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Vision Problems Increase The Risk Of Death In Older People

NPR Health Blog - 37 min 16 sec ago
Vision Problems Increase The Risk Of Death In Older People August 21, 2014 4:26 PM ET

Seeing better can mean living longer because it helps people remain independent.

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An eye exam may be the ticket to a longer life, researchers say, because good vision is essential for being able to shop, manage money and live independently. And maintaining independence in turn leads to a longer life.

Researchers have known for years that people who have vision problems as they get older are more likely to die than those who still see well. But they weren't sure why that was so.

To answer that question, scientists looked at data from the Salisbury Eye Evaluation, which tracked the vision and health of people ages 65 to 84 living in Salisbury, Md., from 1993 through 2003.

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People's visual problems at the start of the study or their loss of vision didn't directly predict an increased death risk, the researchers found. Instead, the vision loss made it less likely that people could pay their bills, do housework and otherwise manage their lives.

People who lost visual acuity equivalent to one letter on an eye chart each year had a 16 percent increase in mortality risk over eight years, and that was due to the loss in independent living abilities, the researchers said.

"An individual who's remaining relatively stable in their visual acuity in their older years is not seeing this subsequent difficulty in functionality," says Sharon Christ, an assistant professor of human development and family studies at Purdue University, and the lead author of the study. It was published Thursday in JAMA Ophthalmology.

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The researchers did look at whether other factors, including physical illness, race, sex, depression, smoking, alcohol use and obesity, could be causing the increased mortality risk. But they found that the correlation between vision loss and instrumental activities of daily living was the strongest.

Reducing the risk may be as simple as getting an eye exam and new glasses or contact lenses, Christ told Shots. "It's really important to deal with impairment and make sure you're getting the eye care that you need."

People with vision problems that can't be corrected should get help with tasks of everyday life, Christ says, and be encouraged to remain physically active, postponing those functional declines for as long as possible.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Would A Prize Help Speed Development Of Ebola Treatments?

NPR Health Blog - 1 hour 29 min ago
Would A Prize Help Speed Development Of Ebola Treatments? August 21, 2014 3:34 PM ET

Dr. Bruce Ribner, medical director of Emory University Hospital's infectious disease unit, embraces Dr. Kent Brantly (left) who was treated with an experimental Ebola medicine and released from the Atlanta hospital Thursday.

John Bazemore/AP

The human toll of the Ebola epidemic in West Africa is becoming clearer by the day. The virus has killed at least 1,350 people, making this the largest outbreak of the disease ever.

There's no Ebola cure, and only a few experimental treatments are in the works.

One called ZMapp, which contains antibodies against the Ebola virus, was used to treat two Americans who fell ill, a Spanish priest and three health care workers in Liberia, despite the fact that the medicine hadn't been safety tested for humans.

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While the World Health Organization has said it's ethical to use unapproved treatments and vaccine in this unprecedented Ebola outbreak, there aren't many options. And supplies of ZMapp "are now exhausted," WHO said Thursday.

The World Health Organization Says Yes To An Experimental Ebola Drug

What would it take to make Ebola drugs a clinical reality? Financial incentives might help.

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Even now, Ebola isn't the most appealing business proposition for drugmakers. While devastating to the people infected, Ebola hasn't, thankfully, been a widespread illness since it was first identified in 1976. Before the current outbreak, fewer than 3,000 people had reportedly died from the disease.

In the U.S., drugs to treat rare diseases have become lucrative, thanks to tax incentives, special regulatory protection and a willingness by insurers and governments to pay for life-saving treatments.

But Ebola, like many other diseases that are mainly a threat in less-developed countries, have been largely neglected by drugmakers.

Dr. Marie-Paule Kieny, WHO's assistant director-general, said last week that the lack of an approved Ebola drug is a "market failure" because the disease typically strikes "poor people in poor countries where there is no market."

Most Ebola drug research has been financed by the U.S. government, she said, with Canada also pitching in.

For Ebola, there may need to be more financial help to get research started and a reward for success. "As an investor, your expectation is that in the future very few people will have this disease and very few will be in rich countries," says Duke health economist David Ridley. "Should you pay money up front for clinical trials, or should you dangle a sufficiently big prize? It's both."

