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California's Board of Pharmacy is considering requiring all pharmacies in the state to provide bilingual labels on prescription medicines.Basecamp Imaging/iStockphoto
Every Saturday morning, a steady stream of Chinese and Vietnamese patients line up at the Paul Hom Asian Clinic in Sacramento. Most of them speak little or no English.
Patient Assistance Director Danny Tao says people come here to get free medical consultations and drug prescriptions. But when patients take those prescriptions to be filled, he says, they don't understand the instructions on the label.
"They go pick them up, and we don't exactly know if they're taking it or not — or if they know how to take it," Tao says.
Tao says drug labels at most pharmacies in California are printed only in English. That puts patients in danger of making of any number of errors — taking too much medicine or not enough, or taking it at the wrong time of day. Such mistakes can cause serious harm or even death.
Tao says that all the drugs his clinic supplies directly to patients have a bilingual label – English and Chinese, or English and Vietnamese.The Salt How To Better Protect Farmworkers From Pesticides: Spanish
"By the time they get home," he says, "they know exactly how to take the medication, because it's in their own language."Shots - Health News Hospitals Put Pharmacists In The ER To Cut Medication Errors
This week California's Board of Pharmacy will discuss new regulations that would require all pharmacies in the state to provide translated labels on prescription drug bottles. Statewide, 44 percent of Californians speak a language other than English at home. New York approved a similar rule last year to make it easier for people who don't speak English to avoid costly mistakes when taking medicine.
But the board's executive officer, Virginia Herold, says the move is very controversial. For starters, there is a concern that requiring translated labels would require larger bottles of pills, too, in order to have room for the extra text. Patients don't like larger bottles, she says.
"They decant the drug out of the large container, put it in a baggie or someplace else," Herold said. "There, you've separated the drug from the container; now the instructions on how to take it have been separated."Shots - Health News A Computer Beats A Pen For Getting Prescriptions Right
Pharmacists don't like the proposal because they say it opens them to liability if there's a mistake in the translation.
"If the label is translated into Russian and there's an error, and I'm a pharmacist that does not speak Russian, I cannot verify that that error exists," says Brian Warren, of the California Pharmacists Association. He says that could increase the cost of malpractice insurance.
"It's an expense that will ultimately make its way down to consumers," Warren says, "and like all other health care costs, will eventually result in higher premiums."
For now, the state's board of pharmacy includes on its website translations of basic instructions such as "take one pill at bedtime" in five languages: Chinese, Korean, Russian, Spanish, and Vietnamese. But both Herold and Warren say pharmacists never took to using them.
Proponents of translating the labels say any concerns about the change are outweighed by problems that patients who speak limited English are facing under the status quo.
"There's a risk right now," said Sarah de Guia, director of government affairs for the California Pan Ethnic Health Network, an advocacy group. The expansion of insurance under the Affordable Care Act puts even more urgency on the issue in California, she says, by adding 1.5 million more people who have limited English to the health care system.
The discussions are in the earliest stages. If new regulations go forward, many details still remain to be worked out, such as how many languages would be included, and who would be responsible for the translation.
This story is part of a partnership between NPR, KQED and Kaiser Health News.Copyright 2014 KQED Public Media. To see more, visit http://www.kqed.org.
Proposed changes in medical training would shift money away from big teaching hospitals to clinics.Erikona/iStockphoto
The way American doctors are trained needs to be overhauled, an expert panel recommended Tuesday, saying the current $15 billion system is failing to produce the medical workforce the nation needs.
"We recognize we are recommending substantial change," says health economist and former Medicare Administrator Gail Wilensky, co-chairwoman of the nonpartisan Institute of Medicine panel that produced the report. "We think it's key to justifying the continued use of public funds."Shots - Health News A Denver Family Of Doctors Has Seen Medicine Transformed
The federal government provides more than $11 billion a year in payments to support the training of doctors who have graduated from medical school, mostly through the Medicare program. Most of that goes to the hospitals that sponsor interns and residents. States, through the Medicaid program, contribute nearly $4 billion more annually.
"The scale of government support for this phase of physician education is unlike that given to any other profession in the nation," said the report, which was funded by a dozen foundations with the support of a bipartisan group of members of Congress.
Even though the system has operated this way for decades, there are few data on how those funds are spent and how well they contribute to the preparation of a medical workforce needed for the 21st century, the panel found.
Despite a growing public investment in graduate medical education, there are persistent problems. They include uneven geographic distribution of physicians, too many specialists and not enough primary care providers, and a lack of cultural diversity in the physician workforce, the report found.
Not only that, the authors note, "a variety of surveys indicate that recently trained physicians in some specialties cannot perform simple procedures often required in office-based practice and lack sufficient training and experience in care coordination, team-based care and quality improvement."Shots - Health News Doctors' Ignorance Stands In The Way Of Care For The Disabled
The committee proposes a sweeping overhaul of the entire financing program for graduate medical education, with the goal of shifting the program "to a performance-based system," rather than one that merely funnels money to any facility with an accredited training program.
The current Medicare medical education payment system would be phased out over 10 years. At the end of the phase-out, policymakers would reassess whether Medicare should continue to subsidize doctor training at all, and if so, to what extent.
The panel calls for spending the same overall amount from Medicare over the next decade, adjusted for inflation. But it would be distributed much differently, with a declining share providing direct subsidies to teaching programs. An increasing share would go instead to a "GME transformation fund" that would finance new ways to provide and pay for training, and to fund training positions "in priority disciplines and geographic areas."
The funds would still be distributed through the Medicare program, but a new "GME Policy Council" would be created under the office of the secretary of health and human services to oversee workforce issues and commission research on how well the federal dollars are being spent. The committee recommended that states impose similar requirements for Medicaid training funds.Shots - Health News When Doctors Play This Game, You Get Better Medical Care
Major teaching hospitals in the Northeast would be most immediately affected, since they account for a disproportionate amount of Medicare medical education funding and number of doctors in training. The panel called for an end to the current system of payments that favor those hospitals. Instead it said that Medicare should make a flat "per resident" payment to training sponsors based on the national per resident amount, adjusted for location.
It's time to close the open checkbook for teaching hospitals, the panel said.
"The statutes governing Medicare's GME financing were developed at a time when hospitals were the central — if not exclusive — site for physician training," the report said. But by doing that, "the Medicare payment system discourages physician training outside the hospital, in clinical settings where most health care is delivered."
Members stopped short, however, of recommending that Medicare stop funding graduate medical education altogether, at least for the near future.
The rapid evolution of the health care sector, said Wilensky, "was an important rationale for potentially using the leverage provided by government funding to try to train the health care workforce we needed for a 21st century delivery system."
But the panel also did not recommend lifting the current cap on the number of residencies that Medicare supports. That cap was imposed in the 1997 Balanced Budget Act.
"Increasing the number of physicians per se is not likely to solve important workforce issues," Wilensky said, "particularly with regard to specialty distribution or geography."
All of the changes proposed in the report would have to be made by Congress, because government support for graduate medical education is written into Medicare and other laws. The politics, however, are unclear because the changes would produce winners and losers among programs training interns and residents.Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Patients who get the comforts of palliative care as well as disease treatment live longer, studies show, than those who only get treatment for the disease.Annette Birkenfeld/iStockphoto
It's a painful dilemma for seriously ill Medicare patients: To receive the extra support, counseling and care provided by the program's hospice benefit, they have to agree to stop receiving curative treatment for their disease.
Faced with that stark either-or choice, many forgo hospice care until the last days of their lives. The median length of time a Medicare patient was in hospice in 2012 was just 19 days, according to the National Hospice and Palliative Care Organization.
Now an experimental project, set to enroll 30,000 people over the next few years, will allow some hospice-eligible Medicare patients to get treatment for the disease and hospice care at the same time.
"I think it's a recognition that this forced choice between palliative care and life-prolonging treatment is irrational," says Dr. Diane Meier, director of the Center to Advance Palliative Care.Shots - Health News As Palliative Care Need Grows, Specialists Are Scarce
The comforts of palliative care focus on treating the pain, stresses and symptoms of serious illness, aiming to maximize the quality of life for people and their caregivers at any stage of illness, says Meier, a professor of geriatrics and palliative medicine at Mount Sinai in New York City. Under the traditional Medicare program, she says, the hospice benefit provides palliative care services only if doctors have certified the patient has less than six months to live if the disease follows its natural course, and if the patient agrees to stop receiving curative treatment for it.
Hospice and palliative care overlap, and Meier explains the difference this way: "All hospice care is palliative care — but not all palliative care is hospice." In palliative care, she says, "the emphasis is on need, not prognosis or how long you might have to live."
“ My prediction is that it will actually be less expensive to provide both approaches at the same time, precisely because it will lead to less need for costly emergency and crisis care.
