NPR Blogs

No Shame, No Euphemism: Suicide Isn't A Natural Cause Of Death

NPR Health Blog - Sat, 08/01/2015 - 7:03am
Keith Negley for NPR

Beware the mention of natural causes, as in my mother's obituary:

"Norita Wyse Berman, a writer, stockbroker and artist ... died at home Friday of natural causes. She was 60."

Sixty-year-olds don't die of natural causes anymore. The truth was too hard to admit.

Fifteen years on, I'm ashamed of my family's shame. Those attending her funeral and paying shiva calls knew the truth anyway. People talk.

One of the many ironies of dying young is that my mother was a true believer in modern medicine. She had a cabinet full of elixirs and potions for which she paid top dollar. For most of her life she never paid retail for anything, so the medicine cabinet was testament to her insecurity about fleeting beauty and a quest for longevity. Others around her might succumb to aging, but my mom had confidence that her vitamins and nutraceuticals could hold back Father Time.

Her anxieties predated the Internet and the rise of Dr. Oz. I know she'd have become a big fan of the telegenic surgeon, and would have asked why I couldn't have a practice more like his. After all, she told me more than once, "Making money is not a sin."

She divorced my father when I was 12. She wanted a career, which was an idea my father did not support. Eventually she became a stockbroker, and in spite of limited financial acumen, she became very successful. She had natural sales ability and made brilliant use of her greatest talent — networking. The fact that the 1980s and '90s witnessed two of the greatest bull markets in Wall Street history certainly helped.

The Schumann family in 1972, including the author, age 3 1/2, center.

Courtesy of John Henning Schumann

My mother remarried soon after my parents' divorce. But 15 years into her career, my stepfather convinced her to retire because of his own declining health.

They moved to Florida, accelerating their senescence by living in a gated golf community. Finances were no issue, but my mother's mental state soon started to unravel.

My mother hated golf. She tried other pursuits like painting and travel. But retirement simply wasn't for her. My sense was she'd lost her self-worth when she no longer felt like a stock market titan.

One day my stepfather called to let me know that he found my mother lying on the floor of the garage with the car running. It was time to get help.

Thus began my family's odyssey in the mental health care system.

Over the next five years, my mother would bounce between despondent lows and powerful highs. Diagnoses abounded, depending on where in the cycle she was. One doctor labeled her bipolar, another "majorly depressed with psychotic features."

Medicines were started, adjusted and then new ones were added. Her doctors tried mightily to find the right cocktail of drugs so she could stay in balance.

Eventually most of her improvement came from lithium. But she hated taking it because it made her urinate frequently and because she saw it as a relic. If she had to be on medication, why couldn't it be one of these newer-fangled drugs with a more impressive name and less stigma?

My mom was the type of patient who thinks there's a pill for every ailment. Antibiotics for colds. Weight-loss pills. Sleep aids. The silver-bullet theory of medicine. She even underwent shock therapy as a potential quick fix. But because her psych meds earned her the label "crazy," she sought any opportunity to shed them.

Twice this behavior led her to other suicide attempts. Her doctors called them gestures. We wanted to believe that she didn't have real intent.

My mother's behavior taught me the first practical thing I learned in medical school: Don't stop taking medication for a chronic condition without first telling someone. Like hospitalized patients that "cheek" their pills, my Mom lied to her doctors about taking her medications because she didn't want to be nagged and didn't want to be dependent on them.

But without her pills her mental health was far too fragile.

We were stuck in twin binds. My mother loved medicines and their potential for miracles, but she always sought to ditch them the moment she felt better.

As my mother's mental health struggles surfaced, I was on my way to becoming a doctor. But I was powerless to help someone closest to me.

It's not that my mother didn't believe in my healing powers. On my very first day of med school I called home to debrief. "I have a rash I need you to take a look at," she interjected.

Did she really think after Day 1 I knew anything about doctoring?

Looking back, I can now see that my mom was giving me my earliest lesson in the culture of expectations. There's a reason medical ethicists warn against treating family and friends. Corners get cut. Judgment becomes impaired. Honesty becomes scarce.

Throughout her illness I believed that I was there for my mother. In our talks I was able to cut through the bull she fed everyone else. My intention was to let her know that my newly acquired medical knowledge would always be available to her. I wanted her to trust me.

But the more I pressed, the farther she receded. She put up a brave front, so convincing that she bluffed her way past my fledgling diagnostic skills. In her last rise out of the depths, we all hoped against reality that she was on the road to a permanent recovery.

Then she hung herself on the day after Thanksgiving.

It's painful to admit even now. But I no longer feel shame. Sadness, yes. Even anger still, though that ebbs.

I also harbor the hope that others can learn from her illness and death. If suicide remains in the shadows of stigma and superstition, it will always plague us.

Suicide, after all, is not a natural cause of death.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as interim president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa's Medical Matters. He's on Twitter: @GlassHospital

Copyright 2015 KWGS-FM. To see more, visit http://www.kwgs.org.
Categories: NPR Blogs

Toxic Lead Contaminates Some Traditional Ayurvedic Medicines

NPR Health Blog - Fri, 07/31/2015 - 12:49pm

Nisha Saini has been practicing an Indian traditional health form called Ayurveda for more than 16 years. She runs a small alternative health center in Manhattan called New York Ayurveda, where customers can get massages and dietary advice. Over the counter, Saini sells an extensive array of traditional remedies concocted from herbs and spices. But there's one kind of Ayurvedic medicine she doesn't sell.

"[They're] mostly made from metal ashes. Those are called rasa products," Saini says. These medicines, also known as bhasmas, come out of an Ayurvedic tradition practiced for thousands of years in India where highly toxic heavy metals like lead, arsenic, mercury and cadmium mix with herbs or spices. Saini says she won't sell them because her American customers have questioned the safety of those concoctions.

They aren't alone in their concerns. The New York health department issued an alert last week warning New Yorkers to stay away from some 20 Ayurvedic compounds after lab testing revealed dangerous levels of heavy metals there. Lead and mercury damage the nervous system and can cause permanent brain damage and death. Arsenic can cause cancer and death in high doses.

Sometimes those warnings come too late. In 2010, a retired lawyer in Iowa brought bhasma medicines home from India. Six weeks after he began taking the medicine, he started struggling to remember simple things. Over the next eight months, he lost almost 40 pounds. He became weak, tired, anemic and depressed.

"It was only several months later that his wife alerted his providers that he was taking Ayurvedic medication, and that there was a possibility lead was being ingested," says Dr. Laura Breeher, an occupational medicine physician at the Mayo Clinic in Rochester, Minn., who was part of the team that treated the man in 2011. When physicians tested his blood lead levels, the results were nine times over the threshold considered acceptable for adults.

That medicine turned out to have hundreds of thousands of times the Food and Drug Administration's recommended limit for lead and arsenic in candy or water. Concerned that others were using the same or similar medicines, his doctors and the local health department reached out to Ayurvedic practitioners and centers in Iowa asking people to get themselves and their medications tested for heavy metals.

"The concentrations varied. The medication with the highest concentration of lead had 43,200 parts per million. The FDA has a recommended maximum level of 0.1 parts per million for candy," Breeher says.

In a paper published online last month in the International Journal of Occupational and Environmental Health, Breeher and her team report that 40 percent of the 115 people tested who were using Ayurveda had lead poisoning.

This is the largest recorded cluster of lead poisoning from Ayurveda in the United States to date, but health providers and researchers have been struggling with heavy metals poisoning from alternative medicinal or herbal supplements for at least a decade.

From 2000 to 2003, the Centers for Disease Control and Prevention reported cases of extreme lead poisoning in New Hampshire, California, Massachusetts, Texas and New York. In 2004 and 2008, researchers found about 20 percent of Ayurvedic products sold in the Boston area and on the Internet had dangerous levels of lead, mercury or arsenic. A group of pregnant women got severe lead poisoning from taking Ayurvedic medicines in 2011 and 2012 in New York City, and two small children there got lead poisoning in 2012.

Shots - Health News Lead Poisoning Cases Offer New Reminder About Hazards Of Ancient Remedies

For some products, heavy metals might have leached into purely herbal formulas from the environment where the plants were grown or the manufacturing equipment used to make the medicine. But concoctions with extreme concentrations most likely had metals intentionally added as part of practice called rasa shastra. Ayurvedic practitioners say that heavy metals can increase the potency of an Ayurvedic mixture. "If they're used properly and in the right ratio, they're very effective properties," says Saini of New York Ayurveda.

That's a hazardous view, says Dr. Robert Saper, director of integrative medicine at Boston University School of Medicine, who led both 2004 and 2008 studies on safety of Ayurvedic medicines.

"There's such a wealth of evidence in the West that these metals have a variety of toxic effects," Saper says. "Until they can prove beyond a shadow of doubt the lack of toxicity, these metal bhasma compounds that contain lead, mercury or arsenic should be immediately stopped."

But Ayurvedic advocates say they have the evidence. One argument is that if these medicines were truly so damaging, then why haven't people in India gotten ill from taking them? "People have done it for thousands of years, and people have benefited from them," Saini says. "In India, [bhasma] will go in hundreds of thousands of people. But I've heard no such problem."

These bhasmas are put through a complicated process sometimes involving goat's urine or other acidic liquids that are said to detoxify heavy metals. In an email, Ayurveda scientist Kalpana Joshi at the University of Pune in India says Western scientists might have a lack of understanding about this process. "I do understand the skepticism of Western doctors. I believe adverse effects [experienced by patients] are due to not following right Ayurvedic methods and faulty shortcuts for large scale productions," she writes.

In recent years, scientists like Joshi have been trying to use Western scientific method approaches to validate Ayurvedic claims. "Rasa sindur is a mercury preparation, and papers have proved it to be safe, nontoxic and improving life-span in fly models," Joshi writes.

But Saper and his colleague Dr. Thuppil Venkatesh, a professor emeritus at St. John's Medical College in Bangalore, say those studies are flawed and these preparations do not convert heavy metals into new, nontoxic compounds.

"They don't understand, and they continue to use toxic heavy metals in some of these preparations," says Venkatesh. In his own practice, he says he sees people suffering from heavy metal toxicity because of Ayurvedic bhasma medicines almost every day. "Children have died. People have lost their lives," he says. Others have suffered permanent brain damage. "It must be stopped."

So far, stabs at effective policies in India and the United States to stop the production or distribution of contaminated Ayurvedics have fallen flat, according to Nancy Clark, the assistant commissioner for the New York Bureau of Environmental Hazards and Health.

For years, health departments like hers have routinely issued cease-and-desist orders to shops from selling specific Ayurvedic or other traditional remedies, but only once a laboratory test confirms the product is dangerous. "And believe me, we also notify the Indian government," Clark says. "There are attempts on the Indian side to regulate products. Obviously, it's not working."

The FDA has an embargo against certain Ayurvedic companies and specific products. "But they're not regulated," Clark says. "In this country Ayurvedics are considered supplements. There aren't any federal requirements for effectiveness or safety." And that doesn't stop people from carrying the preparations home from India in suitcases.

Large U.S.-based retailers of Ayurvedic remedies like the Chopra Center generally will not sell supplements containing bhasmas. Chopra Center representative Felicia Rangel writes in an email that all their products are "triple tested for common metal contaminants" to meet California recommendations.