Ridley is one of the architects of an idea to encourage the development of drugs for neglected tropical diseases that has become U.S. law. Companies that get Food and Drug Administration approval for a drug to treat one of 16 neglected diseases disease get a voucher that moves any drug of their choice to the head of the line for agency review. The fast-track voucher can be sold to another drugmaker that's willing to pay for a shortcut.

Earlier this year, Knight Therapeutics, a Canadian firm, won a voucher when FDA approved its leishmaniasis drug, just the sort of medicine WHO's Kieny wants to see more of. Knight is now trying to cash in its leishmaniasis prize by selling the priority voucher to the highest bidder.

Funding by the Defense Department and National Institutes of Health has provide a push for Ebola research, Ridley says. "An extra pull, like the voucher, would be a great move," he says.

Ebola isn't on the list of neglected tropical diseases that automatically qualify for an FDA voucher. But Ridley says that would be easy to fix. The secretary of Health and Human Services can amend the voucher regulation to cover "any other infectious disease for which there is no significant market in developed nations and that disproportionately affects poor and marginalized populations."

That sounds like Ebola, doesn't it?

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Mental Health Meets 'Moneyball' In San Antonio

NPR Health Blog - 4 hours 58 min ago
Mental Health Meets 'Moneyball' In San Antonio August 21, 201412:05 PM ET

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Leon Evans, director of the community mental health system for Bexar County and San Antonio, broke through barriers that had hindered care.

Jenny Gold/Kaiser Health News

The jails aren't overflowing in San Antonio anymore. People with serious mental illnesses have a place to go for treatment and the city has saved $10 million a year on. How did it happen?

"You know Brad Pitt in the movie Moneyball?" asks Gilbert Gonzalez, Director for the Bexar County Mental Health Department. "Well, the success in that movie was based on the data and analytics. We needed to do the same thing."

Gonzalez's task was to look at all the money San Antonio was spending on mental health in one way or another.

Just eight years ago, the jails, hospitals, courts, police and mental health department in Bexar County all worked separately.

Each part of the system was encountering the same people with serious illnesses, but the people were just cycling through, not getting better. Gonzalez found that the city was spending enormous sums of money while taking care of people with mental illness poorly.

So Leon Evans, director of the community mental health system for Bexar County and San Antonio, got everyone talking. That turned out to be the most challenging piece of the puzzle.

"If you think law enforcement and mental health workers have anything in common, we don't," says Evans. "We speak a different language. We have different goals. There's not a lot of trust there."

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But once the decision-makers saw what could be done if they pooled their resources, every sector chipped in and the county built a single, integrated system where people with mental illnesses could actually get better.

Among other things, the San Antonio center has a 48-hour inpatient psychiatric unit, outpatient primary care and psychiatric services, help with substance abuse, housing for people with mental illnesses and job training. More than 18,000 people pass through the Restoration Center each year.

"San Antonio is ahead of what's a growing trend across the country to try to build a non-hospital alternative for people who are experiencing a psychiatric emergency, often with co-occurring alcohol or other drug abuse," says Dr. Mark Munetz, a psychiatrist and professor at Northeast Ohio Medical University who toured the Restoration Center last year.

But he says the San Antonio model might not work everywhere. The Restoration Center and homeless shelter, he says, felt like "a psychiatric oasis, removing the people from the most central part of the city. It felt a little like segregating people in that part of the city, especially with the homeless shelter next door. I'm not sure how that would fly in other parts of the country."

Nonetheless, the rest of the country has started to notice. City officials say every state in the country has sent delegates to San Antonio to see if they can model their own mental health systems after this one.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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What Kids' Drawings Say About Their Future Thinking Skills

NPR Health Blog - Wed, 08/20/2014 - 9:23am
What Kids' Drawings Say About Their Future Thinking Skills August 20, 2014 9:23 AM ET

Researchers asked 4-year-olds to draw a child. Here's a sample of their artwork.

Twins Early Development Study/King's College in London

At age 4, many young children are just beginning to explore their artistic style.

The kid I used to babysit in high school preferred self-portraits, undoubtedly inspired by the later works of Joan Miro. My cousin, a prolific young artist, worked almost exclusively on still lifes of 18-wheelers.