Under the experimental Medicare Care Choices Model, people with advanced cancers, chronic obstructive pulmonary disease, congestive heart failure or AIDS will be able to receive a range of hospice services, even as they continue to see their regular health providers for treatment of the illness. Hospices selected to participate in the program will be responsible for coordinating their patients' care.
Medicare expects 30,000 patients to take part in the program, from at least 30 rural and urban hospices that have applied to participate. Medicare administrators will announce the names of the hospices within the next several months.
Patients in the program might, for example, continue to receive radiation and chemotherapy to treat a tumor that's pressing on bone and causing pain. It treats their cancer but it also makes them feel better, says Meier.
Allowing people to receive both types of care may actually save money, she says. Several studies have shown that patients who receive both palliative care and disease treatment actually live longer than those who receive only disease treatment.
"It makes sense," says Meier. "People aren't in excruciating pain; they're not depressed. And if, very importantly, people are able to avoid the very real risks of hospitals, it's no surprise that they live longer."
"My prediction is that it will actually be less expensive to provide both approaches at the same time," she says, "precisely because it will lead to less need for costly emergency and crisis care."Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Some marathons are warning runners when conditions increase the risk of heatstroke.iStockphoto
When a runner's heart stops during a marathon, it gets a lot of press — even though it's actually a pretty rare event. A more common killer among runners, and a condition that needs more prevention efforts, is heatstroke, according to a study by Israeli researchers.
During a 2011 running race, physicians at a Tel Aviv hospital noticed there were far more heatstroke victims admitted than cardiac patients. They wondered if this was an anomaly, so they analyzed local races from March 2007 to November 2013, encompassing 137,580 runners.Shots - Health News When Heat Stroke Strikes, Cool First, Transport Later
Across those races, there were two serious cardiac events, neither of which was fatal or life threatening. But there were 21 serious heatstroke cases, including two fatalities and 12 that were life threatening.
There's a continuum of heat illnesses, ranging from milder heat cramps all the way to heatstroke, which is defined as a fever above 104 degrees and symptoms including dry, hot skin, rapid breathing and unconsciousness. When the body gets that hot, the kidneys, brain and other organs can fail.
One caveat: It gets hot in Tel Aviv. It's possible that not every race site will face the same heatstroke danger, though "it's reasonable to assume that heat stroke is just as common in other countries with similar climate," Dr. Sami Viskin, senior author of the study and a cardiologist at Tel Aviv Medical Center, told Shots via email. (And heatstroke can occur in mild climates too.)
It's important for racers to be prepared for heat. That means acclimatizing to warmer weather — though that can take up to two weeks, so it's not always practical. The authors say it may be better to schedule races during the summer, when participants are used to the heat, rather than the spring. People also should beware of racing if they've recently had a fever, since that can reduce the body's ability to ward off heatstroke, the authors say.Shots - Health News A Safety Checklist To Save Teen Athletes' Lives
The National Athletic Trainers' Association also recommends drinking enough fluids before, during and after exercise to help avoid overheating.
And race organizers need to be able to diagnose heatstroke quickly by taking a runner's body temperature rectally on site, so they can provide proper cooling, most effectively by immersing the person in a cold water bath.
Heatstroke is a big problem, says Dr. George Chiampas, a Northwestern Medicine emergency medicine physician. He's also medical director of the Chicago Marathon, which made some changes after the 2007 race was halted amid high temperatures that sickened hundreds. (The single death that year was actually a result of a heart condition, not the heat.)
Now runners see green, yellow, red or black flags along the route to indicate whether the conditions, including weather, are good, less than ideal, potentially dangerous or so bad that the race has been stopped, Chiampas tells Shots. Post-race surveys show that runners run more slowly and adjust their strategy if conditions are yellow or red, he says.
And medical personnel near the finish line are trained to talk with runners to see if their mental status has been affected — a sign of heat illness.http://www.npr.org/.
Medicare's Hospital Insurance Trust Fund, which finances about half of the health program for seniors and the disabled, won't run out of money until 2030, the program's trustees said Monday. That's four years later than projected last year, and 13 years later than projected the year before the passage of the Affordable Care Act.
But that's not the case for the part of Social Security that pays for people getting disability benefits. The Disability Insurance Trust Fund is projected to run out of money in 2016, just two years from now, unless Congress intervenes, the trustees said.
"Medicare is considerably stronger than it was just four years ago," Health and Human Services Secretary Sylvia Burwell said Monday. She noted that slower growth of the program's spending will very likely mean that the Medicare Part B premium charged to beneficiaries — currently $104.90 per month — remains the same for the third year in a row. "That's a growth rate of zero percent," she noted.Shots - Health News A Doctor Takes A Look In The Medicare Mirror
All the trustees, however, including the secretaries of HHS, Treasury and Labor and two public members, stressed that Medicare's financial problems are far from fixed, particularly as 78 million baby boomers are on the precipice of joining.
"Notwithstanding recent favorable developments, both the projected baseline and current law projections indicate that Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation," the report said.
And "the sooner lawmakers face that reality, the better," said Robert Reischauer, a public trustee and former head of the Congressional Budget Office.Shots - Health News For Some Doctors, Almost All Medicare Patients Are Above Average
For the first time, the Medicare report deviates from current law and does not assume that scheduled deep cuts in reimbursements to physicians who treat Medicare patients will occur. Congress has suspended the cuts each year since 2003, and in this report the trustees assume that will continue until Congress fixes the formula, known as the sustainable growth rate, or SGR.
The change "should make the Part B cost projections more useful than they have been in the past," said Reischauer. Part B pays for most physician and outpatient costs. It technically does not have a trust fund because it is financed by a combination of general tax revenues and beneficiary premiums, but the trustees make projections for its spending each year.
The trustees opted not to wade into the ongoing debate over the extent to which the slowdown in Medicare's spending increases can be attributed to changes to the program made in the 2010 health law.Shots - Health News Following Abuses, Medicare Tightens Reins On Its Drug Program
"No one knows and certainly there is an active debate," said Charles Blahous, the other public trustee and lone Republican on the panel. "And that's not something the trustees are going to settle," said Blahous, a fellow at the conservative Hoover Institution.
But whatever the reason, no one contests that the slowdown has been dramatic. Medicare, which covered an estimated 52.3 million people in 2013, spent $582.9 billion, "and, for the second year in a row, per beneficiary costs were essentially unchanged," the report said.
The financial picture for Social Security's disability insurance fund, by contrast, is much more dire.
"The projected reserves of the DI Trust Fund decline steadily from 62 percent of annual cost at the beginning of 2014 until the trust fund reserves are depleted in the fourth quarter of 2016," the Social Security report said. After that, the program would be able to pay only 81 percent of scheduled benefits.
The disability program has seen a dramatic increase in enrollment in recent years, yet Congress has not taken any action to change its financing, which is 1.8 percentage points of the overall 12.4 percent Social Security payroll tax paid by employers and workers.Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
The human Y chromosome (left) holds the code for "maleness"; that's the X on the right.Andrew Syred/Science Source
Basic biology has it that girls are girls because they have two X chromosomes — the things inside cells that carry our genes. Boys are boys because they have one X and one Y. Recently, though, there's been a lot of debate in scientific circles about the fate of that Y chromosome — the genetic basis of maleness.
Very early in the evolution of the Y chromosome, explains Dr. David Page, a geneticist at the Massachusetts Institute of Technology, something pretty dramatic happened: The ancestral Y lost most of its genes. And scientists basically ignored the little that was left.The End of Men? Making Sperm, No Men Necessary
"The Y chromosome was essentially written off as the runt of the human genome," Page says, "as a sort of genetic wasteland that didn't really merit anyone's serious attention."
When the Y did get any attention, it wasn't good news. Some scientists, like geneticist Jennifer Graves at La Trobe University in Melbourne, Australia, speculated that the Y might be destined to just keep sort of ... rotting away.
“ The idea that the Y chromosome might disappear altogether, possibly taking men with it — I think that idea has now been firmly dismissed.
"As soon as it becomes a male-determining chromosome, then the rot sets in," Graves says. "That's kind of the kiss of death for that chromosome," meaning the Y chromosome could be headed toward oblivion — completely disappear.
But other scientists, including Page, say: Not so fast. Step away from my Y chromosome.
"I've really spent the better part of my career defending the honor of the Y chromosome in the face of insults of this sort," Page says.
For the Y, size really doesn't matter, he says. Page has done a detailed analysis of the chromosome's evolution and says the string of genes has been solidly stable now for millions of years.
“ When I give lectures about the demise of the Y chromosome, I see men sort of hunching up into this protective stance as though I'm physically attacking them.
