbooks, deciding what to make for dessert.

Mr TBTAM has brought home a big box of gorgeous plums from Costco, and there are some mission figs on the verge of becoming too dry to eat alone. Although I am certain the flavors will go well together, I can find no recipe for a fig-prune tart. So I decide to create my own.

Natalie helps me in the kitchen, and we spend the early afternoon baking. This is followed by a late afternoon bike ride in Central Park with Mr. TBTAM and then a wonderful dinner with our friends.

Yep, it’s been pretty much an almost perfect day.

Fig and Plum Tartlets
Makes 6 -4 inch tartlets

Fig Base
12 dried figs
3 tbsp sugar
1 tsp lemon juice
2 tbsp Calvados brandy

Pate Brisee
1 2/3 cups unbleached, all-purpose flour
1 tbsp. sugar
1/8 tsp. salt
12 tbsps. unsalted butter
4 ½ tbsps. ice water

Tart filling
(This is what I used for these tarts, next time I would increase to 3 plums per tart)
12 plums, halved, pitted and sliced
1/4 cup sugar

Topping
Sliced almonds

Vanilla Ice Cream for serving
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Remove the stems and chop the figs.

Toss the figs with 3 tbsp sugar in a small saucepan.

Add 1/4 cup water and a squeeze of lemon to the figs and cook over very low heat for 15 minutes.

Add 2 tbsp calvados (and a bit more water if necessary to keep from drying out), and cook till figs are soft, about 15 munutes more.

Remove from heat and let sit a few minutes to cool. Process in food processor a few seconds until smooth.

Set aside (and try not to eat any…)

Make pate brisee.

Process the flour, sugar and salt in a food processor to mix. Cut butter into pieces and add to the processor.

Pulse to the consistency of coarse meal, about 10 seconds.

Pour ice water through feed tube while processing. Stop motor as soon as dough begins to form a ball.

Turn out onto a lightly floured surface and shape into a disc about 1 inch thick. (Can be made ahead and refrigerated.) Cut into 6 equal pieces. Flatten each piece into a disc about 4 inches round, then place into tart pan and, using your fingers, press the dough up the sides of the pan and across the bottom evenly.

Using a small rubber spatula, spread about 2 tbsp fig paste across the base of each tartlet.


Toss the plum slices with 1/4 cup sugar

and arrange them, overlapping slightly, in the tartlet pans. Place an almond slice in the middle.

You could do an eggwash on the crusts at this time – I forgot to do it.

Bake at 400 degees for 10 minutes. Lower heat to 350 and bake an additional 40 minutes, till the fruit is soft and bubbly and the crust is golden brown.

Serve warm or at room temperature with vanilla ice cream on the side.

Strep Throat and Medical Ethics

So here’s the dilemma – I was diagnosed with a strep throat at about 6 pm tonight. I have patients scheduled for tomorrow am, and a lunch at the home of the head of the volunteer board I sit on.

I’ve taken one dose of antibiotics so far (at 7 pm tonight). I feel pretty crappy right now, but not so bad that I can’t work tomorrow.

Is my obligation to see my patients or to protect them from infection and cancel their appointments?

God knows if I infected anyone today – I saw about 20 patients, but the truth is that I am extremely obsessive about washing my hands before and after examining every patient.

UPDATE
I stayed home. But only after calling my patients myself to cancel them last night. (One of the advantages of the EMR is that I can access it at home). None were urgent visits, most were patients I’ve known for years, and everyone was happy not to be seen and wished me well. I actually feel worse this morning than last night, so I think it was the right decision.

Thanks, everyone, for your input.

TBTAM Does Italy – Part Last. Three Memorable Meals in Maratea

Il giardino di Epicuro

Il Giardino Di Epicuro is a family-owned restaurant in Massa de Maritea that serves food made from ingredients that, for the most part, the owners grow themselves. They also cure their own meats.

Fernando calls the restaurant “the Philosopher”. If so, the philosophy seems to be that of Horatius, whose famous quotation adorns the walls. (Translation – “Eat, drink…there is nothing else beyond that.)

The night we eat at the Philosopher is a quiet one, so the owner himself takes our orders, or rather tells us what to order, in a gruff but lovable way that adds to the ambiance of this find of a restaurant.

Best part of the meal? Hands down, the Chickpea noodles. I have to learn to make this…

Other highlights? Gnocci with truffles

the homemade grappa

and standing outside onto the vine covered patio looking at the moon while the kids play in the garden.