These early works may be good for more than decorating your refrigerator and cubicle, researchers say. There appears to be an association, though a modest one, between how a child draws at 4 and her thinking skills at 14, according to a study published in the journal Psychological Science.

The findings don't mean parents should worry if their little ones aren't producing masterpieces early on. But the study suggests that intellectual and artistic skills may be related to each other in a way that reveals something about the influence of our genes.

Researchers from King's College London enlisted 7,700 pairs of 4-year-old identical and fraternal twins in England to draw pictures of a child. The researchers scored each drawing on a scale of 0 to 12, based on how many body parts were included. All of the kids also took verbal and nonverbal intelligence tests at 4 and 14.

Kids with higher drawing scores tended to do better on the intelligence tests, though the two were only moderately linked. And that was expected, says Rosalind Arden, a cognitive geneticist who led the study while at the King's College Institute of Psychiatry. The drawing test researchers used was first developed in the 1920s to measure children's cognition. And studies have shown the test to be useful but not always accurate.

In a surprise to the researchers, the drawings and the test results from identical twins (who share all their genes) were more similar to one another than those from fraternal twins (who share only half their genes). "We had thought any siblings who were raised in the same home would be quite similar," Arden tells Shots. The findings add to the growing body of evidence that suggests genes can play a role in both artistic and cognitive ability, she says.

This doesn't mean that a child's genetic predisposition necessarily hurts his or her chances of succeeding in artistic and intellectual endeavors, Arden says. As previous studies have shown, countless factors affect a person's abilities — and genes are only one of them.

How would Jackson Pollock and Mark Rothko have done on the drawing test when they were kids? Arden says she and her colleagues are trying to figure out whether judging the children's art in some other way (maybe based on creativity instead of accuracy) would reveal something different about their intelligence.

But we shouldn't assume that these abstract masters couldn't draw realistically, Arden says. Picasso was a prodigy, who could draw everything from birds to busts with amazing accuracy at a young age. In fact, the artist famously said he easily learned to draw like Raphael when he was young, but it took him a lifetime to learn to draw like a child.

The most amazing thing about the drawings collected for this study is that they represent such a range of both ability and style, Arden says. "I had a fantastic time looking through them."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Cardiologist Speaks From The Heart About America's Medical System

NPR Health Blog - Tue, 08/19/2014 - 3:01pm
Cardiologist Speaks From The Heart About America's Medical System August 19, 2014 3:01 PM ET Listen to the Story 27 min 27 sec   Additional Information: Doctored

The Disillusionment of an American Physician

by Sandeep Jauhar

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The Disillusionment of an American Physician
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As a young doctor working at a teaching hospital, Sandeep Jauhar was having trouble making ends meet. So, like other academic physicians, he took a job moonlighting at a private practice, the offices of a cardiologist. He noticed that the offices were quick to order expensive tests for their patients — even when they seemed unnecessary.

It was "made very clear from the beginning" that seeing patients alone was not financially rewarding for the business, he says.

"Spending 20-30 minutes with a patient might be reimbursed $80, $90, but sending the patient for a nuclear stress test was much more profitable," Jauhar tells Fresh Air's Terry Gross. "A nuclear stress test, at the time when I started working, was reimbursed roughly $800 to $900."

Jauhar was supervising the tests that had been ordered by a physician — and some physician assistants.

"So even though I wasn't ordering the tests, I was in the office while these tests were being performed — and I felt really dirty about it," Jauhar says.

Jauhar's new memoir, Doctored: The Disillusionment of an American Physician, is about how doctors are growing increasingly discontent with their profession. And they're facing more pressures: As the number of patients they're expected to see increases, so does the amount of paperwork. While some doctors who perform a lot of procedures may be paid too much, he writes, many doctors, such as primary care physicians, aren't paid enough.

And, he adds, "the growing discontent has serious consequences for patients."

Jauhar, creator and director of the Heart Failure Program at Long Island Jewish Medical Center, talks about not only unnecessary testing but also uncoordinated care by multiple specialists.