But Clark says bhasmas can still be found in small stores where people personally imported or formulated them. Still other Ayurvedic medicines containing high amounts of heavy metals could simply be going unnoticed by customs and health departments.

It's difficult to say how many people in the world use Ayurveda. On the Indian subcontinent, estimates range from 10 percent to 80 percent of the population, and there are large global communities centered on the discipline. Saper fears a large percentage of those people are at risk for heavy metals toxicity, but he doesn't want people to cease the practice altogether.

There's much more to Ayurveda than bhasmas of metals and ashes, Saini says; it's a whole system of medicine. She says it's better thought of as a lifestyle that combines yoga, exercise, sleep routines, purely herbal supplements and nutrition.

"Every Indian kitchen is like an Ayurvedic pharmacy. We have pepper, ginger, turmeric," says Venkatesh. "It's a great medicine, but one has to be very cautious."

Saper says that approach focusing on exercise and good diet could be very beneficial, but the use of heavy metals in medicine is injuring people. "If this problem is not addressed, it really destroys the reputation of the system as a whole, and that's unfortunate."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

More Previously Uninsured Californians Got Coverage Under Obamacare

NPR Health Blog - Fri, 07/31/2015 - 9:56am

Enrollment counselor Vue Yang (left) reviews health insurance options for Laura San Nicolas (center), accompanied by her daughter, Geena, 17, at Sacramento Covered in Sacramento, Calif., in February.

Rich Pedroncelli/AP

Just over two-thirds of Californians who did not have health insurance before the Affordable Care Act went into full effect in 2014 are now covered, according to a survey from the Kaiser Family Foundation.

The newly insured are much less likely to say that paying for health care is a problem, compared to when they were uninsured.

"This is really great news for California," said Sarah de Guia, executive director of the California Pan-Ethnic Health Network, an advocacy group. She spoke of people being lifted from the fear of paying for care. "There's this sense of relief, that they're not one accident or incident away from bankruptcy. ... They can keep their costs contained."

The rate of newly insured — 68 percent — is an increase over the first Obamacare open enrollment last year. Then, 58 percent of the previously uninsured had gained covered.

At the same time, nearly a third of those surveyed this year — 32 percent — are still uninsured. Many of them fall into two categories. One group, about four in 10, are undocumented immigrants and ineligible for coverage.

"Another chunk of those people who are remaining uninsured have been uninsured for a long period of time and therefore may be harder to reach, a harder group to bring into the fold," said Bianca DiJulio, associate director with the foundation's Public Opinion and Survey Research Program.

The largest share of the newly insured — 34 percent — are covered in the Medi-Cal, the state's version of Medicaid. Fourteen percent say they are insured through their employer and 12 percent purchased insurance through Covered California, the marketplace established under the ACA.

Shots - Health News Meet The California Family That Has Made Health Policy Its Business

The newly insured largely say their health care needs are being met with 86 percent saying their needs are being "very well" or "somewhat" well met, up from 51 percent in 2013.

Before the health law, nearly 6 million adults in Californians were uninsured, the most of any state, and Latinos made up more than half of them. While initial campaigns to reach Latinos were widely criticized, newer efforts seem to be more successful. The survey found that whites and Latinos signed up in nearly equal proportions, 79 percent for whites and 74 percent for Latinos (after excluding those Latinos who would be ineligible for ACA benefits due to their immigration status).

Yet last year's survey of the previously uninsured after the first open enrollment concluded showed that whites and Latinos signed up at the same rate, 61 percent.

Advocate de Guia said the small gap found this year — five percentage points — was worrisome, because grants to community groups to help people sign up have declined by millions of dollars. "Enrollment dollars are going down or being cut," she said. "We don't want to see that gap widen over time."

Gerald Kominski, director of the UCLA Center for Health Policy Research said the survey findings were "obviously very good news," but cautioned that the findings have a limitation. The group of people that is being followed all had previously lacked insurance.

"There's another cohort of Californians who are not in this survey — people who had insurance and lost it," he said in an interview. "Some portion of those individuals remain uninsured."

Overall, those saying it's hard to afford health care dropped from 86 percent in 2013 to 49 percent today.

In the survey, 85 percent of the uninsured say paying for health care is their top financial concern — ahead of paying their mortgage or rent. Of those who have gained coverage, paying for health care now ranks fourth among financial concerns — behind rent/mortgage, utilities and even gasoline.

"It's below the price of gas," said UCLA's Kominski. "I found that truly remarkable ... the fact that health care for people newly insured (is) no longer a primary concern, I think is significant."

While 76 percent of the newly insured say their experience with their plan has been positive, some are reporting issues in accessing care, including 28 percent who say they had to wait longer than they thought they should have to for an appointment or finding that a doctor said they would not accept their insurance (17 percent of Medi-Cal recipients; 23 percent of people with a Covered California plan).

This survey is the third in a series of people who were uninsured in 2013, before the Affordable Care Act went into full effect. From February 18 to May 13, 2015, 1,105 adults who had participated in the first survey were contacted. The margin of sampling error is plus or minus 4 percentage points for results based on the full sample, 5 percentage points for recently insured Californians, and 8 percentage points for those Californians who remain uninsured.

This story was produced by State of Health, KQED's health blog.

Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.
Categories: NPR Blogs

Low-Income Teens Have Best Shot At Getting HPV Vaccine

NPR Health Blog - Thu, 07/30/2015 - 5:16pm

A teenage girl gets a shot of HPV vaccine, which protects against a virus that causes cervical cancer.

Sharon Gekoski-Kimmel/MCT/Landov

When it comes to getting the HPV vaccine to protect against cervical cancer, teens below the poverty line are doing better than the rest.

Among teenage girls ages 13 to 17 whose total family income was less than the federal poverty level for their family size, 67.2 percent have received the first dose of the human papillomavirus vaccine, compared to 57.7 percent for those at or above the poverty line. For teen boys, it's 51.6 percent compared to 39.5 percent.

That's data released Thursday by the Centers for Disease Control and Prevention's 2014 National Immunization Survey for teens.

There are multiple factors behind this trend, according to Dr. Anne Schuchat, director of CDC's National Center for Immunization and Respiratory Diseases.

Differences in provider behavior might be one reason. Clinicians might not want to miss out on the opportunity to give poor children the vaccines that they need since they may not know when they'll next see the family.

There's also the issue of cost. The federally funded Vaccines for Children program covers vaccines for uninsured or low-income teens, which means clinicians don't need to worry about billing and reimbursement at the moment of care.

Morbidity and Mortality Weekly Report, July 31, 2015/CDC

But the fact that teens from lower-income families are doing better does not mean that we as a country are doing a good job.

Nationwide, four out of 10 adolescent girls and six out of 10 adolescent boys still have not started the three-dose HPV vaccine series recommended by the CDC for all kids who are 11 or 12 years old.

The contrast is stark when you compare HPV vaccination rates with the two other recommended vaccines for teens. The rate is near 80 percent for meningococcal conjugate vaccine and well over 80 percent for the Tdap vaccine for whooping cough, the new numbers show.

Vaccination isn't an easy sell for teens, as Shots previously reported, even when the most common vaccine protects against nine strains of human papillomavirus that account for 90 percent of cervical cancer in the U.S. Parents worrying that the vaccine promotes riskier sexual behavior in teens — it doesn't — might be one reason for the lack of coverage.

There is still good news. The total number of teens getting HPV vaccinations increased slightly for the second year in a row. The number rose from 56.7 percent to 60 percent for girls, and 33.6 percent to 41.7 percent for boys.

"This is a patchwork progress," Schuchat said at a media briefing on Thursday. "There's quite a range in HPV vaccination coverage around the country."

Shots - Health News Early Push To Require The HPV Vaccine May Have Backfired

Indeed, there's a 37.7 percent difference between the state with the highest rate of girls getting a first dose of HPV vaccine and the state with the lowest rate. That would be Rhode Island and Kansas, with 76 percent and 38.3 percent respectively.

Four states (Illinois, Montana, North Carolina and Utah) and two areas (Chicago and the District of Columbia) averaged an increase of roughly 20 percent, with Washington, D.C., jumping from 55.6 percent in 2013 to 75.2 percent in 2014. The big changes are due to a combination of strategies in spreading awareness to the public, clinicians and families, Schuchat said.

Teenagers were better at getting shots overall, with 87.6 percent getting at least one Tdap shot, which protects against whooping cough, compared to 84.7 percent in 2013. The rate for meningococcal vaccine rose from 76.6 percent to 79.3 percent.

"[The data] show that it is possible to make real progress in different areas," says Schuchat. "It is possible to do much better."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Meet The California Family That Has Made Health Policy Its Business

NPR Health Blog - Thu, 07/30/2015 - 3:37pm
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Peter Lee, executive director of Covered California, (left) poses with his uncle, Philip Lee, and father Peter Lee (seated) at the younger Peter Lee's home in Pasadena, Calif., in 2013.

Gina Ferazzi/LA Times via Getty Images Shots - Health News Mix Of Young And Old Signing Up For Health Care In California Shots - Health News Happy 50th Birthday, Medicare. Your Patients Are Getting Healthier

If there's such a thing as the first family of health care, the Lees may be it.

Five decades ago, two brothers helped start Medicare. Their father inspired them and they, in turn, have inspired the next generation.

To mark the anniversary of President Lyndon Johnson signing Medicare into law on July 30, 1965, three Lees sat down to reflect on the U.S. health care system.

It can be hard now to imagine a time when Medicare met serious opposition. But 92-year-old Dr. Peter Lee, a founder of the family medicine department at the University of Southern California, remembers that time well.

"I was one of the people who was supporting the idea," he says. "And in response to that some people from the USC alumni association wanted me fired because they thought that was socialized medicine."

The Los Angeles County Medical Association, too, called for Lee's ouster. While Lee didn't get fired, he did get called a lot of names. The same thing happened to his now 91-year-old brother, Dr. Phillip Lee, who helped implement Medicare in the Johnson administration.

"They called me a socialist more often than a communist, but occasionally they referred to me as a communist," he recalls.

Among those who did that, he says, was former President Ronald Reagan, who lent his voice to an ad by one of Medicare's biggest opponents, the American Medical Association.

"One of the traditional methods of imposing state-ism or socialism on a people has been by way of medicine," Reagan says in the ad.

The AMA opposed Medicare out of fear the government would become too deeply involved in the practice of medicine. But that didn't sway the Lee brothers. Their work as ardent foot soldiers for Medicare, was borne in part from family legacy of health policy started by their father, Dr. Russell Lee, says his grandson Peter Lee.

"One of the things my grandfather did was he was involved in the Truman Commission, which in the 40s was one of the early reports generated to say we need national health care," says the younger Peter Lee.

He went into the family business when he became a health policy expert. And he now runs Covered California, overseeing the largest expansion of insurance coverage in California since Medicare. His father, the elder Peter Lee, says the passage of Medicare changed the game. Before the law, the medical center where he worked was overflowing with elderly patients who had been discharged but needed some interim care before going home.

The Lees (from left): Hewey, Dick, Russell, Peter and Phil. All the Lee children, including a sister not shown, became doctors.

Courtesy of the Lee family

"So we always had patients in the hall," he says. "Then Medicare was passed and then the halls were all empty."

His son, Peter, explains, "They were empty because seniors all of a sudden had someone that would pay for long-term care that wasn't there before. And it was a dramatic overnight change that affected millions of Americans."