"The idea that the Y chromosome might disappear altogether, possibly taking men with it — I think that idea has now been firmly dismissed," he says.
In fact, the relatively few precious genes that are left on the Y look like they're special — very special.
"There are genes on the Y chromosome that are active throughout every nook and cranny of the body," Page says. "The skin, the blood, the brain, the lungs — you name it. They look to be sort of global entrepreneurs within the human genome. They are sort of master regulators."
Still, Graves remains skeptical.
"I don't think that one can assume that just because they're there and they do something useful they'll be there forever and ever," she says. "A small accident could tip it over the edge, or the evolution of a new sex-determining system that works better."
Graves says she is always surprised by the ferocious reaction she gets to any suggestion that the male chromosome might be vulnerable.
"I've been accused in print of being, you know, a ball-breaking feminist," she says. "Well, no — not really. I'm just pointing out that things change, and evolution is wonderful, and it can do things lots of different ways."
Graves has a theory about why the reaction is so intense, especially among men.
"There's some deep-seated insecurity that men have about their Y chromosomes," she says, half-joking. "When I give lectures about the demise of the Y chromosome, I see men sort of hunching up into this protective stance as though I'm physically attacking them."Shots - Health News Popular Testosterone Therapy May Raise Risk Of Heart Attack
And there's a twist in all this. Even if the Y chromosome is here to stay, that may be something of a double-edged sword for men. Even if those master genes on the Y chromosome are important, they may also help explain why men are more prone to certain diseases than women are — and tend to live shorter lives.
Jan Dumanski, of Uppsala University in Sweden, and his colleagues recently reported, for example, a possible link between the Y chromosome and an increased risk for lots of cancers. He sees the human Y chromosome as "the Achilles' heel for men."
"It's making us men," Dumanski says, "but also causing us some trouble when we are getting older."
Clearly, our relationship with Y continues to be complicated. And it's not all about size.Copyright 2014 NPR. To see more, visit http://www.npr.org/.
We know that happiness and social connection can have positive benefits on health. Now research suggests that having a sense of purpose or direction in life may also be beneficial.
To find out if having a sense of purpose has an effect on aging and adult development, Patrick Hill, an assistant professor of psychology at Carleton University in Ottawa, Canada, looked at data from the Midlife in the United States (MIDUS) study, which is funded by the National Institute on Aging.
Hill and his colleague Nicholas Turiano of the University of Rochester Medical Center looked to see how more than 6,000 people answered questions like "Some people wander aimlessly through life, but I am not one of them," and other questions that gauged positive and negative emotions.
They found that 14 years after those questions were asked, people who had reported a greater sense of purpose and direction in life were more likely to outlive their peers.13.7: Cosmos And Culture Does Life Have A Purpose?
In fact, people with a sense of purpose had a 15 percent lower risk of death,compared with those who said they were more or less aimless. And it didn't seem to matter when people found their direction. It could be in their 20s, 50s or 70s.
Hill's analysis controlled for other factors known to affect longevity, things like age, gender and emotional well-being. A sense of purpose trumped all that.
Hill defines it as providing something like a "compass or lighthouse that provides an overarching aim and direction in day-to-day lives."
Of course, purpose means different things to different people. Hill says it could be as simple as making sure one's family is happy. It could be bigger, like contributing to social change. It could be more self-focused, like doing well on the job. Or it could be about creativity.13.7: Cosmos And Culture The Mayan Apocalypse And The Meaning Of Life
"Often this is individuals who want to produce something that is appreciated by others in written or artistic form, whether it's music, dance or visual arts," Hill says.
It's not exactly clear how purpose might benefit health. Purposeful individuals may simply lead healthier lives, says Hill, but it also could be that a sense of purpose protects against the harmful effects of stress.
An experiment in Chicago tested this theory. Anthony Burrow, a developmental psychologist at Cornell University, had college student volunteers of different races and ethnicities ride rapid transit through the diverse neighborhoods of Chicago, recording their emotions as individuals of different racial and ethnic groups boarded.
Earlier research has shown that when people are surrounded by people of different ethnic or racial groups than their own, their level of stress increases. Burrow wanted to know if thinking about their sense of purpose might reduce that stress.Shots - Health News Mindfulness Meditation Can Help Relieve Anxiety And Depression
He had about half the students write for about 10 minutes about their life's direction. The other half wrote about the last movie they saw. They were all then given packets that listed the name of every stop. When they got to a stop, they were asked to assess how they felt and how much they felt that way by placing an "X" in a box next to negative emotions such as feeling scared, fearful, alone or distressed.
It turned out that the students who wrote about the last movie they saw experienced the expected levels of stress as the percentage of people of different ethnicity increased. But the students who wrote about their sense of purpose reported no feelings of increased stress at all.
More research is needed, but Burrow says his findings suggest that having "a sense of purpose may protect people against stress," with all of its harmful effects, including greater risk of heart disease. And that may explain why people with a sense of purpose live longer.Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Medical tests are rarely a pleasant experience, especially if you're worried that something could be seriously wrong. That's true even though we know that regular screenings and tests often help doctors catch issues early.
But of course, humans don't always behave rationally. Sometimes people will go to great lengths to avoid hearing bad news. Social scientists call this sort of behavior information aversion, or the ostrich effect (based on the old myth that ostriches bury their heads in the sand when they're scared). And it can have important implications for our health, researchers say.
In order to gauge how information aversion affects health care, one group of researchers decided to look at how college students react to being tested for a sexually transmitted disease.Shots - Health News Feds Cracks Down On 'Bogus' STD Remedies
That's a subject a lot of students worry about, according to Josh Tasoff, an economist at Claremont Graduate University who led the study along with Ananda Ganguly, an associate professor of accounting at Claremont McKenna College.
The students were told they could get tested for the herpes simplex virus. It's a common disease that spreads via contact. And it has two forms: HSV1 and HSV2.
The type 1 herpes virus produces cold sores. It's unpleasant, but not as unpleasant as type 2, which targets the genitals. Ganguly says the college students were given information — graphic information — that made it clear which kind of HSV was worse.
"There were pictures of male and female genitalia with HSV2, guaranteed to kind of make them really not want to have the disease," Ganguly says.
Once the students understood what herpes does, they were told a blood test could find out if they had either form of the virus.Shots - Health News People Can Spread Herpes Easily, Even When Free Of Symptoms
Now, in previous studies on information aversion it wasn't always clear why people declined information. So Tasoff and Ganguly designed the experiment to eliminate every extraneous reason someone might decline to get information.
First, they wanted to make sure that students weren't declining the test because they didn't want to have their blood drawn. Ganguly came up with a way to fix that: All of the students would have to get their blood drawn. If a student chose not to get tested, "we would draw 10 cc of their blood and in front of them have them pour it down the sink," Ganguly says.
The researchers also assured the students that if they elected to get the blood tested for HSV1 and HSV2, they would receive the results confidentially.
And to make triply sure that volunteers who said they didn't want the test were declining it to avoid the information, the researchers added one final catch. Those who didn't want to know if they had a sexually transmitted disease had to pay $10 to not have their blood tested.
So what did the students choose? Quite a few declined a test.
And while only 5 percent avoided the HSV1 test, three times as many avoided testing for the nastier form of herpes.
For those who didn't want to know, the most common explanation was that they felt the results might cause them unnecessary stress or anxiety.
The researchers say that this study — and the growing body of evidence on information avoidance — has important implications.Shots - Health News Quick DNA Tests Crack Medical Mysteries Otherwise Missed
Many health screening messages urge people to get tested by reminding them how awful diseases can be. But these scare tactics might be a mistake, Ganguly says.
"Scaring people more about the implications may scare them away from getting tested," he says.
That lines up with previous research. In a 2009 study that looked at adolescents in a high school and at a juvenile detention center, scare tactics about sexually transmitted diseases proved to be unnecessary for teenagers who were receptive to health messages. And they were ineffective for teenagers who were indifferent to such messages.
There's a second approach to consider, Tasoff says. The ostrich effect is produced by anxiety. One way to keep anxieties at bay is to draw as little attention to tests as possible, to make them routine.
Of course, these ideas need more testing. Keeping people in the dark about their health doesn't square with our notions of patient choice and autonomy. And if you don't tell people how bad a disease can be, that can affect the incentive to get tested at all.
But one thing seems clear. If we want people to pay attention to their health, it doesn't make sense to stick our heads in the sand about the ostrich effect.Copyright 2014 NPR. To see more, visit http://www.npr.org/.
fromWNYCListen to the Story 7 min 9 sec
Lissette Encarnacion in her apartment at The Brook, a supportive housing complex in the New York City borough of the Bronx.Natalie Fertig/WNYC
Standing outside her sixth-floor apartment in the Bronx, Lissette Encarnacion says she sometimes forgets the place belongs to her.