"American medicine is the best in the world when it comes to providing high-tech care," he says. "If you have an esoteric disease, you want to be in the United States. God forbid you have Ebola, our academic medical centers are second to none. But if you have run-of-the-mill chronic diseases like congestive heart failure or diabetes, the system is not designed to find you the best possible care. And that's what has to change."

Interview Highlights

On common complaints doctors have

One of the issues with medicine today is that it's just become so complicated. More and more people are surviving with chronic illnesses, so you have folks in every patient panel who have multiple chronic diseases. And they come to the doctor and they have a whole host of issues that have to be dealt with. And [that doesn't even] mention preventative care, which has become a huge time problem for a lot of primary care physicians.

Dr. Sandeep Jauhar is the creator and director of the Heart Failure Program at Long Island Jewish Medical Center, a teaching hospital. He's the author of an earlier memoir called Intern and contributes to The New York Times.

Janine Sandy/FSG

There's no denying that reimbursement[s] for office visits and for procedures have been drastically cut in the last two or three decades. And that was really an attempt to control health costs. And it seemed to make sense, but it resulted in doctors basically running on a treadmill seeing patients every eight to 10 minutes. So the lack of time to spend with any one patient is a big factor.

On "defensive medicine"

There's no question that there's a lot of unnecessary testing in American medicine today and the reasons for it are manyfold. Part of it is ... a lack of time. You have a patient come into your office and you have eight minutes with them and they have lower back pain and you don't want to miss something because one of the major causes of dissatisfaction among doctors today is malpractice liability; there's that fear.

A lot of doctors are practicing defensive medicine. There have been various estimates that defensive medicine costs up to $100 billion a year out of the roughly $3 trillion we spend on health care, so it's a huge, huge waste. ... It takes time to evaluate the patient, get a good history, examine the patient, and it's just so much easier to order a test— especially when the financial incentives of the system are to reward for more and more testing.

On uncoordinated care by multiple specialists

Today if you go to a hospital, it's rare that you won't have multiple specialists on your case. And I'm a specialist [in cardiology], and when I'm called to see someone with a nonspecific symptom like shortness of breath, which could be a whole host of diagnoses, I'm apt to view the problem through my own expertise. And that's true of rheumatologists and hematologists and so on.

One patient who came in with shortness of breath — his primary care physician called 15 specialists onto the case. ... He underwent 12 procedures in the hospital, and when he was sent home he had follow-up visits with seven different specialists. ... We actually never figured it out. This is so common. ...

When you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician. But when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise and these recommendations are frequently not coordinated and so you get a whole host of recommendations and suggestions for care. But no one is really talking and trying to coordinate this care, so it makes it very difficult for the physician who is trying to manage the whole patient and treat the whole patient and getting these multiple inputs to know what to do.

On treating patients near the end of life

“ I've seen patients have their last days prolonged in misery because of the actions of their well-meaning family members who don't want to let go, and sometimes even by physicians and — unfortunately, at least in one case — by me.

I've seen patients have their last days prolonged in misery because of the actions of their well-meaning family members who don't want to let go, and sometimes even by physicians and — unfortunately, at least in one case — by me.

I had a very dear patient of mine who had severe congestive heart failure and had a very leaky heart valve and she became one of my favorite patients. ... She was in her late 80s and one day I was told she was in the intensive care unit and it turns out she had gone to the emergency room with shortness of breath. ... She had gone into kidney failure because of the poor blood flow to her kidneys.

And I took the attending physician aside and said, "So are we going to provide dialysis?" And he said, "No." And I said, "Why not?" And he said, "Because I don't think it's appropriate, it's futile. She's at the end of her life." I couldn't see that because she had been so vibrant despite all the medical problems.

In the end I argued for being aggressive and he wouldn't budge and so I actually went to the chairman of the department and I transferred the patient to my care in the cardiac unit. ... And there I went through a lot of ... very aggressive interventions to try to save her. It wasn't because of financial incentives — I'm on salary — it was because I just didn't want to lose her. ...

About eight or nine days later she died. There's no question that I deceived myself — that I thought somehow I could keep death at bay and that my judgment was clouded by my love for this patient and not wanting to let her go. ...