That's because Medicare paid for, transitional nursing home care and other treatments for those 65 and older, no matter their income. Today Medicare provides health care for nearly every American 65 and older.

And the law prompted something else: the desegregation of hospitals. Among those at the front line of that battle, the elder Peter Lee's brother, Philip.

"Desegregation was critical," says Philip Lee. "You couldn't have a segregated medical care system."

Philip Lee was sent to the South to make sure hospitals didn't discriminate. He says it took the threatened loss of federal Medicare dollars to overcome resistance by many hospitals that ultimately integrated. And integration meant everyone and everything — from patients and staff all the way to the blood supply.

"And we made a lot of progress, even if it wasn't perfect," he says.

Today, both of the elder Lees say the biggest issues facing the nation's health care system is making sure everyone gets medical care.

It's a job that the younger Peter Lee says he's taken on with inspiration from his family legacy and support from his father and uncle. And, he says, they set a high bar.

"It take persistence. It takes hard work. But change happens," he says.

This story is part of a reporting partnership with NPR, KPCC and Kaiser Health News.

Copyright 2015 Southern California Public Radio. To see more, visit http://www.kpcc.org/.
Categories: NPR Blogs

A Path From 'Blackout' Drunkenness To Sobriety And Self-Acceptance

NPR Health Blog - Thu, 07/30/2015 - 3:24pm
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Before Sarah Hepola got sober five years ago, she considered alcohol to be "the fuel of all adventure." These adventures included taking off her clothes in public, pouring beer on people's heads and waking up in strangers' beds. Frequently, Hepola didn't remember these incidents afterward because she had been in an alcohol-induced blackout.

Sarah Hepola is the personal essays editor at Salon.com.

Zan Keith

"A blackout is very different from passing out," Hepola tells Fresh Air's Terry Gross. "You're still walking and talking and interacting with people, but the recorder in your brain isn't going."

Hepola once performed in front of 300 people while in a blackout state. "I don't think they knew that I was in a blackout, and I didn't know I was in a blackout, but later I had no memory of that event," she says.

In her memoir Blackout: Remembering the Things I Drank to Forget, Hepola, who is now an editor at Salon.com, wrestles with her reasons for drinking and examines how alcohol fit in with — and distorted — her idea of being an empowered woman.

Interview Highlights

On what she was later told about her behavior during her blackouts

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One of the things that I was told [was] I would always take off my clothes. And that was really surprising to me. Even though, if you were raised in a Girls Gone Wild era, maybe that's not so strange; but see, that wasn't me. I was always so self-conscious, and I didn't want people to see me. And so the idea that I would get so drunk that I would take off my clothes — often my pants for some reason — it was really surprising to me. ... It was almost like maybe this uninhibited part of me felt true freedom. .... So it was, "Yeah!" It was just like, "Look, me!" Because maybe that's maybe what my true self wanted — to be seen — but I was so loaded down by my fear of rejection, my fear of judgment.

The other thing that I would do — I would be aggressive. I would pour beer on people's heads, which was funny for a little while. I sometimes would say things that were kind of nasty and mean to friends of mine that I really liked. And again, I don't know exactly what that was about. You know, you have that whole idea of "in vino veritas," that idea that when you drink, the truth comes out. Well, that may be true for maybe the first three drinks, but after 11 or 15, I'm not sure that's truth anymore. I think they felt like a version of a truth.

On how her drinking life changed as her friends got married and had kids

When you drink a lot like I did, you surround yourself by other heavy drinkers — and what becomes normal is what's around you. As long as everybody's drinking as much as you do, you don't necessarily have to look at your behavior. But then, as people got older, the behaviors changed. It was getting lonelier on the party bus. There weren't as many people around me. But one thing happened in the last 10 to 15 [or] 20 years ... is that a lot of my married friends, and even friends who had kids, it became very important for them to still be cool and to still prove that they could hang. So sometimes even my mother-friends would still go out and get drunk with me, because it was like they wanted to show me that they hadn't lost it; they weren't just homebodies who sat around watching Netflix. That they could still go out and party.

There are times in life when you realize that maybe your dream wasn't the right dream for you.

You know, one of the things that happened to me is that I started to get the message from some of my friends, in various ways, that what I was doing wasn't necessarily cool anymore, and that it wasn't funny. And for them it wasn't like they were mean about it. It wasn't like they were saying, "Well, you're not cool anymore." It was more like my friends were really worried about me. And I was somebody who prided herself on being very independent. I mean, here I am this single woman — all of you guys got married, but I'm still out here in the big city alone. I'm an independent woman and all my friends are starting to give me this message that I'm not OK, and that I'm not necessarily taking such good care of myself. That really hurt. It really wounded my pride.

On how sex changed after she got sober

When I stopped drinking I actually thought I was never going to have sex again, because it just didn't make any sense to me — like, how would that happen? Because I only knew one way, which was that you get drunk. And you've just taken away my one — you know, that's all the game I have. That's my one method. So if I don't have that, what am I going to do? ...

Additional Information: Related NPR Interviews Author Interviews After Years Of Blackouts, A Writer Remembers What She 'Drank To Forget'

When I got sober, it's almost like I had some turtle skin or something, everything was really super sensitive, and I did not want to be around men at all. I was so scared of them. One thing I would do is, I would get these, kind of, fantasies about guys — maybe like the barista at the coffee shop or like a guy in the meeting — and I would live with them in my mind. This is what I used to do when I was a little girl, too, by the way, and I was really lonely. I think it's a form of self-soothing that a lot of us do. You know, if you can't have closeness you create closeness in your own mind. But then when it came time to actually date people — and, by the way, I did not start dating until two years into sobriety, so I took my time — when I started dating, I was petrified. I was so scared.

On her decision to move back to Dallas, where she grew up, after she stopped drinking

When I got sober, what happened was that things became a lot more clear to me. I didn't necessarily need a new job, but I did not like New York. And I think that was really surprising to me, because I grew up as this kid in Dallas, Texas, kind of reaching for the greatness of New York. That's the greatest city on Earth, right? And everybody should be there. I always longed to be somebody that was living in New York — a writer. That was my dream. And I think there are times in life when you realize that maybe your dream wasn't the right dream for you.

And I would go back to Dallas — which is this city that is not necessarily cool. And it certainly wasn't cool when I was growing up in it. I have this line in my book — "I grew up in Dallas wondering why." ... And I always wanted to get out of there, just get out of this place! And [after I stopped drinking] I would go back and I would feel the beauty of home.

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How A Beauty Queen With Diabetes Found Her 'Sugar Linings'

NPR Health Blog - Thu, 07/30/2015 - 12:02pm

Sierra Sandison, Miss Idaho 2014, during the "Show Us Your Shoes" parade at the Miss America pageant.

Courtesy of The Miss America Organization

Last July, a photo changed Sierra Sandison's life. She went onstage in the Miss Idaho pageant with an insulin pump clipped to her bikini bottom. The photo and the #ShowMeYourPump hashtag she created went viral on social media and became NPR's most popular online story of the year.

By the time the Twin Falls native walked the runway at the Miss America pageant in September with the insulin pump again clipped on her bikini, Sandison had become an inspiration to many people with Type 1 diabetes, and indeed any chronic medical condition.

Her Miss Idaho reign ended in June, but you'd barely notice. She's still traveling all over the country giving inspirational talks and has just come out with a book called Sugar Linings: Finding the Bright Side of Type 1 Diabetes. Here's our conversation, edited for length and clarity.

Interview Highlights

What are "sugar linings?"

Shots - Health News Hey, Miss Idaho, Is That An Insulin Pump On Your Bikini?

"Sugar linings" are the good things that come out of a diabetes diagnosis, but my book is really aimed towards anyone who's facing adversity. They're the positive things that come out of any difficult experience you go through.

For example, becoming Miss Idaho would never have happened if I didn't have diabetes. I was not popular growing up, not anyone's idea of a beauty queen. I was diagnosed with diabetes senior year in high school, and I hid it. I wasn't taking care of myself. I refused to get a pump for a long time. I thought that if I had an insulin pump it would disqualify me from being beautiful. But when I saw Miss America 1999, Nicole Johnson, wearing an insulin pump and still being beautiful, it gave me new confidence. I vowed to get an insulin pump for myself and then I also wanted to go to Miss America one day and do for others what Nicole had done for me.

The diabetes has also helped me find my passion. I've been privileged to travel the country and speak. But anybody diagnosed with diabetes or any adversity can use that later to make a difference in the lives of people who are going through the same thing, whether you have diabetes and spend time raising money for that, or if you're homeless and later can serve the homeless when you're back on your feet.

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I really like how you talk about moving to Ecuador at age 14, when your dad was volunteering in a medical clinic. You hadn't been serious about school. But when you saw kids there who had to work on farms because they couldn't afford school, you realized "if I had this awesome opportunity right in front of me at home, I needed to take advantage of it to the fullest extent."

And you also say for you, the insulin pump is a symbol. How can that be, when it's a medical device you're using all day, every day?

One of my messages is that we all have our own "pump," things that make us insecure, that make us feel different, that we sometimes want to hide or hate about ourselves. I really want to encourage people not only to tolerate those things, but also learn to love and embrace them because they make you unique. We're taught by society that we should fit this certain mold, but there's so much beauty in diversity.

What are you up to now that your reign is over?

I'm no longer Miss Idaho, but the traveling isn't going to stop. Since giving up the crown, I've been to the huge Children with Diabetes conference at Disney World, and I'll be going to other events in California, New Orleans, Illinois and Minnesota, all before mid-August. So I'm going to be able to continue to spread my message, and now that I have my book, I'm squeezing in book signings. My schedule keeps getting fuller and fuller.

I have my things I call my "umbrellas" that make managing my diabetes easier, including the pump, a continuous glucose monitor and home glucose meter that are accurate. They're not necessarily things I love to have in my life, but since I have diabetes they make it easier to deal with.

And when the book tour's over, will you get a job?

Probably not this year, but my friend and I want to start a business. I want to be an entrepreneur. To start, I want to have a crepe cart. It's a low startup cost, and I think it will be fun.

Miriam E. Tucker is a freelance journalist specializing in medicine and health. You can follow her on Twitter @MiriamETucker.

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Close Listening: How Sound Reveals The Invisible

NPR Health Blog - Thu, 07/30/2015 - 4:47am
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Hanna Barczyk for NPR

Over the years, scientists have mostly interpreted the world through what they can see. But in the past few decades, a culture of listening has blossomed, especially among biologists who seek to understand how animals communicate. This week Morning Edition embarks on a weekly summer series called Close Listening: Decoding Nature Through Sound. We begin with an innovation that transformed medicine by searching sounds for clues to illness and health.

Microscopes illuminate the invisibly tiny; telescopes reveal the heavens. But sound? Scientists didn't really see it as all that important, until an amazing invention came along that opened new worlds: the stethoscope.

"I think the first time one can see this kind of 'listening culture' is with the development of the stethoscope at the beginning of the 19th century in Paris," says Trevor Pinch, a Cornell University sociologist.

"You couldn't see inside a body back then," Pinch says, "unless of course it was dead, which was a bit late for anyone except a pathologist." But a stethoscope told a living story — of circulating blood, or the seesawing of lungs.