"I'm thinking I'm at somebody else's [house]," she says. "I'm ringing my own doorbell."
Encarnacion used to have a career in banking, and lived in a real home with her son and husband. Then one night everything changed, she says, when her husband came home drunk and angry, and threw her off a balcony.
"He came home, pulled me from the hair, and just started beating the hell out of me," she says. She was seven months pregnant with her second child, a boy.
Encarnacion suffered traumatic brain injury and was never the same. She and her sons moved in with her sister, but Encarnacion often wandered off.
Eventually she became homeless, she tells NPR affiliate WNYC, and remained that way for a decade. She suffered from epileptic seizures, and was frequently picked up by paramedics and taken to emergency rooms.
Then two years ago, she moved into The Brook, an apartment complex that provides supportive housing to its residents — more than half of whom are formerly homeless.
“ You know, we as a society are paying for somebody to be on the streets.
Now Encarnacion lives in a studio apartment, which she has decorated with stuffed animals and Christmas lights. And though the place is small, she likes to think of it as her "penthouse" apartment.StoryCorps A Homeless Teen Finds Solace In A Teacher And A Recording
Brenda Rosen, the director of Common Ground, the organization that manages the building, says The Brook offers a full range of services to keep its residents healthy: social workers, security, a doctor and even an event planner.Economy A Campaign To House The Homeless Reaches A Milestone
And while these services don't come without a cost — an apartment at The Brook runs at about $24,000 a year — Rosen says they are cheaper than the estimated $56,000 per year that the city spends on the emergency room visits and stays at shelters and jails, where many people with severe mental illness end up.
"You know, we as a society are paying for somebody to be on the streets," says Rosen.
Few people would dispute that Lissette Encarnacion is better off in her studio apartment than she was when she was living under the bridge. And it's far cheaper if she has a doctor downstairs than if she has to show up regularly in the ER.
The question is, who pays for this kind of housing?
New York now has about 47,000 supportive housing units, and the state intends to invest $260 million Medicaid dollars over the next two years. But the federal government won't match it.
At the crux of this debate is the question of whether housing qualifies as health care.
“ Medicaid is supposed to be health insurance, and not every problem somebody has is a health care problem.
This past December, the outgoing New York State commissioner of health argued in an article in The New England Journal of Medicine that housing is health care. Providing housing to the chronically homeless saves health care money, he argues, so Medicaid should help pay capital costs.
New York State Medicaid Director Jason Helgerson went further, arguing that federal Medicaid money already pays for housing, through long stays in nursing homes and hospitals.Education After Months Of Homelessness, A Teen Leaves The Woods Behind
But Bruce Vladeck, who formerly administered Medicaid and Medicare in the Clinton administration, says federal Medicaid dollars can't and shouldn't be used to pay for housing — it's not cost-effective.
"Medicaid is supposed to be health insurance, and not every problem somebody has is a health care problem," says Vladeck.
Instead, Vladeck argues that housing programs should be paid by housing agencies.
"As a society, both in the private sector and the public sector, we are really cheap and niggling and resentful about paying for social services, and we are much more generous when it comes to paying for health services," he says.
At the moment there is not enough housing money to go around for all the people who need it — people like Encarnacion, who are done living on the streets but still need support. For her, The Brook offers a place in between.
"I stuck it out, and it's good," she says. "And God's been real good to me. And the people that work here have been very good to me — and patient, because I am not easy. I am not easy."
To hear and read more about The Brook and other innovative initiatives in health care reform in New York, check out WNYC's series Prescription for the Bronx.Copyright 2014 WNYC Radio. To see more, visit http://www.wnyc.org/.
Traditional warning labels on medicine boxes tend to be long on confusing language, critics say, but short on helpful numbers.iStockphoto
Anybody who has ever seen a drug advertisement or talked over the pros and cons of a medicine with a doctor can be forgiven for being confused.
Sorting out the risks and benefits of taking a medicine can be complicated even for professionals.i i
This 2007 ad for the sleeping pill Lunesta stresses insomnia relief — not the relative usefulness of the drug.Lunesta
This spring, the Institute of Medicine convened a workshop with the Food and Drug Administration. The topic: How best to communicate to doctors and patients the uncertainty in the assessment of benefits and risks of pharmaceuticals.
The FDA not only approves drugs, it also approves the prescribing instructions that come along with them. For some drugs, the wad of paper filled with fine print about the risks and benefits of using the drug is accompanied by a medication guide that is supposed to summarize the main points.
During one question-and-answer session, Dr. Robert Temple of the FDA's Center for Drug Evaluation and Research, acknowledged that those guides are full of information. "But it's remarkably nonquantitative for the most part," he said. "And I think we should try to think about whether there are quantitative ways of presenting that stuff."
The husband-and-wife team from Dartmouth are on a decade-long mission. They have been pushing the FDA to get useful and readable quantitative data about drugs to doctors and their patients.
Schwartz and Woloshin have designed a format they call a drug facts box. It shows the gist of what they say is buried in all the fine print: How does the drug compare to a placebo?i i
Drs. Lisa Schwartz and Steven Woloshin designed this "fact box" as a prototype to show how package inserts for medicines could be more helpful.Courtesy of Dr. Steven Woloshin
That's in contrast to what usually happens, Schwartz says. "The prescribing info is written by industry, and then negotiated with FDA, and then FDA ultimately approves it. And we have documented examples where important info — like how well the drug works — is not in the label."
This drives Schwartz and Woloshin crazy.
Better Than A Sugar Pill
So, here's their experiment: They showed people ads for two competing heartburn drugs, one plainly more effective than the other.
They also showed people two of their drug facts boxes, one for each of those two heartburn drugs, showing how each drug fared against a placebo (a sugar pill) in testing.
"When the people are presented with the standard information they see — like a drug ad — about 30 percent of people chose the better drug," Woloshin says. "But when we showed them information in the drug facts box form, 68 percent of people were able to choose the objectively better drug. So that's a really dramatic improvement. It just shows you that if you show people information in a way that's understandable, they can use it, and it can improve their decision."
Using FDA data, Woloshin and Schwartz developed a drug facts box for the sleep aid Lunesta.
Two columns compare people with insomnia who took Lunesta and people with insomnia who, unknowingly, took a sugar pill.
The results? Those who used Lunesta took 30 minutes to fall asleep. Those who got a sugar pill took 45 minutes — a difference of 15 minutes. Those who took Lunesta stayed asleep 37 minutes longer than those who took a sugar pill.Shots - Health News What's In Your Painkiller? Study Finds Most Are Clueless
Woloshin and Schwartz say some people might consider those benefits worth taking the drug, and some might not.
"That's the whole point of the drugs facts box," Woloshin says, "to let people look at the evidence and come to their own judgments. But you can't make those judgments without the facts.
He and Schwartz believe passionately in the numeracy of patients. They say we can handle numbers, like percents. It's just that too often we're given incomplete or misleading information.
How Good A Deal Is That Sale?
For example, a claim that some drug reduces the likelihood of a particular disease by 50 percent can be misleading.
Woloshin explains why. "If you heard about a sale, and it said 50 percent off, would you travel a great distance to go to the sale? Well, you might if it was on things that are really expensive, like a flat-screen TV or something," he says. "But what if the thing that was on sale was gum, and you save only a couple of cents? So when you hear 50 percent reduction, you have to ask 50 percent of what?"
The doctors' dream is to get those drug facts boxes into health systems and electronic medical records, so that doctors and patients can study the information and decide what's best before the drug is prescribed.
"What we hope is that the box will encourage people to take drugs that are effective and that work, and discourage people from taking drugs that don't work or are just harmful," Woloshin says. "And also that just having this information in front of people will stimulate better drug research, because drug companies realize people are paying attention and looking at these numbers — and then we'd have a better quality of drug trials."Shots - Health News Say What? Jargon Busters Tackle Health Insurance
Woloshin and Schwartz say medical information should be as quantitative as other information. And we digest quantitative data all the time.
"If you were reporting on an election, you wouldn't say Obama won by a little," he says. "You'd give the numbers. If you were reporting sports scores, you wouldn't say the Celtics, won, hopefully won, by a bit. You'd give the score."
Why should health care be different?
He and Schwartz are convinced that we can understand risk described by numbers, provided the numbers are clearly and honestly presented.
They have been lobbying the FDA to develop drug facts boxes, but say that seems unlikely. So they started their own company to do it — Informulary. It's funded by the Robert Wood Johnson Foundation, which also supports NPR.
This is the final part of an All Things Considered series on Risk and Reason.Copyright 2014 NPR. To see more, visit http://www.npr.org/.