Now I'm much more circumspect about how I handle these cases. And in recent years, I've created much more of a relationship with the palliative care team and the hospice team in my hospital. And I think it's been much better for my terminally ill patients.

Read an excerpt of Doctored

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How To Make Sense Of Health Insurance Alphabet Soup

NPR Health Blog - Tue, 08/19/2014 - 12:34pm
How To Make Sense Of Health Insurance Alphabet Soup August 19, 201412:34 PM ET

Partner content from

There must be an HMO in here somewhere.

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What's in a name? When it comes to health plans sold on the individual market, these days it's often less than people think.

The lines that distinguish HMOs, PPOs, EPOs and POS plans from one another have blurred, making it hard to know what you're buying by name alone, assuming you're one of the few people who know what an EPO is in the first place.

Ideally, the plan name provides a shorthand way to determine the sort of access members have to hospitals and doctors, including cost-sharing for such treatment. But since there are no industry-wide definitions of plan types and state standards vary, individual insurers often have leeway to market similar plans under different names.

"Now, there's a lot of gray out there," says Sabrina Corlette, project director at Georgetown University's Center on Health Insurance Reforms.

In general:

Health maintenance organizations cover only care provided by doctors and hospitals inside the HMO's network. HMOs often require people to get a referral from their primary care physician in order to see a specialist.

Preferred provider organizations, or PPOs, cover care provided both inside and outside the plan's network. Patients typically pay a higher percentage of the cost for out-of-network care.

Exclusive provider organizations are a lot like HMOs: They generally don't cover care outside the plan's provider network. People in EPOs, however, may not need a referral to see a specialist.

Point of Service, or POS, plans vary, but they're often a sort of hybrid HMO/PPO. Patients may need a referral to see a specialist, but they may also have coverage for out-of-network care, though with higher cost sharing.

Although insurers identify plans by type in the coverage summaries they're required to provide under the health law, one PPO may offer very different out-of-network coverage than another.

"You have PPOs with really high cost sharing for out-of-network services, which from a consumer perspective seem a lot like HMOs," says Corlette. Some plans labeled as PPOs don't offer out-of-network services at all. On the other hand, some HMOs have an out-of-network option that makes them seem similar to PPOs.

Higher premiums didn't necessarily correlate with better out-of-network coverage, says Caroline Pearson, vice president at Avalere Health, a research and consulting firm.

Since you can't rely on plan type to provide clear guidance on out-of-network coverage, there are three basic questions to investigate when evaluating a plan, says Pearson:

  1. Is there out-of-network coverage?
  2. Does that out-of-network spending accrue toward your out-of-pocket maximum? Legally it doesn't have to, but some plans include it.
  3. Do you need a primary care physician gatekeeper?

That's only the beginning. Once you figure out whether a plan covers out-of-network care, it can be difficult to find out whether your doctor is even in that plan. You can check with you doctor's office, but sometimes they don't know.

You can also look at provider directories to see who is and isn't in a plan's network, however, that information frequently proved inadequate or inaccurate during the last open enrollment period. But understanding the alphabet soup of plan types is an important first step.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Pittsburgh Health Care Giants Take Fight To Each Other's Turf

NPR Health Blog - Tue, 08/19/2014 - 3:38am
Pittsburgh Health Care Giants Take Fight To Each Other's Turf August 19, 2014 3:38 AM ET Listen to the Story 5 min 47 sec  

The headquarters for University of Pittsburgh Medical Center and Highmark Blue Cross/Blue Shield dominate the Pittsburgh skyline much as they organizations have dominated health care in the region for decades.

Jeff Brady/NPR

Pittsburgh's dominant health insurance company and its largest healthcare provider are, essentially, getting a divorce.

For decades, Highmark Blue Cross/Blue Shield and University of Pittsburgh Medical Center worked together. But as the line between insurance companies and health care providers across the country blurs, these longtime allies are venturing into each other's business and becoming competitors.

In the process, patients can get caught in the middle. Day-care worker Gail Jameson has Highmark insurance and she's been going to the same UPMC medical office for more than 20 years. "I could go in and just stop in if I needed to because it's close to my work," Jameson says. "I go past it every day."