"It was one of the first ways of getting a diagnosis on a patient independent of their own version of what was happening," says Pinch. "In fact, it's become so important that the emblem of the physician is often the stethoscope around the neck — that's how you tell who the doc is."

We asked one of those doctors to help us hear the way he hears. Dr. Adam Law, an endocrinologist and primary care physician in Ithaca, N.Y., was teaching a medical student how to use a stethoscope to diagnose a heart problem in one of his patients, and we brought along recording equipment so we could listen in. Law's student is Nick Maston, in his third year at Weill Cornell Medical College.

Shots - Health News A Scientist Deploys Light And Sound To Reveal The Brain

Law ushered the patient into the examining room, and turned to his student. "Nick, why don't you examine this patient's cardiovascular system?" We'd already plugged our recorder into the electronic stethoscope, but Law and Maston both warned us — interpreting sounds from inside a body is not for amateurs.

"As a student," said Maston, "it's hard to learn ... you have to listen to thousands of hearts to find that out."

Maston placed the bell of the instrument on the patient's neck — right on the carotid artery — and we all heard this:

Heart Sounds At Carotid Artery

It's the sound of the heart pumping blood through its aortic valve and out into the pulsing carotid artery. Then Maston moved the bell to the patient's side, placing it just under the man's armpit. A slightly different sound came through:

Heart Sounds Under Arm

Law turned to his student: "Hear the difference in quality?" Maston didn't hesitate: "Yeah; very loud second heart sound."

Law's patient has a heart murmur — a malfunction of the heart valves that control blood flow. Textbooks say you can hear a murmur's "swishing" sound. But if you didn't hear it, don't feel bad — we journalists couldn't make out any swishing sound, either.

Maston apparently could. "So, do you want me to talk about what I heard?" he asked us. "It sounded like a mitral murmur; but I heard it best where I expect to hear an aortic murmur. So ... this is a situation where Dr. Law is going to have to jump in and rescue me."

Law confirmed that Nick had it right. The patient's heart has a little bit of both types of murmur, he said, from the mitral and aortic valves.

We amateurs didn't hear it because we simply didn't know what to listen for. Think of the sound as if it were the audio version of a fossil bone or relic lying in the dirt; a seasoned archaeologist can pick those out more readily than other people because the pros have a sort of "search image" in their brain.

"The musical note of the heart is actually complicated," Law said. "It has harmonics; it has overtones. And that gives the sound — and the murmurs — in the heart a certain quality," he explained. "One has to tune one's ears."

So how do you tune your ears? "Pattern recognition is the key," Pinch told us later.

Some patterns, like the start of Beethoven's Fifth Symphony, are easy:

Easily recognized. But it gets harder as the sounds get more complex. Two moustached wrens singing a duet start as two seemingly random singers. Then they suddenly synchronize their songs, and a pattern emerges:

Wren Duet

Pinch has made a career of studying how scientists listen. He notes that listening has certain advantages over vision. "The visual field is kind of in front of us — like a kind of screen," he says, while sound is "all around."

Listen To This: Whales Can't Hear Over Our Noise Science Eavesdropping On Nature Gives Clues To Biodiversity

If seeing is like being in an art gallery, hearing is more like being in a swimming pool — where we're swimming all the time. At night, we'll wake up to a baby's cry, or to the sound of danger — a predator, perhaps. Such sounds trigger an ancient alarm system buried deep within our species' brains. Listening, says Pinch, especially at night, "has probably been evolutionarily very, very important."

The problem of using sound to understand physical phenomena — from the weather to animal behavior, to the fact that an engine needs oil — is that sound is ephemeral. It's in one ear and out the other.

An advertisement for Edison's phonograph circa 1900.

Miami University Libraries/Flickr

That is, until, as Pinch points out, people invented a way to nail down sound. "I think the development of the phonograph, in particular, around 1880 ... really does change how we think about sound," Pinch says. "Because, for the first time ever, sound is really transportable. ... You can store it in a medium."

Once people could capture sound, and really listen, Pinch says, that opened up a universe of new possibilities.

Editor's note: An alert reader reminds us that heart murmurs can arise from other sources, too, and that many such sounds are harmless.

Bill McQuay is an audio producer at the Cornell Lab of Ornithology.
He's on Twitter: @mcquay_bill.

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Categories: NPR Blogs

Doctors Devise A Better Way To Diagnose Shaken Baby Syndrome

NPR Health Blog - Wed, 07/29/2015 - 4:05pm

Frustration with a crying baby can lead some parents and caregivers to shake a baby.

iStockphoto

To tell whether a baby has been injured or killed by being shaken, the courts use three hallmark symptoms: bleeding and swelling in the brain and retinal bleeding in the eyes. Along with other evidence, those standards are used to convict caregivers of abusive head trauma, both intentional and unintentional, that can result in blindness, seizures, severe brain damage or death.

But in recent years a small cadre of experts testifying for the defense in cases across the country has called into question whether those symptoms actually indicate abuse. Though they are in the minority — disputing the consensus of child abuse experts, pediatricians and an extensive evidence base — they have gained traction in the media and in courtrooms by suggesting that shaking a child cannot cause these injuries. Instead, they argue that undiagnosed medical conditions, falls or other accidents are the cause.

So researchers have developed and validated a tool doctors can use to distinguish between head injuries resulting from abuse and those from accidents or medical conditions. The method, described in the journal Pediatrics on Monday, asks doctors to check for six other injuries, each of which increases the likelihood that a head injury resulted from severe shaking, blunt force or both.

"It is vitally important that abuse head trauma is diagnosed accurately so that the team looking after the child can ensure that they receive appropriate support and are protected from further harm," lead study author Laura Elizabeth Cowley, a doctoral student at the Cardiff University School of Medicine in the U.K., said in an email.

"However, it is also important that accidental head injury cases are not wrongly diagnosed as abusive," she continues, "because this can have devastating consequences for the families involved."

The tool itself is simple: listing rib fracture, seizures, long-bone fractures, bruises on the head or neck, periods of not breathing called apnea and bleeding in the retina of the eyes. The more of those a child suffers, the more likely the case resulted from abuse.

The researchers used medical records and child protection files of 198 babies with head trauma to see how well the tool identified child abuse. Extensive investigations, often including confessions or independent witnesses, had already established whether these children, mostly under 1 year old, had been abused.

By using a standard that at least three of the six symptoms were needed to presume abuse, the method correctly identified 82 percent of 133 cases as not abusive. It also correctly found that two-thirds of the other 66 children had suffered abusive head trauma, though it missed 13 cases of abuse in which the child had few of the physical symptoms used by the tool. Twelve cases mistaken for abuse involved substantial injuries from a car accident or other situations in which a pediatrician would probably not use this tool.

"Part of the challenge is that there is no gold standard for making a diagnosis of child abuse — you can't do a blood test," said Cindy Christian, chair of both Child Abuse and Neglect Prevention at The Children's Hospital of Philadelphia and the American Academy of Pediatrics' Committee on Child Abuse and Neglect. "It's always going to be a clinical diagnosis with social investigation. A bruise is a bruise. A broken bone is a broken bone. A subdural hemorrhage is a subdural hemorrhage. There are certain injuries that are much more highly correlated with abuse, and there aren't very many things that cause these together."

More than a half million U.S. children suffer abuse each year, including approximately 30 cases of abusive head trauma among every 100,000 infants, according to the American Academy of Pediatrics. Each year about 80 children die from abusive head trauma. They are among the 1,500 children who die each year from abuse or neglect in the U.S.

In 2009, the AAP reclassified "shaken baby syndrome" as abusive head trauma to be more inclusive of all the ways a child's head can be injured through abuse, including but not limited to violent shaking.

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Doubters of shaken baby syndrome exploited this shift in terminology to claim that shaking alone could not cause the triad of injuries often used in court cases — brain swelling, subdural hemorrhaging (bleeding between the brain and its outer membrane) and retinal bleeding. One of those doubters is Jan Leestma, a neuropathologist from Chicago who has testified for the defense in dozens of court cases on abusive head trauma.

"The idea that you can shake a baby and cause subdural brain hemorrhage — you can't without an impact," Leestma said. "I don't mean to say there's no child abuse — of course there is — but shaking as abuse is a straw man. It probably can't produce the kinds of things that people say it can."

Yet a strong body of research shows that shaking can injure infants and toddlers and cause these symptoms. A study in which perpetrators confessed to shaking the child showed that violent shaking, on average about 10 times until the baby stopped crying, could cause all these symptoms, even when three-quarters of them involved nothing more than shaking.

The real straw man argument is the idea that diagnosing abusive head trauma relies solely on those three injuries and can lead to false accusations of abuse, said Bob Sege, division director of Family and Child Advocacy at Boston Medical Center and a member of the AAP Committee on Child Abuse and Neglect.

"At a personal level, our first reaction is really hoping it's not child abuse and to go through all the other possibilities to make it be something else, but sometimes you can't," Sege said.

When a child comes in with those symptoms, pediatricians conduct a thorough physical exam to look for other injuries, get a full history from the parents and look for inconsistencies in caregivers' stories. They also often enlist other experts, such as radiologists, ophthalmologists and child abuse specialists, to look at the evidence.

"There are certain bleeding problems and very rare metabolic diseases that might cause some of these symptoms," Sege said. "They're unfortunately very uncommon compared to child abuse, which is not as uncommon as I wish it was."

A common pattern in these cases arises when good but overwhelmed parents become frustrated with a baby's crying and reach their breaking point, so they shake the baby to stop the crying, Sege said.

"If you're a parent and you feel that [frustration], that's the time you put the baby down screaming and crying, close a door, make a cup a tea, call a friend, whatever you need to."

The method described in the study quantifies what pediatricians see in their clinical work, Christian said. She hopes it will make it more difficult to deny abuse when it occurs.

"All of our clinical experience and evidence shows that shaking can be extraordinarily harmful to a baby," she said.

Tara Haelle is a freelance health and science writer based in Peoria, Ill. She's on Twitter: @tarahaelle.

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Texting While Walking: Are You Cautious Or Clueless?

NPR Health Blog - Wed, 07/29/2015 - 2:10pm

Good thing that coat is coffee-colored.

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Do you roam city sidewalks with your nose buried in your phone, oblivious to what's going on around you? If so, you may want to look up and start paying attention.

Texting while walking decreases the ability to walk in a straight line and slows down pace significantly, according to a study published Wednesday in PLOS ONE. But this gait change may not be as dangerous as it sounds, the researchers say.

"We hypothesized that more people would trip," says Conrad Earnest, an exercise scientist at Texas A&M University who studied people while walking and texting. "But nobody tripped and that's surprising; people actually slowed down and engaged in a more protective or cautious walking pattern."

Several years ago, Earnest noticed that people who text and walk tend to weave around, almost as if drunk. This change of gait got him wondering: What's the effect of being distracted with a mobile phone while walking?

To find out, he and two students created an obstacle course that mimics city pathways. There were curb-like steps, stairs, a platform to step on and off of, and traffic posts and dummies to maneuver past.

Thirty people were recruited to make their way through the course three times. In the first instance, participants walked the course undistracted and without a phone. They texted during the second walk-through. In the third scenario, they texted and used an app to solve basic math problems. Thirteen nearby cameras captured the participants' movements and collected motion data.