When weighing the risk of heart disease, how the numbers are presented to patients can make all the difference.iStockphoto
Many of us get confused by claims of how much the risk of a heart attack, for example, might be reduced by taking medicine for it. And doctors can get confused, too.
Just ask Karen Sepucha. She runs the Health Decisions Sciences Center at Boston's Massachusetts General Hospital. A few years ago she surveyed primary care physicians, and asked how confident they were in their ability to talk about numbers and probabilities with patients.
"What we found surprised us a little bit," Sepucha says. "Only about 20 percent of the physicians said they were very comfortable using numbers and explaining probabilities to patients."Shots - Health News What The Odds Fail To Capture When A Health Crisis Hits
Doctors, including Leigh Simmons, typically prefer words. Simmons is an internist and part of a group practice that provides primary care at Mass General. "As doctors we tend to often use words like, 'very small risk,' 'very unlikely,' 'very rare,' 'very likely,' 'high risk,' " she says.
But those words can be unclear to a patient.
"People may hear 'small risk,' and what they hear is very different from what I've got in my mind," she says. "Or what's a very small risk to me, it's a very big deal to you if it's happened to a family member."
Simmons and her colleagues are working on ways to involve their patients in shared decision-making. The initiative at Mass General gives patients online, written and visual information to help them. One of the goals is to make risk understandable — bridging the gap between percent probabilities and words.
Dots Help Decide
Simmons tried it with her patient Joe Bianco, 60, when talking over his risk for heart disease a few weeks ago. Rather than just using a number to tell him his risk for a heart attack, she made it visual with this statin/aspirin decision aid calculator, developed by the Mayo Clinic.
The calculator displays 100 green dots arranged in a 10-by-10 grid. Each has a little smile on it and symbolizes a person. Once a patient's information is entered, some of the green dots turn yellow and some smiles may turn upside down into frowns, indicating in the next 10 years, how many people are expected to have a heart attack.i i
A tool to assess heart attack risks changes in response to treatment choices patients might make.Courtesy of Mayo Clinic
When Bianco's profile is submitted, 12 dots turn yellow and 88 remain green — meaning 12 percent of men like him will have a heart attack within 10 years. "It looks like my chances are slim," he says.
Bianco had decided earlier not to take a cholesterol-lowering statin medicine to lower his risk of a heart attack. The dozen frowning yellow dots don't change his mind.
Next, Simmons enters another factor into the online calculator. What if all 100 men fitting Bianco's profile take a statin drug every day for the next ten years?
The number of yellow dots on the screen — the percent who will have a heart attack — changes for the better.
"That number goes down to seven — so five people are saved from a heart attack by taking a medication," Simmons says. "Some people look at that and say, 'Well that's almost cutting the risk in half.' Other people say, 'Well, that's still 88 people who didn't benefit either way. And only five who had a benefit.'"
For Bianco, seeing the graphic validated his previous decision not to take medicine. And for Simmons, as a doctor, it's made that conversation easier.
Numbers Still Valuable
But the graphics and words alone don't work for everyone. At Mass General's orthopedics department, Jim Westberg of Nashua, N.H., has come to see surgeon Andy Freiberg, who is in charge of hips and knees.
Westberg is very active at 59. He hikes, swims, skis and rock climbs when he's not at work, selling 3-D printers. He wants a hip replacement and in the course of examining him, his doctor cites some numbers.
"Your risk of infection is probably under 1 percent, probably half a percent," Freiberg tells him.
That the risk is less than 1 percent doesn't deter Westberg. Before his appointment, he had received a shared decision-making packet that included a booklet and a DVD, all about hip replacement. He also did some other research and — just as importantly — talked to people he knew who had had the surgery and were thrilled with the outcome.
For him, Westerberg says, the numbers and percent probabilities are still valuable.
"I think they're fairly important because I actually have an engineering degree," Westerberg says. "I have a technical background so maybe I'm a little biased, but numbers do mean something to me. The risk we talked about, half of 1 percent, really doesn't concern me that much."
What Is 'Very Common'?
The Food and Drug Administration also likes numbers and urges drug companies to give numerical values for risk — and to avoid using vague terms such as "rare, infrequent and frequent."
But the European Medicines Agency (a part of the European Union) has matched a scale of terms — very common, common, uncommon, rare and very rare — with numerical definitions for each of those five levels of frequency.
So, what percent of cases qualified for the top level "very common" side effect? You might think over 50 percent, but according to those EU definitions, a side effect is "very common" if occurs in more than 10 percent of cases.
And if a drug label says that a particular side effect was "very rare"? That means it occurs in fewer than one in every 10,000 cases.
This is part four of an All Things Considered series on Risk and Reason.Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Dr. Donald Brown inoculated Kelly Kent with the HPV vaccine in his Chicago office in the summer of 2006 — not long after the first version of the vaccine reached the market.Charles Rex Arbogast/AP
Though the vaccine against human papilloma virus is highly effective in preventing certain forms of cancer, the number of preteens getting the vaccine is still dismally low, doctors from the Centers for Disease Control and Prevention announced Thursday.Shots - Health News Vaccine Against HPV Has Cut Infections In Teenage Girls
"One of the top five reasons parents listed is that it hadn't been recommended to them by a doctor or nurse," the CDC's Dr. Anne Schuchat told reporters at a press briefing.Shots - Health News HPV Vaccine Doesn't Raise Risk Of Blood Clots, Study Finds
"Parents who aren't planning to vaccinate lacked knowledge and didn't hear a physician recommendation," said Schuchat, who directs the CDC's National Center for Immunization and Respiratory Diseases. "We don't think it's an issue of politics. This is something that parents seem to be open to."
Federal health officials have for several years been recommending that all preteen boys and girls be vaccinated around age 11 or 12 — before the initiation of sexual activity. That's when the vaccine has been shown to be most protective against HPV infections that can lead to cervical cancer, genital warts and oral and anal cancers.
But data from the national survey released Thursday, and published in this week's Morbidity and Mortality Weekly Report, suggest that only 57 percent of young women ages 13-17 — and only 35 percent of young men that age — have received one or more vaccine doses.
Every year more 27,000 people in the U.S. get cancer caused by HPV, Schuchat said.
“ We don't think it's an issue of politics. This is something that parents seem to be open to."
Protection against the virus did go up a little bit in 2013, the survey showed, compared with 2012, when 53.8 percent of young women and 20.8 percent of young men had received the vaccine. Still, more needs to be done, Schuchat said.
Doctors and nurses are missing many good opportunities to vaccinate for HPV, she said. For example, they are already successfully immunizing preteens at a high rate against tetanus, diphtheria and pertussis (Tdap), and against meningitis. Roughly 77 percent of 13- to 17-year-olds have been immunized against meningitis, and about 86 percent have received the Tdap vaccine.
The problem is not that doctors are reluctant to give the vaccine, Schuchat said; it's more often a problem of miscommunication. Surveys show many are actually forgetting to mention it to patients.
"Physicians need to know that the vaccines they give can prevent very serious cancers in the U.S.," she said.
At every appointment for adolescents, doctors should tell parents, " 'Today there are three recommended vaccines,' " Schuchat advised. Had shots against HPV been administered when other routine vaccines were given to preteens in the last several years, she says, about 91 percent of today's 14-year-old girls would be protected.
NIS-Teen, which collected information on more than 18,000 teens in the 2013 survey, has been collecting vaccination information since 2006 through use of random-digit-dialing of both landlines and cellphones. After a teen's parent or guardian provided permission to contact the teen's health provider, the survey team mailed the parents a questionnaire. Results from the survey were then verified via a check of medical records.Copyright 2014 NPR. To see more, visit http://www.npr.org/.
A Missouri mother recently posted this video on YouTube of what she claims to be an encounter with hospital security after taking a picture of her son during an audiology test.
In the name of patient privacy, a security guard at a hospital in Springfield, Mo., threatened a mother with jail for trying to take a photograph of her own son.
In the name of patient privacy, a Daytona Beach, Fla., nursing home said it couldn't cooperate with police investigating allegations of a possible rape against one of its residents.
In the name of patient privacy, the U.S. Department of Veterans Affairs allegedly threatened or retaliated against employees who were trying to blow the whistle on agency wrongdoing.
When the federal Health Insurance Portability and Accountability Act passed in 1996, its laudable provisions included preventing patients' medical information from being shared without their consent and other important privacy assurances.
But as a litany of recent examples show, HIPAA, as the law is commonly known, is open to misinterpretation — and sometimes provides cover for health institutions that are protecting their own interests, not patients'.
"Sometimes it's really hard to tell whether people are just genuinely confused or misinformed, or whether they're intentionally obfuscating," said Deven McGraw, partner in the healthcare practice of Manatt, Phelps & Phillips and former director of the Health Privacy Project at the Center for Democracy & Technology.