Ristorante Vincenzo a Mare
Located in Port Maratea, Ristorante Vincenzo a Mare has a lovely, vine-covered porch overlooking the port. Fernando tells us he chose it, “so we can look at Fabrizio’s boat”. He and Fabrizio have reason to be proud of that boat. They brought her back to life with a new motor in a two-day long adventure that at one point had them stranded on the sea a windless hot afternoon with no sunscreen.

The menu at Vincenzo a Mare is handwritten, a charming touch that only added to the ambiance of a wonderful meal. The food is fresh and delicious, especially the snapper up there, which though bony, is exceedingly flavorful and well-spiced.

But the best part of the meal? The lesson Fernando gives us in Italian table manners. Here, I’ll let him show you, as he explains how to do Scarpetta or “The little shoe”.


Double click on arrow to view video.

Beach Party Maratea

For our last night in Maratea, Fernando has the perfect dinner suggestion, this time a beach party. Fabrizio, Emily and I take the boat into the Porta for pizza as the setting sun shines through gathering evening clouds.

Fernando supplies the beer, and Diego brings his ipod and speakers. By the time we arrive with the pizza, it is growing dark, and the fire is blazing.

Party may not be the best word for what we are doing, for we don’t really drink much, and the families talk softly as we listen to the music and watch the Sea. I take a brief dip at the water’s edge, and come back to find everyone starting to fall asleep. Time to put out the fire and head back to our hotel.

There is no more perfect a way to end a perfect vacation.

TBTAM Does Italy – Part 7. Maratea

We spent the last part of our vacation in Maratea, a lovely town about 2 1/2 hours south of Naples at the southern end of the Campagna Region of Italy. The area is like the Amalfi Coast without the crowds, the prices or the tourists. Italian families come here year after year to summer, as do Wanja’s friends Fernando and Martina, who generously allowed us all to tag along their annual vacation.

Maratea is really three towns. First, there is Porta Maratea, which is at sea level.


Then there is the main town, or Centro Storico, nestled on the mountainside 1,000 ft above the Porta.

It has a square,

a mermaid fountain,

charming little alleys

filled with restaurants,

shops

and galleries,

and a bakery called Iannini that sells the most amazing cookies I have ever eaten.

The old town is Maratea Superiore, which sits atop Mt San Biago above cliffs so steep that the road extends out from the rock walls to allow cars to make the climb. (Photo blatantly stolen from Europe for Visitors)

Overlooking the town is the Statua del Redentore, or Christ statue, seen up there on the left. Our kids did not want to visit the statue, being freaked out by the urban legend that the statue had the face of the dead young man in whose memory it had been built.

We three families split ourselves between 2 apartments at Pianeta Maratea, a Catskills-like resort in the hills, complete with pools and a nightly teen disco

and the rustic but lovely Hotel Illicini, a cluster of well-appointed but simple adobe huts along the Mediterranean Sea.

Here, we could choose to sit in the shade on the upper beach just outside our room

along with the salamanders,

or walk down a short path to the lower beach for a swim.


We could also join Fabrizio on his sailboat,

or take the shuttle bus to the larger public beach, which has two cafes, changing areas and kayaks to rent.

One afternoon, we took the kayaks out along the coast, and the bravest among us swam into a hidden grotto. This, my friends, was everything a vacation should be.

“But what”, I hear you asking, “do the Italians eat at the beach?”

I’ll tell you what they eat. They eat Friselle.

Friselle with Tomatoes, Olive oil and Capers

Friselle are hard, double-baked bread from Puglia. We soften the Friselle by dipping them into the sea and …

Wait. Let’s ask Wanja to explain it, she does it so much better than I.


Double-click on arrow to start video (Sorry it’s sideways…)

Opening a Restaurant is Like Having a Baby

Shuna, whose blog Eggbeater is one of my regular reads, is blogging the day-to-day life of a pastry chef in a new restaurant soon to open in the Bay Area. Leaving out pertinent details like the name and location of this exciting new venture, she tells us…

I am like a pregnant woman who wants to keep it a secret until I feel like I’m out of the woods

Wish I could be there for the delivery…

I Love Technology!

Just testing out my new Verizon Air Card, and I am pleased as punch to say that it works! I am blogging this while driving on Rte 78 in New Jersey. Well, technically, my friend Andy is driving, but the point is I AM FREE, UNTETHERED AND ON THE ROAD, BABY, AND I AM SURFING THE WEB AND BLOGGING AT 70 MPH!

Damn, life is good…

NY Attorney General Questions Insurer’s Health Care Ranking Methodology

NY State attorney general Andrew Cuomo has come out against the use of claims data for ranking doctors.