After analyzing the data, the research team found that people took significantly longer to complete the course while using a phone. While they tended to deviate from the path, text walkers didn't trip or bump into anything. They also lifted their feet higher to clear steps. When they were walking without distractions, for example, participants cleared the curb by about 3.7 inches. But when using their phones, they would raise their feet higher to about 4.37 inches.

Shots - Health News Want To Perk Up Your Love Life? Put Away That Smartphone

"That suggests they were being more careful to make sure they cleared the step," Earnest says. He adds that people could be slowing down to avoid potential accidents while they're distracted.

Psychologist David Schwebel, a professor at University of Alabama at Birmingham, agrees.

"I think the participants recognized that their brain was overloaded and to protect themselves, became more cautious and slowed down to make it safer," says Schwebel, who was not involved with the study.

Still, he does not advocate texting while walking. His own research has shown that pedestrians who are distracted with their phones are more likely to be in traffic accidents.

City and regional planner Jack Nasar, on the other hand, does not believe a slower pace implies more caution. He thinks it simply proves that text walkers are having trouble multitasking.

Nasar, a professor emeritus at The Ohio State University who was not involved with the study, points to his own research on pedestrians using phones.

The Two-Way Keep Your Head Up: 'Text Neck' Takes A Toll On The Spine

In one experiment, Nasar found that people on cellphones are 48 percent more likely to walk unsafely into oncoming traffic. Another study showed that injuries of pedestrians on phones more than doubled between 2004 and 2010. In fact, in 2010, the number of pedestrian injuries while texting exceeded the number of texting and driving injuries.

"Pedestrians using cellphones are getting hurt, and that suggests they're not being cautious," Nasar says. "If they were being cautious, they wouldn't be getting injured."

Whether text walkers are being careful or not, the general consensus seems to be: Don't do it.

Despite his findings, Earnest says people should pocket their phones and just enjoy the walk at hand.

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Progress For Bill To Bolster Medicare Patients' Hospital Rights

NPR Health Blog - Wed, 07/29/2015 - 10:58am

Hospitals can call people who stay overnight outpatients, a classification that can have surprising financial consequences.

iStockphoto

The Senate unanimously approved legislation Monday night requiring hospitals across the nation to tell Medicare patients when they receive observation care but haven't been admitted to the hospital as inpatients.

The distinction is easy for patients to miss — until they get hit with big medical bills after a short stay.

Hospitals are placing many older patients on observation status. They may be there for days, but technically they're still outpatients. One reason for the practice is it lowers the risk that a hospital will have to repay the government if an auditor decides afterward that someone should have been treated as an outpatient rather than an inpatient.

The vote follows overwhelming approval in the House of Representatives in March. The legislation is expected to be signed into law by President Obama, said its House sponsor, Texas Democratic Rep. Lloyd Doggett.

It's called the NOTICE Act, short for "Notice of Observation Treatment and Implication for Care Eligibility." The law would require hospitals to provide written notification to patients 24 hours after receiving observation care, explaining that they haven't been admitted to the hospital, the reasons why and the potential financial implications.

Those implications can be dire. Observation care hurts seniors in two ways: It keeps Medicare's more comprehensive hospitalization coverage from kicking in, and it means they may not get Medicare's limited nursing home benefit if they need care in a facility after being in a hospital.

To qualify for Medicare's nursing home coverage, beneficiaries must first spend three consecutive midnights as an admitted patient in a hospital. Observation days don't count.

Without that coverage, seniors could pay thousands of dollars for the nursing home care their doctor ordered, or else try to recover on their own. Observation care is a classification used when patients are not well enough to go home but not sick enough to be admitted.

Because observation care is provided on an outpatient basis, observation patients usually also have co-payments for doctors' fees and each hospital service, and they have to pay whatever the hospital charges for any routine drugs the hospital provides that they take at home for chronic conditions such as diabetes or high cholesterol.

A handful of states already require observation care notices, including New York, Connecticut, Maryland, Pennsylvania and Virginia, said Doggett. But Medicare officials have been reluctant to take similar steps.

Hospitals will have to comply with the NOTICE Act 12 months after it becomes law.

A Medicare official declined to answer questions about the NOTICE Act because he said the agency does not comment on pending legislation. However, he said an online brochure from Medicare describing observation care advises patients to talk to their physicians or other health staff if they have questions about whether they have been admitted.

Just two months ago, Sean Cavanaugh, a deputy administrator at the Centers for Medicare & Medicaid Services, fielded a barrage of questions on the issue from members of the Senate Special Committee on Aging.

"There is an assumption if [patients] are being wheeled into a hospital bed," and they are getting treatment, then they have been admitted, Sen. Claire McCaskill, a Missouri Democrat, told Cavanaugh. When Sen. Susan Collins, a Maine Republican, repeated McCaskill's question asking if CMS would require notification, he said the federal government has been "pushing very hard" to encourage hospitals to educate patients about observation care. But he said it wasn't clear that the agency could require hospitals to do more to inform patients.

"A new legislative requirement was the most direct way to address the problem," Doggett said.

Meanwhile, the number of claims hospitals submitted for observation care continues to skyrocket. According to the most recently available data from CMS, total claims increased 91 percent since 2006, to 1.9 million in 2013. Long observation stays, lasting 48 hours or more, rose by 450 percent to 170,219 during the same period, according to a Kaiser Health News analysis.

In 2013, Medicare officials attempted to control the use of observation care by issuing the so-called two-midnight rule, which would require hospitals to admit patients who doctors expect to stay at least two midnights. But Congress delayed its enforcement after hospitals said the rule was confusing and arbitrary.

Although it's better for patients to know when they are on observation status, Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, said they may not be able to do much about it. She said there is no set process for challenging observation care while in the hospital, unlike issues such as disputing a discharge order when admitted patients feel they are not ready to leave.

The only way to switch from observation to admitted status is to persuade a physician or the hospital to make the change, said Edelman. And that decision doesn't apply to the time the patient has already spent on observation.

But challenging observation care after leaving the hospital can be frustrating since Medicare appeals judges may decide that a patient's condition did not require inpatient-level care — even though they received care that could have been provided nowhere else but a hospital.

Some hospital officials are worried that patients may panic when they find out that they are receiving observation care and haven't been admitted.

Marna Borgstrom, CEO and president of Yale-New Haven Hospital in Connecticut, told the Senate Special Committee on Aging last year she detected a small but alarming trend: When patients learned they were receiving observation care, they left the hospital against medical advice.

"I'm confident it would be an even greater number if more patients knew about the potential burden of being deemed an outpatient," Borgstrom said.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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A Sense Of Self: What Happens When Your Brain Says You Don't Exist

NPR Health Blog - Tue, 07/28/2015 - 1:17pm
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Additional Information: The Man Who Wasn't There

Investigations into the Strange New Science of the Self

by Anil Ananthaswamy

Hardcover, 305 pages | purchase

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Science journalist Anil Ananthaswamy thinks a lot about "self" — not necessarily himself, but the role the brain plays in our notions of self and existence.

In his new book, The Man Who Wasn't There, Ananthaswamy examines the ways people think of themselves and how those perceptions can be distorted by brain conditions, such as Alzheimer's disease, Cotard's syndrome and body integrity identity disorder, or BIID, a psychological condition in which a patient perceives that a body part is not his own.

Ananthaswamy tells Fresh Air's Terry Gross about a patient with BIID who became so convinced that a healthy leg wasn't his own that he eventually underwent an amputation of the limb.

"Within 12 hours, this patient that I saw, he was sitting up and there was no regret. He really seemed fine with having given up his leg," Ananthaswamy says.

Ultimately, Ananthaswamy says, our sense of self is a layered one, which pulls information from varying parts of the brain to create a sense of narrative self, bodily self and spiritual self: "What it comes down to is this sense we have of being someone or something to which things are happening. It's there when we wake up in the morning, it kind of disappears when we go to sleep, it reappears in our dreams, and it's also this sense we have of being an entity that spans time."

Interview Highlights

On how to define "self"

When you ask someone, "Who are you?" you're most likely to get a kind of narrative answer, "I am so-and-so, I'm a father, I'm son." They are going to tell you a kind of story they have in their heads about themselves, the story that they tell to themselves and to others, and in some sense that's what can be called the narrative self. ...

We can think back to our earliest memories. We can imagine ourselves in the future, and whatever perceptions arise when we remember or when we imagine, whatever emotions arise, they again feel like they're happening to the same person. So all of these things put together, in some sense, can be called our sense of self.

There are also other ways of thinking about the self. For instance, you and I right now are probably sitting on our chairs, and we have a sense of being a body that is in one place and we can feel sensations in our body. ...

We can think back to our earliest memories. We can imagine ourselves in the future, and whatever perceptions arise when we remember or when we imagine, whatever emotions arise, they again feel like they're happening to the same person. So all of these things put together, in some sense, can be called our sense of self.

On Cotard's syndrome, in which a person believes he or she is already dead

Cotard's syndrome was something that was first identified by a French doctor in the late 1800s. His name was Jules Cotard, and it's named after him. It's a constellation of symptoms ... and the most characteristic symptom is the situation where people say that they don't exist. This is a perception that they have, and you cannot rationalize, you cannot really give them evidence to the contrary and expect them to change their mind. It is a complete conviction that they have that they don't exist. ... It's very, very paradoxical. It poses a great philosophical challenge to people who are trying to understand what it means to say "I exist" or "I don't exist." It also makes you wonder about all the other things that we are certain about, like you and I probably are very certain that we exist, well, these people are just as certain that they don't. So it makes you question about perceptions that arise in the brain and somehow, in this case, the delusion is so complete and so convincing that you really cannot shake their conviction that they are dead.

On what brain imaging of a patient with Cotard's syndrome shows us

Anil Ananthaswamy is a consultant for New Scientist Magazine.

Prasad Vaidya/Dutton

What seems to be happening is that there is a network in the brain that is responsible for internal awareness, awareness of our own body, awareness of our emotions, awareness of our self-related thoughts, and in Cotard's, it seems like that particular network is tamped down. In some sense, their own experience of their body, in all its vividness, in experience of their own emotions in all its vividness, that's compromised very severely. In some sense they're not feeling themselves vividly. It's as simple as that. But, then there's something else that's happening in the brain. It seems like parts of the brain that are responsible for rational thought are also damaged. First of all, what might be happening is a perception that arises in their brain saying that they are dead because they're not literally perceiving their own body and body states and emotions vividly and then that perception — irrational though it is — is not being shot down.

On body integrity identity disorder, which causes a person to believe that a body part is not his or her own

It really is a very disturbing condition in the sense that it's not something you would normally ever experience. ... If you look at your hand, there is no doubt in your mind that it is your hand. Now imagine you looked at your hand and it didn't feel like yours and it didn't feel like yours for 20, 30 years; it could be a very debilitating thing. It seems to be like that for people experiencing or suffering from BIID. They do take extreme measures. It's basically a mismatch between the internal perception they have of their own body and the physical body and what's intriguing and interesting in terms of the self is that what is most important for our sense of self, our bodily self, is the internal perception of it. You can look at your body and you can see your hand or leg that is fully functional, and yet if it doesn't feel like yours. The feeling is the much more important part of one's self, not the fact that you can see it and you can function with this leg.