For example, McGraw said, a frequent health privacy complaint to the U.S. Department of Health and Human Services Office of Civil Rights is that health providers have denied patients access to their medical records, citing HIPAA. In fact, this is one of the law's signature guarantees.
"Often they're told [by hospitals that] HIPAA doesn't allow you to have your records, when the exact opposite is true," McGraw said.
I've seen firsthand how HIPAA can be incorrectly invoked. In 2005, when I was a reporter at the Los Angeles Times, I was asked to help cover a train derailment in Glendale, Calif., by trying to talk to injured patients at local hospitals. Some hospitals refused to help arrange any interviews, citing federal patient privacy laws. Other hospitals were far more accommodating, offering to contact patients and ask if they were willing to talk to a reporter. Some did. It seemed to me that the hospitals that cited HIPAA simply didn't want to ask patients for permission.
The incident at the Missouri hospital, Mercy, began after Mandi Wilson took her son to an audiologist to get his hearing tested, according to the Springfield News-Leader. A security guard questioned her and asked to see her phone to confirm that she had deleted any photos. When she refused, the officer told her that she was "being trespassed for violation of HIPAA" and threatened to send her to jail if she came back, the paper reported.
A hospital spokesperson told the newspaper that it is reviewing how its photo and video policy is being enforced.
The Daytona Beach police chief filed a complaint to the Florida Agency of Health Care Administration saying that, based on HIPAA, "his detectives have been impeded from investigating a possible sexual battery of a 75-year-old resident at a local healthcare facility," the Daytona Beach News-Journal wrote.
Lawyers for the nursing home, Daytona Beach Health and Rehabilitation Center, told the paper that privacy laws prevented them from turning over information without a subpoena. An attorney hired by the home's parent company told the paper he found no evidence of any sexual assault.
The HIPAA issues involving the VA emerged as the department grappled with a scandal in which employees were accused of falsifying records to disguise how long veterans were waiting for appointments, drawing ire from veterans groups and lawmakers and prompting the ouster of senior leaders.
The Washington Post reported that the top lawyer for the American Federation of Government Employees cited several cases in which the VA invoked patient privacy restrictions to "stifle whistleblowers."
"We routinely hear from our members who wish to make disclosures about problems with the patient care system and other conduct within the VA," the union's lawyer wrote in a June letter to the VA's general counsel. "Most are reluctant to do so both because of a history of reprisals by VA management, and because of recent experience with laws designed to protect patients which are instead being used as a sword against employees by VA management."
The letter cited how two employees were unable to get a written HIPAA waiver in order to report information to the Office of Inspector General.
"VA routinely uses HIPAA as an excuse to punish into submission employees who dare to speak out," Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans' Affairs, told the Post.
McGraw said that HIPAA has specific allowances for police officers investigating crimes and for whistleblowers sharing information with government authorities.
"You certainly can disclose patient information for health oversight activities, including government oversight over government benefit programs," she said. "You certainly can disclose when a police officer comes and is investigating a crime. ... There are provisions in HIPAA that allow them to make a disclosure about a victim of crime as long as the victim has agreed or they're incapacitated."
What has been your experience with patient privacy? Email ProPublica Charles Ornstein at firstname.lastname@example.org to let him know.Copyright 2014 ProPublica. To see more, visit http://www.propublica.org/.
Sure, your doctor can do this. But you can, too. And for stroke patients, it could be a lifesaver.iStockphoto
An irregular heartbeat called atrial fibrillation is a big cause of stroke, especially for people who have recently had a stroke. But it's not something that most people can feel.
Doctors test for atrial fibrillation by hooking people up to an electrocardiogram machine at the office, or having them wear a Holter monitor for a day or a week. There are also implantable monitors to check for afib, but they aren't widely used.
Learning to take your own pulse may be as effective and a lot simpler, according to German researchers.
They trained 220 older people who had had a stroke to tell the difference between a normal pulse and the fluttery abnormal rhythm of afib.
The training was considered a success if the people were able to correctly measure their pulse twice in a row; 196 people aced the test, for an 89 percent success rate.
To find out if the amateurs' measurements actually detected afib, the patients also were being continuously monitored on an electrocardiogram. But they weren't able to see the ECG monitor while doing the self-test.
It found that 57 of the patients had irregular heartbeats.Shots - Health News Hospitals Can Speed Stroke Treatment, But It's Not Easy
The patients who checked their own pulse rate provided reliable results 89 percent of the time. They identified irregular rhythms 54 percent of the time, and normal rhythms 96 percent of the time. They incorrectly thought they had afib just 3 percent of the time.
False positives are one downside of having people self-test, says Dr. Bernd Kallmunzer, a neurologist at Universitatsklinikum Erlangen in Germany who led the study. They typically would be told to go get an ECG test. But because there were only 6 people who thought they had afib when they didn't, "the number of 'unnecessary' ECG recordings are expect to be rather low," Kallmunzer said in an email.
Relatives also were trained to take the patients' pulses, and they did even better, identifying irregular rhythms 77 percent of the time.
The results were published online Wednesday in the journal Neurology.
"Many times people don't know they're in afib," says Dr. Ralph Sacco, chairman of the department of neurology at the University of Miami. "This group is trying to propose a more simple, cheap method that may work, having stroke patients and their caregivers monitor pulse.
"There's very little downsides other than maybe the extra anxiety if you thought there was something wrong if it wasn't," Sacco told Shots.
He can forsee the day when people would check their pulse rates the way they check their blood pressure, but notes that the test will be less useful in younger people and older people not at risk of stroke.
People with atrial fibrillation can be given medications that substantially reduce their risk of a blood clot and stroke.
Want to try it yourself? The American Heart Association has written instructions. Or check out this nifty video from the British Heart Foundation that also lets you hear the difference between regular and irregular heartbeats. Thanks to our perspicacious readers for flagging it!Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Even after the open enrollment deadline, HealthCare.gov remained a popular destination.J. David Ake/AP
For months, journalists and politicians fixated on the number of people signing up for health insurance through the federal exchange created as part of the Affordable Care Act. It turned out that more than 5 million people signed up using HealthCare.gov by April 19.
But perhaps more surprising is that, according to federal data released Wednesday to ProPublica, there have been nearly 1 million transactions on the exchange since then. People are allowed to sign up and switch plans after certain life events, such as job changes, moves, the birth of a baby, marriages and divorces.
The volume of these transactions was a jolt even for those who have watched the rollout of the ACA most closely.
"That's higher than I would have expected," said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. "There are a lot of people who qualify for special enrollment, but my assumption has been that few of them would actually sign up."
The impact of the new numbers isn't clear because the Obama administration has not released details of how many consumers failed to pay their premiums and thus were dropped by their health plans. All told, between the federal exchange and 14 state exchanges, more than 8 million people signed up for coverage by April 19. A big question is whether new members will offset attrition.
ProPublica requested data on the number of daily enrollment transactions on the federal exchange last year under the Freedom of Information Act because the Obama administration had declined to release this information, a key barometer of the exchange's performance, to the public. The administration also has not put out any data on the exchange's activity since the open enrollment period ended.
The data show so-called 834 transactions, which insurance companies and the government use to enroll new members, change a member's enrollment status or disenroll members. The data cover the 36 states using the federal exchange, which include Texas, Florida, Illinois, Georgia and Michigan.
When HealthCare.gov rolled out last fall, insurance companies complained that the information in the 834s was replete with errors, creating a crisis at the back-end of the system.
Between April 20 and July 15, the federal government reported sending 960,000 so-called 834 transactions to insurance companies (each report can cover more than one person in the same family). That includes 153,940 for the rest of April, 317,964 in May, 338,017 in June and 150,728 in the first 15 days of July. The daily rate has been fairly stable over this period.
It wasn't immediately clear how many of the records involved plan changes or cancellations and how many were for new enrollments.
An insurance industry official estimated that less than half of the transactions are new enrollments. The rest are changes: When an existing member makes a change to his or her policy, two 834s are created — one terminating the old plan and one opening the new one.
Charles Gaba, who runs the website acasignups.net that tracks enrollment numbers, estimates that between 6,000 and 7,000 people have signed up for coverage each day on the federal exchange after the official enrollment period ended. Gaba's predictions were remarkably accurate during the open enrollment period.
"That doesn't account for attrition. That doesn't mean that they paid," Gaba said. "That's been based on limited data from a half dozen of the smaller exchanges, extrapolated out nationally."
The federal data obtained by ProPublica confirm some other facts about the rollout of HealthCare.gov, which was hobbled initially by technical problems. The slowest day was Oct. 18, when no 834 transactions were sent. That was followed by Oct. 1, the day the website launched, when a grand total of six records were sent to insurers.