In letters to Aetna and Cigna, Cuomo questioned the insurers’ use of claims data to rank specialists. According to Cuomo, claims data does not contain complete information and can skew rankings. He also criticized the insurers for failing to disclose the accuracy of the rankings and said insurers “have a profit motive” to recommend physicians who cost less but might not be the most qualified. Cuomo asked Aetna and Cigna to provide details about the criteria they use to rank doctors, how the insurers measure a physician’s performance and what incentives are used to steer patients to or away from providers.

He’s right. Here are just a few of many examples of how use of claims-based ranking data was found to be erroneous for docs in our institution:

  • A woman who is rubella immune comes to see an ob-gyn for her third pregnancy. The doc is dinged by the insurer for not doing a rubella titer, since no claims were submitted for this test. The fact was that the patient already had immune titers in her prior two pregnancies and did not need this test done a third time.
  • The insurer claimed a doc did not refer for BMD testing. It had already been done the prior year when she was covered under another insurance plan
  • Insurer claimed no pap was done. It was done, but for some reason a bill was never submitted by the outside lab.

It’s as if Zagat decided they were going to rate restaurants by looking at the bill…

Abortion Politics and Mini-Storage – Strange Bedfellows?

That’s a real billboard up there, one that’s creating a lot of controversy here in Manhattan. I happen to like it, although I wonder how I’d feel if the other side started putting up similar ads.

Manhattan Mini-storage ad’s have been raising eyebrows for some time now. Previous billboards have had such slogans as:

“Your closet’s so narrow it makes Cheney look liberal”

“Your closet’s scarier than Bush’s agenda.”

And my personal favorite –

“Your closet’s so shallow, it makes Paris look deep.”

What do you think? Should Manhattan Mini-Storage be allowed to mix politics and advertising?
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(Photo from Gothamist)

Caring for Our Aging Parents – Lessons from Italy

Our visit to Italy included a brief overnight at Fabrizio’s family home in Velletri, a town in the Alban Hills about an hour outside of Rome. Fabrizio, Wanja and the kids come every weekend to this lovely old villa, and not just because they want to escape the heat in Rome.

You see, Fabrizio’s Dad has Alzheimer’s disease. And though he has a nurse who stays with him during the week, Fabrizio comes to stay with him most weekends, a duty he shares with his sibs who live nearby. They feed, shave and bathe their Dad, and most importantly, watch to be sure he does not wander off, as he has done on more than one occasion.

I am moved, not just by Fabrizio’s personal attention to his Dad, but by the family’s acceptance of this lovely childlike man in their midst. His dad joined us at the dinner table, and although he did not speak, he smiled a lot. Like a small child, he was taken from the table when he was finished, and sat on the nearby sofa while we finished dinner. Then off to bed early, Fabrizio holding his hand as he led him upstairs to his room. No apologies were made to us, no complaints. My children did not skip a beat. Fabrizio’s Dad was simply part of the family, just the way he was.

This sort of loving acceptance is exactly what NY Times writer Denise Grady writes about this week in an article entitled, “Zen and the art of Coping with Alzeimers“.

If Dad wants to polish off the duck sauce in a Chinese restaurant like it’s a bowl of soup, why not? If Grandma wants to help out by washing the dishes but makes a mess of it, leave her to it and just rewash them later when she’s not looking. Pull out old family pictures to give the patient something to talk about. Learn the art of fragmented, irrational conversation and follow the patient’s lead instead of trying to control the dialogue.

Basically, just tango on. And hope somebody will do the same for you when your time comes. Unless the big breakthrough happens first.

Along with acceptance, my friends express an unquestioning belief that care of their parents is just another part of life. Wanja tells me stories of friends in similar circumstances doing much the same for their parents as Fabrizio does for his dad.

“We don’t have nursing homes here,” Wanja tells me. “This is just what we do.”

She’s right. Italy has few nursing homes, and in almost all families, care of aging parents happens in the home. Acccording to a 1997 survey of nursing home care in 10 countries:

Italy has a national heath care system with universal coverage, modelled on the UK’s National Health Service [20]. There is, however, a major difference, in that no provision was made for the long-term care of elderly people. There is no uniform policy and there are literally hundreds of local solutions to meet the needs of elderly people… in Italy the care of elderly people is almost exclusively the concern of families.

The need for good home care in Italy has created a huge market for caregivers in Italy, a need that apparently is being filled in large part by Ukranian caregivers. It’s a patchwork of a solution to a growing problem, as the average life expectancy in Italy rises and families with two working parents struggle to keep their parents at home.

And it speaks of a nation that still has the family at its center.

Though our stay in Villetri was brief, it has left an indelible impression upon me. As I watch my own parents aging, I can only pray that if the need ever arises, my sibs and I can care for them with the same grace that my dear Italian friends have shown in caring for their Dad.