On a patient with BIID who got his leg amputated

I talked to him a few times before the operation trying to find out what it was really that he was suffering from and he really felt like this leg, part of his leg, was not his, it was really something he didn't want. He would try a whole range of things to make it seem as if he didn't have it. He would fold his leg and pretend it wasn't there, he would push it to one side, it really seemed to ruin his life. I remember asking him once, "So what does it exactly feel like?" He says, "It feels like my soul doesn't extend into that part of my leg." ...

One way to kind of understand might be happening in BIID is actually to look at the converse problem. Most people by now will be really well aware of this phenomenon called phantom limbs [syndrome] where you actually have an amputation because of some unfortunate accident or infection and you lose an arm or a leg. Many people continue to feel that the limb still exists and some people even feel pain in that imaginary limb. What that's telling you is what you are perceiving as your limb is actually some representation of the limb in your brain, not the physical limb.

On how Alzheimer's disease affects the narrative self

Alzheimer's disease ... unfortunately literally erases a very important part of our sense of self, which is the narrative that we have in our heads about who we are. This narrative is something that the brain constructs and we're not even aware that it's actually a constructed thing. When we just think of ourselves, we have this expansive narrative inside us about who we are and what Alzheimer's unfortunately does is it puts a stop to the narrative forming. So because short-term memory formation is impaired, it becomes harder and harder for a person with Alzheimer's to start having new memories, and once you stop having or forming new memories, these memories don't get incorporated into your narrative. So, in some sense, your narrative stops forming. As the disease progresses it starts eating away at the existing narrative. It starts basically destroying a whole range of memories that go toward constituting the person that you are. ...

In terms of talking about the self, what this is telling you is that the self is multilayered. There's a narrative component to it, and what Alzheimer's seems to be doing is destroying the narrative component to the point that the person really cannot recognize anyone. ... We really don't know what the situation is from the perspective of the person suffering from Alzheimer's, especially late stage Alzheimer's.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Happy 50th Birthday, Medicare. Your Patients Are Getting Healthier

NPR Health Blog - Tue, 07/28/2015 - 11:01am
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A Yale University study analyzed the experience of 60 million Americans covered by traditional Medicare between 1999 and 2013, and found "jaw-dropping improvements in almost every area," the lead author says.

Ann Cutting/Getty Images

Here's a bit of good news for Medicare, the popular government program that's turning 50 this week. Older Americans on Medicare are spending less time in the hospital; they're living longer; and the cost of a typical hospital stay has actually come down over the past 15 years, according to a study in the Journal of the American Medical Association.

Doctors, hospitals and government administrators have put a lot of effort into making Medicare more efficient in the past 15 years. Dr. Harlan Krumholz and colleagues at Yale University took on a study to see whether that effort has paid off.

"The results were rather remarkable," says Krumholz, a cardiologist and leading health care researcher. "We found jaw-dropping improvements in almost every area that we looked at."

The researchers looked at the experience of 60 million older Americans covered by traditional Medicare between 1999 and 2013. They found that mortality rates dropped steadily during that time, and people were much less likely to end up in the hospital.

"If the rates had stayed the same in 2013 as they had been in 1999, we would have seen almost 3.5 million more hospitalizations in 2013," Krumholz says.

"People who were being hospitalized were having much better outcomes after the hospitalization," he says. "They had a much better chance of survival."

And the average cost of a hospital stay dropped too, he says, from $3,290 to $2,801 in inflation-adjusted dollars over the 15-year period for patients in the traditional Medicare program. (Researchers couldn't quantify the experience in Medicare Advantage, the managed-care alternative to Medicare).

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Krumholz attributes the improvement to a wide variety of measures designed to boost patients' health, from prevention programs to advances in medical care. He says some of the savings also came about because medical care shifted from hospitals to less expensive outpatient clinics.

"They're pointing out a very good thing in the medical system," says economist Craig Garthwaite at the Kellogg School of Management at Northwestern University. He says the recession, which helped slow rising health care costs overall, apparently played a minor role in this story of Medicare.

Costs really are being contained, Garthwaite says. One other reason that's happening is that the federal government is reimbursing hospitals and doctors less for treating Medicare patients.

"That's an easy way to get control of medical spending in Medicare," Garthwaite says, but "it's just not something we can do in the private market, and we have to worry about how sustainable it is for the Medicare program overall."

With the post-World War II baby boom now reaching retirement age, more and more people are turning 65 and becoming eligible for Medicare. That growth continues to drive up the overall cost of the program, even as that average cost per illness or hospitalization comes down. And as older Americans live longer lives, they use Medicare for more years than previous generations did.

Shots - Health News Experiment In Coordinated Care For Medicare Failed To Show Savings

Medicare is still running a bit of a deficit, but the situation is improving. The program's trustees say its trust fund will be solvent through 2030. Some adjustments would be needed to keep the program in good financial health beyond that date.

Garthwaite says other recent trends could make matters worse, with one especially worrisome example being sharply rising drug prices.

"Some of these [new cancer] products are providing only a few months of life for several hundred thousand dollars," he says. And the system doesn't do a good job of making difficult judgments in situations like that.

Shots - Health News Home Health Agencies Get Medicare's Star Treatment

Joseph Antos, an economist in health policy at the American Enterprise Institute, agrees that the good news from the Yale study doesn't assure a rosy future. He's concerned about the financial health of Medicare if, for example, an effective drug for Alzheimer's disease is developed.

"I would argue that if anybody came up with an effective treatment for Alzheimer's today, that treatment would be hailed as a major breakthrough and we wouldn't be looking at the cost," Antos says.

And that would almost certainly break the pattern that's been documented over the past 15 years, where improving health has actually helped drive down the cost of medical care.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Rehab Before Cancer Treatment Can Help Patients Bounce Back

NPR Health Blog - Tue, 07/28/2015 - 8:05am

Putting some work in ahead of cancer therapy can help speed up recovery afterward.

iStockphoto

Cancer patients who do rehabilitation before they begin treatment may recover more quickly from surgery, chemotherapy or radiation, some cancer specialists say. But insurance coverage for cancer prehabilitation, as it's called, can be spotty, especially if the aim is to prevent problems rather than treat existing ones.

It seems intuitive that people's health during and after invasive surgery or a toxic course of chemo or radiation can be improved by being as physically and psychologically fit as possible going into it. But research to examine the effect of prehab is in the beginning stages.

Prehabilitation is commonly associated with orthopedic operations such as knee and hip replacements or cardiac procedures. Now there's a growing interest in using prehab in cancer care as well to prepare for treatment and minimize some of the long-term physical impairments that often result from treatment, such as heart and balance problems.

"It's really the philosophy of rehab, rebranded," says Dr. Samman Shahpar, a physiatrist at the Rehabilitation Institute of Chicago.

The main component of cancer prehab is often a structured exercise program to improve patients' endurance, strength or cardiorespiratory health. The clinician establishes baseline measurements, such as determining how far a patient can walk on a treadmill in six minutes, and may set a goal for improvement. He also evaluates and addresses existing physical impairments, such as limited shoulder mobility that could be problematic for a breast cancer patient who will need to hold her shoulder in a particular position for radiation. Depending on the program, patients may also receive psychological and nutritional counseling or other services.

Some early research suggests prehab may improve people's ability to tolerate cancer treatment and return to normal physical functioning more quickly. In one randomized controlled trial of 77 people with colorectal cancer who were awaiting surgery, two groups of patients participated in an exercise, relaxation and nutritional counseling program. Half went through the program in the four weeks prior to surgery and half in the eight weeks after it.

Eight weeks after their surgery, 84 percent of prehab patients' performance on a six-minute walking test had recovered to or over their baseline measurements compared with 62 percent of rehab patients, according to the study, published last year.

"Prehab could be a relatively cheap way to get people ready for cancer treatment and surgery, both of them stressors," says Dr. Francesco Carli, a professor of anesthesiology at McGill University in Montreal who co-authored the study.

More research is needed to determine the effect of prehab on cancer patients' outcomes. "There are some physiatrists who don't believe in prehab," says Catherine Alfano, vice president of survivorship at the American Cancer Society. "They feel like the science isn't there yet."

Insurance plans typically cover rehabilitation services such as physical therapy and occupational therapy. But patients can face problems with coverage such as preauthorization requirements and limits on visits. There may be even more coverage obstacles with prehab.

"What we need is a system that systemically screens people for problems with physical and mental health that is then coordinated with their oncology care," Alfano says.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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How Finns Make Sports Part Of Everyday Life

NPR Health Blog - Tue, 07/28/2015 - 5:00am
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In Helsinki, sports facilities pop up all over the place, sometimes in some pretty odd nooks and crannies. One bomb shelter hosts an archery club, another an underground swimming pool and an ice hockey rink.

Though they hardly need it, there's a national plan in Finland to get people to sit less. It reminds them, in fact, that, "Under the Constitution ... physical activity is a basic cultural right."

"It's been kind of a social right to provide citizens with sporting possibilities," says Hanna Vehmas, a sports scientist at the University of Jyväskylä. She says it's a Nordic thing to consider sports a social right. That thinking started in the 1970s, when governments started subsidizing sports gyms in even the smallest towns.

Now, she says, "there's an estimate of some close to 30,000 sports facilities in this country, which is said to be more per capita than in any other country in the world."

Those facilities are one reason why Finland and its Nordic neighbors always make the top-five list of most physically active European countries, according to surveys by the European Commission. These days, municipalities spend about $700 million a year subsidizing sports facilities and clubs. A portion of lottery funds also goes toward funding sports facilities and research.

Walkways and bike paths snake through the cities. Public swimming pools are busy year round, even above the Arctic Circle. And during the cold, dark winters, cross-country skiers cut tracks in the snow through parks, across the solid lakes, even on the frozen Baltic Sea.

"Here you can more or less just step out of your door and go," Vehmas says.

Finns do just that. Half of women, and a third of men, say they bike to work. About a fifth of the country belongs to sports clubs or federations. Some people even play sports at work.

A Helsinki bomb shelter now serves as a shooting range for an archery club.

Rae Ellen Bichell for NPR

A poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found there's a gender gap when it comes to sports in adulthood in the U.S. Men are more than twice as likely as women (35 percent to 16 percent) to say they play sports.

Every Wednesday morning, a group of scientists at the Finnish Meteorological Institute and the University of Helsinki ditch their desks to play "futsal," an indoor form of soccer, in a gym across the street. It's one of the most popular team sports in the country, along with floor hockey and Finnish baseball.

The bosses of these meteorologists and computer scientists encourage them to play sports on the clock for an hour a week.

"My own boss plays badminton, floorball and futsal. And his boss also plays futsal," says Mika Heiskanen of the Finnish Meteorological Institute.

When it comes to employee fitness, these employers are hardly exceptional in Finland. The postal service has orienteering and riflery teams. A nearby chocolate factory has a gym and offers aerobics classes. And, Heiskanen says, he and his teammates regularly take on other government agencies, like customs officials and police units.

Ossi Aura, who specializes in occupational health care at the health care company Terveystalo, says the trend of employers encouraging sports participation started about a century ago with the forestry industry.

"Nowadays, 90 percent of employers support their employees' physical activity in some way," he explains.

Each year, Finnish employers spend an average of about 200 euros per employee for physical activity, or about $220. The money goes to anything from gym vouchers to providing workout facilities and saunas. Even factories offer such services.

"Yes, in fact, they have their locker rooms, they have their showers, they have their saunas, based on the ancient agreements between workers' unions," says Aura.