By contrast, the busiest day was March 31, which was supposed to be the end of open enrollment, when 202,626 of the so-called 834 reports were sent to insurers. The entire last week in March was busy.
About 86 percent of those who signed up for coverage on the federal exchange were eligible to receive government subsidies to help lower their monthly premiums. Those subsidies are being challenged by lawsuits in federal court contending they aren't allowed by the Affordable Care Act.
Two federal appeals courts came to conflicting decisions Tuesday on the permissibility of the subsidies (one said yes; the other no). They will remain in effect as the cases proceed in the courts, the Obama administration said.
The next time that the general public can sign up for coverage through the exchanges is from November 15 to February 15, 2015.
Click here to download the data released to ProPublica under the Freedom of Information Act.
ProPublica is an independent, nonprofit newsroom that produces investigative journalism in the public interest.Copyright 2014 ProPublica. To see more, visit http://www.propublica.org/.
Oh, I don't wanna share you with nothing else, I gotta have you to myself.iStockphoto
When you kiss your husband, does your dog try to get your attention? And does that mean that your dog feels jealous? Threatened? Or are we just imagining that?
Many if not all dog owners are sure that their pets have feelings. And we've known for a while that animals exhibit behaviors that look like jealousy, guilt and shame. But it's hard to find out what animals are really feeling. And researchers say that understanding that could give us valuable insights into human emotions, too.
A study published Wednesday in PLOS ONE has brought us a tiny bit closer to proving that dogs do get jealous. Psychologists from the University of California, San Diego adapted a test that has been used on human infants to see whether dogs exhibit jealous behavior.
They videotaped how 36 dogs reacted to their owners ignoring them and instead petting and talking sweetly to a plastic jack-o'-lantern or an animated, stuffed dog. When their owners were interacting with the stuffed animals, over three-quarters of the dogs pushed or touched their owners. The dogs also tried to get in between the stuffed animal and the owners, or growled at the plush pets.Shots - Health News How Dogs Read Our Moods: Emotion Detector Found In Fido's Brain
The dogs seemed less jealous of the jack-o'-lantern. But 40 percent acted aggressive when their owners started talking to the plastic pumpkins.
Psychologist Christine Harris, who led the study, says she's been studying jealousy for many years — but in humans. "The motivation that you have when you're jealous is to really break up the liaison between your loved one and your rival," she told Shots.
The fact that these dogs seemed like they were trying to draw their owners away from the stuffed animal indicates that they're feeling something very similar to human jealousy, Harris says.
"This is really a landmark study," says Marc Bekoff, an emeritus professor of evolutionary biology at the University of Colorado in Boulder, and author of Why Dogs Hump and Bees Get Depressed. "It opens the door to a lot more research on animal emotion."Shots - Health News Bacteria On Dog Lovers' Skin Reveal Their Affection
Bekoff, who wasn't involved in the research, says that he's definitely seen what looks like jealousy in his work with not only dogs but also coyotes and wolves. But this study is one of the first controlled experiments that tries to show it.
Of course, the study still doesn't prove that dogs feel jealousy. "The problem is that [the researchers] didn't look at how dogs would react just to those objects," says Laurie Santos, director of the Canine Cognition Center at Yale University.
It could be that the dogs were jealous of the stuffed animal, Santos says. Or it could be that the dogs really distrusted the stuffed animal and were acting out of fear.
But this study does build on previous research that shows dogs react negatively when they're treated unfairly, she tells Shots. "This is a very new science. We are just developing new tools to better understand animal emotions."
In humans, jealousy can be a very complex emotion, Santos says. It can bring up a host of other emotions like anger and rejection. And when humans feel jealous, we start suspecting and speculating, she says. "We think, 'If my husband is talking to another woman, maybe he's cheating.' "
If we find out that dogs feel the same way, she says, "either jealousy is less complicated because animals show it, or animals are more complicated than we thought."Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Intrauterine devices can be used immediately after a woman has given birth to prevent future pregnancies.iStockphoto
A woman is about to give birth. It will be her second child, and she's not looking to have a third anytime soon. She doesn't want to take birth control pills while she's breast-feeding. And condoms aren't as error-proof as she'd like.
Here's the catch: Her Medicaid plan won't pay for contraception if she tries to get it while she's still at the hospital.
New York has just joined five other states in making it easier for our fictional mom to have access to the kind of family planning options she was seeking without worrying about the price tag.
At first glance this is a technical issue about Medicaid reimbursements. But it is also about postpartum contraception and which women have access to it.
There are a number of reasons why states would want women who have just given birth to have access to birth control. For one, waiting longer before having another baby is healthier. Plus, studies have shown that paying for birth control is cheaper in the long run.
The "bottom line priority" is to remove barriers to contraception, says Deborah Kaplan, New York City's assistant health commissioner.
A relatively small group of people is directly affected by the policy change announced by New York state and city health officials on July 17. It relates only to women in the Medicaid fee-for-service program who have just given birth.Shots - Health News Hobby Lobby Ruling Cuts Into Contraceptive Mandate
With a fee-for-service plan, health care providers get money from Medicaid so that low-income people can get the care they need without the cost.
There are rules, of course, about what the plan will pay for. In most states, for example, Medicaid will not reimburse the doctor for delivering a baby and giving a woman an IUD in the same visit.
If the mom waits six weeks for a postpartum appointment, she can get an IUD and her doctor will get money from Medicaid.Shots - Health News Doctors Don't Know What Women Want To Know About Birth Control
But women are much less likely to get contraception at that point, says Kaplan.
So New York has changed its Medicaid reimbursement rules. Now, women with fee-for-service plans can get an IUD or implant immediately after giving birth.
IUDs and implants are not popular with women in the U.S., despite being among the most effective methods of birth control. Women's health advocates are trying to convince more women to consider them. With the Affordable Care Act, new insurance plans should fully cover these methods, though there are exceptions.Shots - Health News It's Time To Rediscover The IUD, Women's Health Advocates Say
An IUD is a T-shaped piece of plastic that is put inside the uterus by a health care provider. One type of IUD releases hormones to prevent fertilization and another uses copper to fight off sperm. The kind with hormones can stay put for 3 to 5 years; the one with copper lasts for about 10.
The hormonal implant is a flexible rod about the size of a match that goes just under the skin in the upper arm (yes, you have to go to the doctor's office for this one, too). It also uses hormones to prevent pregnancy. It works for three years.
No daily reminders or regular pharmacy trips needed with these methods. If a woman decides she wants to have a baby, she can have a doctor take out the IUD or the implant at any time.
With hormonal birth control such as the pill, there are risks to consider — particularly for women who plan to breast-feed. But the hormone found in the IUD and the implant, progestin, is regarded as safe for women who are breast-feeding.
New York is not trying to imply that IUDs and implants are the best choice for everyone, Kaplan told Shots. But the state is trying to make a point.
"We want women to have the options," she says, "and then [work] with their provider to make the best decision with all the information available."
Kaplan says New York officials are hoping that this small policy decision will persuade other states and insurance providers to look at their coverage, too.Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Fun hikes offer health benefits for kids of every shape and size.Annette Birkenfeld/annedde/iStockphoto
Kids can be cruel, especially about weight. So you might think overweight or obese children know all too well that they're heavy — thanks to playground politics. But that's not necessarily so, according to government data covering about 6,100 kids and teens ages 8-15.
About 30 percent "misperceived" their weight status (underweight, normal weight, overweight or obese), according to a report from the Centers for Disease Control and Prevention's National Center for Health Statistics. (The CDC bases those categories on body mass index, adjusted for gender and age.)
Among children and teens who were actually designated by the CDC as overweight — or between the 85th and 95th percentiles on the CDC's growth chart — 76 percent thought they were "about right"; about 23 percent said they were overweight. Among obese kids and teens (those in the 95th percentile and higher on the chart), roughly 42 percent thought they were OK weightwise, while 57 percent thought they were in the "overweight" category. Boys, younger kids and children from poorer families were more likely to misperceive their status.
So is it a bad thing if a kid doesn't know he's overweight? The report notes that research has linked knowing your weight status to trying to change behaviors.
"Children who don't have a correct perception of their weight don't take steps to lose weight," such as increasing physical activity or changing eating habits, Neda Sarafrazi, a nutritional epidemiologist with NCHS and an author of the report, tells Shots.
Other studies have suggested that parents are in the dark about their kids, too, with about half underestimating their obese or overweight child's weight. Sarafrazi says it's key for parents to know the truth.Shots - Health News A Dire Sign Of The Obesity Epidemic: Teen Diabetes Soaring, Study Finds
But kids and teens already worry a lot about their weight, as an NPR parenting panel discussed recently.