Today, one reason employers tend to support their employees' physical activity is because of a tax break. Businesses can deduct money spent on employees' physical well-being, which includes promoting sports and exercise.

But there's something else. "We have a lot of research showing that investing in work well-being will bring back as much as six times" the money invested, says Matleena Livson of the Finnish Sports Confederation. "Because you reduce sick leaves, you improve the cohesiveness and good spirit, and you improve employer image at the workplace."

Livson and Aura say it's understood in Finland and other Nordic countries that healthy employees do better work. They also don't have as many sick days. And staying fit, especially by playing sports together, could help build company cohesion and loyalty. "And that's actually even more important than the health side," says Aura.

Physically active people also save the health care system a lot of money. According to a calculator devised by the World Health Organization, the Finnish Ministry of Social Affairs & Health estimates that people who bike and walk save the health care system as much as 5 billion euros, or about $5.5 billion, each year.

But state subsidies are now being cut in Finland. The University of Jyväskylä's Hanna Vehmas says sports funding is taking a hit. "The private sector has become more responsible for providing sports supply," she says. "Sports participation is more than before becoming a commodity, something that you need to buy. And then people can afford it or they cannot afford it."

Our Sports and Health series continues over the summer, based on the results of our poll with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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California Health Insurance Exchange Keeps Rate Hikes Low — Again

NPR Health Blog - Mon, 07/27/2015 - 7:14pm

At sign-up events like this one in Los Angeles in 2013, Covered California pledged "affordability" in health insurance as one of its main selling points.

Lucy Nicholson/Reuters/Landov

Monthly premiums for California's 1.3 million Covered California customers will rise a modest 4 percent, on average, officials with the agency said Monday. This increase is slightly less than last year's increase of 4.2 percent for consumers who bought policies on the state's health insurance marketplace.

Some consumers could even achieve a reduction in their premium, of an average of 4.5 percent, if they choose to shop around.

"This is another year of good news for California's consumers and further evidence that the Affordable Care Act is working," said Peter Lee, Covered California's executive director.

Consumers who live in different parts of the state will see varying rates. In Southern California, consumers who stay in their plan will see an increase of just 1.8 percent, or an average of $296 per month. But in Northern California, where health care costs are typically higher, because of greater consolidation among doctors and hospitals, the increase is an average of 7 percent monthly, or $384.

Shots - Health News Covered California Votes To Cap What Patients Pay For Pricey Drugs

Lee stressed that shopping around could help consumers save money.

"Health care is also local," he said. "Where you live frames what your options are. If you live in Los Angeles and you shop around, you could see your premiums go down 11 percent."

Betsy Imholz, an attorney and advocate with Consumers Union, called the average increase "terrific," and also encouraged people to shop on price. "Often you can get a lower rate by moving to another carrier," she said.

Lee said Covered California spent weeks negotiating with insurers.

"We've created a market where the consumer drives what's working in California," he said. "Throughout our negotiations, consumers in California saved more than $200 million."

Larry Levitt, senior vice president of the nonpartisan Kaiser Family Foundation, was positive about what he called "modest" increases. "This shows what a stable, competitive individual insurance market can look like," he said, via email.

In part, Levitt credited the cost-containment to Covered California's "substantial enrollment so far." It's a sign, he said, that the marketplace is likely attracting healthy people to help spread the risk of the sicker people.

Levitt also said the state agency's active role has helped keep premium increases down. "I think a key element of California's success is the standardization of insurance policies," he said, "which simplifies the choices for consumers and focuses competition squarely on premiums."

Covered California also announced that two new insurers will join the marketplace. UnitedHealthcare, the largest health insurer in the nation, will now offer plans in parts of the state, including the group of counties that start north of Sacramento and stretch to the Oregon and Nevada borders. Where some people had a choice of only one plan, now they will have two or three.

"Covered California did the right thing by targeting the new additions to the places where more choice is needed," Imholz said.

Shots - Health News Limited Insurance Choices Frustrate Patients In California

Under the UnitedHealthcare plan, people who live near the Oregon and Nevada borders will also be able to cross state lines to see a doctor, a practice that was often prohibited in other plans.

"Sometimes people were driving many hours in order to get care," said Beth Capell, who is with the advocacy group Health Access. People who live in Susanville, for example, were accustomed to getting care in nearby Reno, Nevada. But through Covered California intially, they had to drive several hours to Sacramento.

"They will now have the choice of another carrier that will be offering them coverage beyond the borders of California."

Parts of Los Angeles County and Orange County will see a new insurer — Oscar Health Plan of California, which currently sells insurance only in the two states of New York and New Jersey.

Lee said that the new additions to the marketplace were chosen because they have good networks and are good for consumers.

"Covered California does not think more plans are always better," he said. "In 2014 and 2015 we turned plans away. We're not adding plans just because they knock on our door."

In addition to the two new plans, all plans from last year were renewed for 2016: Anthem Blue Cross, Blue Shield, Chinese Community Health Plan, Health Net, Kaiser, Molina Healthcare, Sharp Health Plan, Valley Health Plan, LA Care Health Plan and Western Health Advantage.

The rates announced Monday are preliminary and will be reviewed by state regulators over the next 60 days.

This story was produced by State of Health, KQED's health blog.

Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.
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Experiment In Coordinated Care For Medicare Failed To Show Savings

NPR Health Blog - Mon, 07/27/2015 - 12:05pm

Coordinating care for high-risk patients was expected to save money and improve quality of care. A Medicare experiment didn't pan out.

Roy Scott/Getty Images/Ikon Images

A $57 million experiment to provide better, more efficient care at federally funded health centers struggled to meet its goals and is unlikely to save money, says a government report on the project.

The test to coordinate treatment for high-risk Medicare patients in hundreds of communities was one of many demonstrations run by the Department of Health and Human Services' innovation center.

The Affordable Care Act created the lab and gave it $10 billion over a decade to test new ways to improve care and save money.

As the trial wound down last fall, 69 percent of the clinics that hadn't dropped out had obtained full accreditation as so-called medical homes. Those are primary care practices that coordinate care across the maze of specialists, hospitals and emergency rooms.

HHS had hoped for 90 percent.

Another project goal was to cut unnecessary hospital visits. But admissions and emergency room care rose in centers that were part of the experiment compared with results in those that weren't. So did expenses.

"It appears that the demonstration will not achieve cost savings," concluded the RAND Corp., an independent research group, in the study commissioned by HHS' Centers for Medicare and Medicaid Services, or CMS. HHS recently posted the report on its website.

There had been talk of extending the three-year demonstration. But the health law requires HHS to stop experiments that don't show signs of saving money or improving care. The program ended in October.

"They're saying that they actually saw potential increases in utilization and costs, which is not what CMS was hoping to see," said Dr. Eric Schneider, senior vice president for policy at the Commonwealth Fund. "But it's not necessarily surprising."

The project steered extra money to community health centers — nonprofit clinics that receive federal funds and care mainly for the poor. Medical homes typically appoint case managers to try to get people with diabetes, asthma and other chronic conditions to take medicine, eat well and stay out of the hospital.

HHS' demonstration may have helped clinics identify patients with pent-up medical needs, causing the spike in treatment and costs, analysts said. Poor people served by federally funded centers often have trouble getting medical care.

The clinics "were developed to care for more-indigent people," said Dr. Katherine Kahn, who led the RAND evaluation. "It's not even entirely clear that one should expect lower costs initially."

Medical homes have been widely promoted as one solution to America's disconnected health system, which by some estimates wastes 30 percent of its spending on unnecessary treatment, fraud and administrative lard.

By making primary care doctors quarterbacks for treating the chronically ill, the thinking goes, patients can be kept healthy and away from expensive providers.

Health-reform specialists cautioned against counting the RAND report as a strike against medical homes.

"It would be a mistake to say we can conclude that the medical home model does not work," said Dr. Marshall Chin, a professor at the University of Chicago medical school who reviewed drafts of the RAND study.

Indeed, the model was barely tested. Even among clinics that did qualify as medical homes, most weren't certified until late in the program. Becoming a medical home, requiring patient-tracking software, referral protocols and lots of training, was more difficult and took longer than many expected.

HHS didn't respond to requests for an interview. The agency has compared the innovation lab to a venture capital fund, in which some investments are expected to fail as the cost of finding high-payoff winners. Republicans have criticized it as a waste.

"No one study should define the value" of medical homes, said Amy Simmons Farber, spokeswoman for the National Association of Community Health Centers.

The report paints a picture of understaffed clinics struggling to file reports and participate in conference calls for the experiment while they did their normal jobs of caring for patients and trying to get paid by insurance plans.

"Sometimes we're so caught up in all of these different requirements to be in our phone calls or webinars or whatever, and nobody has any time left to do the work that needs to be done," said one unidentified nonprofit executive helping guide the clinics, who was quoted in the RAND study. "And I think that that's kind of what the health centers are feeling, too."

Others suggested that the extra money from HHS — a median of only $26,000 a year per clinic — wasn't nearly enough to make a difference. Instead of trying to transform 500 outpatient centers, some said, HHS should have focused the same amount of money on fewer clinics.

"That's going to go nowhere in supporting the kind of staff or information technology or the time it will take to reconfigure the clinic," Chin said.

Other research shows mixed results on medical homes.

Many analysts believe the X factor for successful medical homes and other payment innovation is giving doctors financial incentives to change referral patterns by letting them share savings from cutting unneeded care. The experiment with federally funded community clinics did not share savings with doctors.

"Transforming to a medical home — it's not fixing one thing," said RAND's Kahn. "It's really changing everything about how the clinic works. On every single level."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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A Scientist Deploys Light And Sound To Reveal The Brain

NPR Health Blog - Mon, 07/27/2015 - 3:57am
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Lihong Wang uses light and sound to create highly detailed images of the living brain.

Chris Nickels for NPR

Lihong Wang creates the sort of medical technology you'd expect to find on the starship Enterprise.

Wang, a professor of biomedical engineering at Washington University in St. Louis, has already helped develop instruments that can detect individual cancer cells in the bloodstream and oxygen consumption deep within the body. He has also created a camera that shoots at 100 billion frames a second, fast enough to freeze an object traveling at the speed of light.

"It's really about turning some of these ideas that we thought were science fiction into fact," says Richard Conroy, who directs the Division of Applied Science & Technology at the National Institute of Biomedical Imaging and Bioengineering.

Wang's ultimate goal is to use a combination of light and sound to solve the mysteries of the human brain. The brain is a "magical black box we still don't understand," he says.

Wang describes himself as a toolmaker. And when President Obama unveiled his BRAIN initiative a couple of years ago to accelerate efforts to understand how we think and learn and remember, Wang realized that brain researchers really needed a tool he'd been working on for years.

"We want to conquer the brain," Wang says. "But even for a mouse brain, which is only a few millimeters thick, we really don't have a technique that allows us to see throughout the whole brain."

Current brain-imaging techniques such as functional MRI or PET scans all have drawbacks. They're slow, or not sharp enough, or they can only see things near the surface.

So Wang has been developing another approach, one he believes will be fast enough to monitor brain activity in real time and sharp enough to reveal an individual brain cell.

Wang's initial idea was to use light. There was a problem, though — one that's obvious if you hold your hand up to a light bulb. When light enters the body, it starts bouncing around.