Marlene Schwartz, a psychologist and director of the Rudd Center for Food Policy & Obesity at Yale University, tells Shots that while she's a big proponent of keeping tabs on kids' BMIs in the aggregate, she's not sure it's helpful to label kids as overweight. More helpful, she says, is giving kids feedback about their physical fitness and what they eat — noting ways to improve.
And if children are obese, or are having weight-related medical problems, Schwartz says, it's better to encourage them to get healthier by cutting out snacking in front of the television or cutting out sugary drinks than to tell them they need to lose 20 pounds to be considered "just right."Deceptive Cadence In 2014, The Classical World Still Can't Stop Fat-Shaming Women
"Shame is a terrible motivator," she says.Living Large: Obesity In America For Teens, Weight Loss Sculpts New Lives
The disconnect occurred mostly — but not exclusively — among kids who were heavier than average. Of the children who were normal weight, most knew it, while less than 4 percent thought they were overweight and less than 9 percent thought they were too thin. About 49 percent of underweight kids thought they were about right; the rest knew they were too thin.Copyright 2014 NPR. To see more, visit http://www.npr.org/.
fromKQEDListen to the Story 4 min 39 sec
Members of the California Nurses Association say they rallied in Sacramento in May to raise public awareness of their concerns about patient care in California hospitals.April Dembosky/KQED
Going to a union meeting of nurses is a little bit like going to an evangelical church service.
"We all have to stand up, and it's a struggle," says Veronica Cambra, a nurse reporting a grievance at Kaiser Hospital in Fremont, Calif., as though she's giving testimony. "And we will overcome this, OK?"
The rest of the nurses respond with the passion of a devout congregation, humming "Mmm hmmm," and "That's right," through the series of speeches.
But this is no church service. The California Nurses Association is rousing its troops for battle. The powerful union will begin bargaining Thursday with Kaiser Permanente on a new four-year contract for nurses at its northern California hospitals. Kaiser operates the largest hospital system in the state — largest by number of hospitals and by number of hospital beds — and is the eighth largest health system in the country.Shots - Health News Health Safety Experts Call For Public Reporting Of Medical Harms
The union is anticipating that Kaiser will propose cuts at the negotiation, and leaders want to make sure nurses are ready to fight back — and, if necessary, go on strike.Shots - Health News Medicare Trying Bundled Payments To Save Money, Improve Care
Four years ago, nurses ratified the first contract proposal Kaiser offered without objection. Both sides had reason to keep tensions to a minimum, according to Joanne Spetz, an economics professor at the University of California, San Francisco School of Nursing.
Last time the nursing shortage was still a recent memory, she says, and Kaiser wanted to hold on to its experienced nurses. It was also the end of a recession, and nurses didn't want to appear greedy.
But a lot has changed in the past four years. The economy in northern California has improved. And the Affordable Care Act has fundamentally changed hospital economics. For starters, Spetz says, the health law is generating a lot of new customers for Kaiser.
And if there is growth, Spetz says, the nursing group is following a union's classic role, "which is to say, 'Well, if there's going to be increased net revenue, we should get a cut of that.' "
But the union isn't talking money yet. The leaders are framing all their demands around patient care. Nurse practitioner Rachel Phillips says she is under unrelenting pressure at work to see more patients in less time.
"When I first started at Kaiser, I wasn't rushed with my patients," Phillips says. "I could have 30 minutes with a new patient. That time has been whittled away. We're currently asked to see patients every 15 minutes, regardless of the complexity of their medical issues."Shots - Health News Heart Of The Matter: Treating The Disease Instead Of The Person
Nurses at Kaiser's intensive care units and emergency rooms say the hospital system has been skimping on care, discharging patients who should be admitted, or closing pediatric or cardiology units.
Kaiser says a lot of the union's claims are misleading or untrue.Shots - Health News Patients With Low-Cost Insurance Struggle To Find Specialists
Barbara Crawford, Kaiser's vice president for quality, says the overall demand for hospital care is going down.
"We actually need [fewer] nurses in the hospital," she says. Improvements in technology and reductions in hospital infections mean there are fewer patients staying in the hospital — 250 fewer now per day, on average, compared with a few years ago. She gives an example from earlier this year when her husband had foot surgery.
"He was in and out the same day, and he did not have general anesthetic — he didn't need general anesthetic — and he did beautifully," Crawford says. "I would say, four years ago, he probably would have been in the hospital four or five days."
The Affordable Care Act also puts pressure on hospitals to cut costs, she says. Medicare reimbursements are going down, which cuts into hospital revenues. And health reform has made the insurance market a lot more competitive, so Kaiser has to keep prices low.
"As consumers have opted to join us," Crawford says, "our expectation and promise to them is that we keep their costs down."
But the nurses have power in numbers, says Spetz. The California Nurses Association founded a national arm — National Nurses United — that has been gaining members across the country, most recently in right-to-work states like Florida and Texas. Spetz says this local fight likely has national aspirations.Shots - Health News Labor Strife Can Pay Off Big For Some Nurses
"Given that Kaiser exists in multiple states, there may be a broader strategy of trying to demonstrate their strength, demonstrate their willingness to fight, demonstrate their political power on a national stage," Spetz says, "which could be beneficial in trying to get representation in other Kaiser regions, as well as other states."
She says if California nurses win on wages, benefits and patient care, they'll inspire nurses in their national network to push for similar fights in their own states.
This story is part of a reporting partnership with NPR, KQED and Kaiser Health News. Kaiser Health News is not affiliated with the company Kaiser Permanente.Copyright 2014 KQED Public Media. To see more, visit http://www.kqed.org.
Walt Whitman High School's Caroline Schweitzer runs through a host of Severna Park High School defenders during a semifinal game in Maryland's Class 4A/3A lacrosse tournament in May.Toni L. Sandys/The Washington Post/Getty Images
Sometimes called the fastest game on two feet, lacrosse is also one of the fastest-growing sports in the U.S.
Between 2008 and 2012, kids' participation in lacrosse climbed 158 percent to a little more than three-quarters of a million, according to a survey conducted by the Sports & Fitness Industry Association/Physical Activity Council. At the same time participation in baseball, basketball, football and soccer has either stagnated or declined.
Kids who play lacrosse will tell you there's lots of action. Now, there's an analysis of injuries sustained by high school lacrosse players that quantifies the risks. Researchers analyzed a database of reports compiled by athletic trainers at high schools across the country.
Overall, there are about 2 injuries for every 1,000 exposures to the game, according to researchers from the Colorado School of Public Health and the Center for Injury Research and Policy at Nationwide Children's Hospital in Columbus, Ohio. An exposure was defined as one athlete taking part in a school-sanctioned game or practice.
The most common injuries were strains and sprains, accounting for about 38 percent of those recorded. Concussions were second, at about 22 percent of injuries. Injuries were three times more likely to occur in games than practice. Boys were 1.5 times more likely to be injured than girls.
Boys, in particular, were more likely to sustain concussions than girls — 0.5 concussions per 1,000 exposures for boys compared with 0.35 per 1,000 for girls. The rate of concussions for boys in games was seven times their rate in practice.
How the male and female athletes sustained concussions also differed. "Among boys nearly 75 percent of concussions were the direct result of contact with another player," said Dawn Comstock, associate professor of epidemiology at the Colorado School of Public Health and senior author of the paper. "In girls, over 60 percent of the concussions occurred when they were struck by the ball or stick."
In boys lacrosse, full-body contact is allowed and helmets are mandatory. In girls lacrosse, full-body contract is forbidden and helmets aren't typically worn. There's been talk about making helmets part of the girls' game. "The data does seem to support the call to put helmets on girl lacrosse players," Comstock said.
Boys lacrosse has injury rates very similar to football and hockey, Comstock said, while injuries in girls lacrosse are in line with those for soccer, basketball and field hockey.
The results were published online Tuesday by the American Journal of Sports Medicine.
While there are risks from playing lacrosse, there are also benefits. "We don't want any parent who hears about this study to be afraid to allow their child to begin playing lacrosse or to continue playing lacrosse," Comstock said. The side effects of an inactive lifestyle are more of a concern, she said, than the very small risk that any young athlete will sustain a serious injury playing lacrosse.
In late 2013, NPR and Truven Health Analytics surveyed Americans about the risk of sport-related concussions for kids, though we didn't ask about lacrosse. Almost all respondents were fine with idea of kids playing basketball or soccer. Three-quarters were OK with football and about two-thirds approved of hockey.
"Parents are very, very interested in their kids being active in sports," Gerald Gioia, a neuropsychologist at Children's National Health System in Washington, D.C., told Shots in February. "We have to make sure that all sports that kids are involved in are understood in terms of the risks — that we are educating and preparing the coaches and the parents and the kids around those risks."Copyright 2014 NPR. To see more, visit http://www.npr.org/.