"This is why we can't even see our own bone in the hands," Wang says. "Because light, after, like, a millimeter, it becomes hopeless to get a very good sharp image."

Wang thought he had a solution. It involved sound. Sound waves don't bounce around much in the body, which is why an ultrasound can show a growing fetus.

Photoacoustic imaging

A photoacoustic image of a mouse's eye shows tiny blood vessels in the iris.

Source: Lihong Wang/Optical Imaging Laboratory/Washington University

But ultrasound images are blurry, sometimes so blurry it's hard to tell a boy from a girl. So Wang began experimenting with a technique that blends the speed and precision of light with the penetrating ability of sound. It's called photoacoustic imaging.

"We're combining the strengths of two forms of energy, light and sound, in a single form of imaging," Wang says.

In the past few years, photoacoustic imaging has become a very big deal in the scientific world. And so has Wang.

Last year, he published more than 50 scientific papers. So far his research has attracted nearly $50 million in grant funding. And Caltech was impressed enough to lure him away from Washington University. His lab will be moved from St. Louis to Pasadena over the next year.

In the meantime, Wang seems to be everywhere, delivering speeches, leading meetings and sitting on scientific advisory boards. "It's really nonstop, right? You have to sleep, but then, other than that, you try to work all the time," he says.

Wang has so many projects going that his lab now has teams working on four different floors of one research building at Washington University.

One of those projects is Wang's latest photoacoustic microscope, which occupies much of a metal workbench the size of a pingpong table. Jinyang Liang, a postdoc, shows me how the device turns light into sound and sound into images of a living brain.

"So that big guy, metal box there, is a laser," Liang tells me. During an experiment, the laser generates pulses of light that travel through a maze of mirrors and filters before reaching an anesthetized mouse on the other side of the table.

A nanosecond pulsed laser beam starts the photoacoustic imaging process.

Geoff Story/Courtesy of Washington University in St. Louis

Once the pulses of light enter the mouse's skull and brain, they start to bounce around. But enough light energy gets through to cause molecules of brain tissue to vibrate. And those vibrations produce distinctive sound waves.

So light goes into the brain, and sounds come out. And just a few months ago, those sounds allowed a lab team to create high-speed, highly detailed, three-dimensional images of a mouse brain at work. "When I first saw that, I was amazed," Liang says.

So was Richard Conroy at the National Institute of Biomedical Imaging and Bioengineering. He says he's often amazed by Wang, who has been funded by the institute for more than a decade.

"He's one of these unique people who's able to take technologies and ideas from one field and apply them to a different field," Conroy says. "So, for example, his work trying to target light at individual cells within the body — that's really borrowing ideas from astronomy."

Photoacoustic imaging can do more than reveal the brain, Conroy says. Wang's lab has helped develop systems that use the technique to show tumors of the breast and skin, and even detect individual cancer cells in the bloodstream.

And Conroy says that's just the beginning. "It's research that really pushes the limits of our understanding of how to image in space and time," he says.

And that could eventually lead to devices as futuristic as the medical tricorder on the starship Enterprise, Conroy says. "It would be great to have a device like they had in Star Trek. You could just lie there, the beam of light would pass over you, it would be able to tell everything that was wrong with you."

Photoacoustic imaging can't do that yet. It still hasn't been used on a human brain. But Wang says he follows a simple rule in his lab: "Never say impossible."

And for Wang, that approach seems to work. A couple of years ago, he got some very special funding from the National Institutes of Health. "This is a grant that gives you unbridled funds for you to do anything you see fit, essentially," he says. "So we were really emboldened to explore very new directions."

One of those directions involved a camera. The goal was to build the fastest camera ever — a camera so fast it could take pictures of light itself.

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Wang picked a small team that included Jinyang Liang, an expert in optics. "We thought, man, I mean, it sounds crazy, but can we see the propagation of light? Because that's literally the fastest object in the universe," Liang says.

Wang suggested an approach to achieve this seemingly impossible feat. And about six months later, the team was showing their boss the first movie ever of a pulse of light reflecting off a mirror.

"At the moment, I feel like he is speechless because, you know, no one has ever seen this before," Liang says.

Wang recalls being awed, but not exactly surprised. "Science really has no limit, you know," he says. "The minute that you reach one limit, you are trying to break it, trying to reach the next limit."

And for Wang, that next limit lies somewhere inside the black box that is the human brain.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

When Alzheimer's Steals Your Appetite, Remember To Laugh

NPR Health Blog - Sat, 07/25/2015 - 5:12pm
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Despite losing his sense of taste and smell to Alzheimer's disease, Greg O'Brien says grilling supper on the back deck with his son on a summer evening is still fun.

Sam Broun/Courtesy of Greg O'Brien

In this installment of NPR's series Inside Alzheimer's, we hear from Greg O'Brien about losing his sense of taste and smell, and how he's learning there's much more to a good meal than food. O'Brien, a longtime journalist in Cape Cod, Mass., was diagnosed with early onset Alzheimer's disease in 2009.

Greg O'Brien has always loved summer grilling with his family on the back porch of his home on Cape Cod, picking up hamburgers or that day's catch to savor with sweet corn and ripe tomatoes. But as his short-term memory has begun to fail, Alzheimer's disease has also begun to deaden his appetite.

Over the past few years, Greg has largely lost his sense of smell, and he can no longer taste most foods. His favorite dishes, he says, "taste like rolled up newspaper."

In fact, every part of putting food on the table has gotten tougher, from driving to the store, to buying groceries, to cooking.

Interview Highlights

On going grocery shopping

In Alzheimer's, now I'm losing my sense of smell and my sense of taste. I used to relish fresh fish and, in the summertime on Cape Cod, right off the dock, the swordfish. But now it all tastes the same.

I'm in the car now, a little reluctant to go inside this big supermarket because last time I saw a good friend of mine in there, and I had something hidden behind my back. It was a case of Depends, because at times I lose my continence. Good buddy, he saw it and he was trying to laugh it through. He said "Greg, you got a problem?" I said, "Eh, it depends!"

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Hear all the stories and subscribe to future entries on the series page.

It's OK to laugh. You've got to have a sense of humor in Alzheimer's. It's OK to laugh.

On how his sense of taste has changed

I used to love tomatoes, sweet corn. [Now] it tastes like toilet paper sometimes. I get Diet Coke or Diet Sprite. I usually have a few swigs during the six or seven times I'm up at night. One thing I can kind of taste are these [frozen] fruit bars. And I really can't taste them — but they feel cold, and that's good.

When memory loss complicates shopping

While at the grocery store, Greg gets a phone call from his son.

Greg: Hey, Conor.

Conor: Did you get my text?

Greg: No, what did it say?

Conor: Get some chicken breast; get some Advil PM; get some good salsa and good chips and, uh, that's it. Oh! And then a little thing of ketchup. And that's it.

Greg: Ketchup! Condiments. OK. All right. Love you! Bye.

(call ends)

Oh [expletive and a laugh], I just forgot what he told me. All I remember now is the ketchup. Maybe I'll get two bottles.

On dealing with Alzheimer's at a small town market

You know it's a nice thing about Cape Cod: Everybody knows everybody. Sometimes it kind of sucks, because everybody knows everybody else's business. And everybody knows I'm slowly losing my marbles.

But they care.

On the sweetness of summer evenings at home.

Sitting on the back deck — a little late, 9:30 — nobody else is here. Conor's watching the Red Sox; my wife and daughter are on their way back from Baltimore. And I'm kind of in my element — which actually makes me feel pretty good.

Greg O'Brien and his family will share more of their experiences with Alzheimer's in coming installments of Inside Alzheimer's on Weekend All Things Considered, and here on Shots.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

California Judge Throws Out Lawsuit On Medically Assisted Suicide

NPR Health Blog - Fri, 07/24/2015 - 9:08pm

Christy O'Donnell, who has advanced lung cancer, is one of several California patients suing for the right to get a doctor's help with prescription medicine to end their own lives if and when they feel that's necessary.

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Three terminally ill patients lost a court battle in California Friday over whether they should have the right to request and take lethal medication to hasten their deaths.

San Diego Superior Court Judge Gregory Pollack said he would dismiss the case, adding that the issues were beyond his role as a judge to decide and should instead be put to the California state legislature or voters to establish new law.

Plaintiffs vowed to appeal the ruling.

"This is certainly frustrating, but it's a temporary setback," said Elizabeth Wallner, a plaintiff in the case, who has been diagnosed with Stage IV colon cancer. "I am optimistic that we'll prevail in the end. It's too big of an issue to leave uncovered."

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Wallner began a series of treatments for her cancer in 2011, including surgeries to remove her colon and parts of her liver, radiation, and numerous rounds of chemotherapy. In the midst of this, when her son was 16, she realized that she wanted to have control over her own death.

"I was throwing up in the bathroom and my son was taking care of me," she said. "I looked over at his face and I saw him absolutely stricken, watching his mother experience this. I thought, that's enough — my son doesn't need to see this. I should have the right to make that decision when it's time."

The case she and others brought to the court seeks to challenge current California law (Section 401 of the state penal code), which makes it a crime to deliberately aid or advise another person to commit suicide. Wallner and the other patients say the law prohibits their doctors from discussing or prescribing medications that could end their lives; and that prohibition, they say, violates their rights to privacy, liberty, and free speech under the California Constitution.

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Attorneys for the plaintiffs — the three patients and a physician — argue that the option to hasten death is an extension of previously recognized legal rights to make end-of-life decisions, including the right to refuse life-sustaining treatments, like a feeding tube or ventilator.

"When you're suffering, and you know you're going to die anyway, it should be up to you to decide when enough is enough," said Kevin Diaz, an attorney and director of legal affairs for the advocacy group Compassion & Choices, which is representing the plaintiffs. "We'll keep trying anyway we can to make sure this is an option."

But California Attorney General Kamala Harris, one of the defendants in the case, argued that there is no right to assisted suicide embedded in California law. Health statutes that protect patients' rights to withdraw treatment, Harris said, do not include a right to provide proactive assistance to end someone's life.

"No court has ever extended the right to privacy to encompass an affirmative medical intervention to kill oneself," Julie Trinh, deputy attorney general, wrote in a legal brief.

She wrote that while the court has sympathized in the past with the plight of the terminally ill, it concluded that the question of allowing physician-assisted suicide is a legislative matter, rather than a judicial one.

The judge in this case agreed. He said he would issue a formal ruling on Monday.

A bill that aims to legalize physician-assisted suicide in California (SB 128) has been tabled for the rest of the year, after stalling in the Assembly Health Committee. Several attempts in other states to pass a similar bill this year have failed.

The practice is legal in five states: The courts authorized the practice in Montana and New Mexico; Vermont passed a law in its legislature; and voters approved ballot measures in Washington and Oregon.

There is one other lawsuit pending in California.

The three patients who are plaintiffs in the case dismissed Friday are worried that the legal process will be too slow to provide relief for them. Christy O'Donnell, a single mother from Santa Clarita, Calif., who is dying from lung cancer, explains her situation in the video below, released earlier this year.

O'Donnell broke down in tears after Friday's hearing. "I don't have much time left to live," she said. "These options are urgent for me."

This story was produced by State of Health, KQED's health blog.

Copyright 2015 KQED Public Media. To see more, visit http://www.kqed.org.
Categories: NPR Blogs