She's about five years from retirement and was disappointed to learn her Highmark policy will no longer include UPMC providers. She has to find all new doctors through another health system that is unfamiliar to her.

The road to divorce began when insurer Highmark got into the hospital business. It bought the struggling West Penn Allegheny Health System, which was UPMC's main competitor.

"Highmark stepped in in order to ensure that there was competition in the marketplace and there would continue to be consumer choice," says Highmark President and CEO David Holmberg. In a town where UPMC controls more than 60 percent of the market, Holmberg says there needs to be healthier competition among providers.

Additional Information: YouTube

Highmark's TV ad from 2013 encourages UPMC to sign a long-term service contract.

There's another reason an insurance company would decide to become a healthcare provider: the Affordable Care Act. It tells insurance companies what basic services to offer; who they must insure and even what percent of premiums can go to administrative expenses and profits. That takes away a lot of what insurance companies used to do, so they're looking for new reasons to exist.

"Insurers are trying to demonstrate that they bring value to the table and are doing more than just brokering a benefit ... and doing more than paying bills," says Gail Wilensky, senior fellow at Project HOPE.

Wilensky says some insurance companies are responding by building more efficient networks of high-quality providers. Highmark went a step beyond that and became a provider of health care itself.

UPMC responded by expanding its existing insurance business and refusing to sign a new long-term contract with Highmark, saying it could not both compete and work with Highmark.

Additional Information: YouTube

UPMC's TV ad from 2013 explains why it can't sign a new long-term service contract with Highmark.

"We couldn't have a contract with them," says UPMC President and CEO Jeffrey Romoff, "Because they [Highmark] have the burden of keeping their provider side alive. So, for every one of their insurance subscribers they will want to steer them to go to their own providers."

The divorce of Highmark from UPMC is all but final now. An agreement between the two companies will expire on January 1, 2015. The state of Pennsylvania negotiated a transition agreement. It does things like ensure Highmark subscribers already in certain kinds of treatment at UPMC can continue receiving care.

Now the Pittsburgh health care landscape looks very different. "It went from one of the least competitive environments that you can imagine — a dominant insurer and a dominant health system joined at the hips with a long term contract," says Romoff, "To one without a long-term contract with, now, five choices."

In addition to the two new competitors, UPMC invited three large insurance companies into the Pittsburgh market: Cigna, Aetna and United Healthcare. "Competition is good," says Romoff, "It keeps us all on top of our game. It gives us incentive to not be fat and sloppy."

With competition come the marketing campaigns. UPMC is banking on its good reputation. Highmark will appeal to those concerned about price. "For some people their monthly premium and the cost of their health care may be more important than having access to everything," Holmberg says.

In Pittsburgh now people have a lot more choices — and decisions — to make when it comes to their health care. That's supposed to be a good thing. But for Jameson, who was satisfied with her Highmark-UPMC combination, the extra work is a pain. "I just don't like change. I shouldn't have to change," says Jameson.

It's not just patients dealing with change. Employers who buy insurance for their workers face difficult decisions too. With two insurance/provider networks that don't allow access to each other, Pittsburgh employers can be put in the position of, effectively, choosing which doctors treat their workers.

"Employers want to provide benefits that allow them to be competitive and attract and retain a productive work force," says Jessica Brooks, executive director of the Pittsburgh Business Group on Health. "They don't want to be in the business of making personal life decisions around who their employees can see and who they can't see," she says.

The Affordable Care Act aims to increase the quality and affordability of health care. Creating competitive marketplaces is part of the plan. It will be a few years before people in Pittsburgh and around the country know whether the changes happening now make those goals reality.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Mental Health Cops Help Reweave Social Safety Net In San Antonio

NPR Health Blog - Tue, 08/19/2014 - 3:34am
Mental Health Cops Help Reweave Social Safety Net In San Antonio August 19, 2014 3:34 AM ET

Partner content from

Listen to the Story 7 min 1 sec  

Officers Ned Bandoske (left) and Ernest Stevens are part of San Antonio's mental health squad — a six-person unit that answers the frequent emergency calls where mental illness may play a role.

Jenny Gold/Kaiser Health News

It's almost 4 p.m., and police officers Ernest Stevens and Ned Bandoske have been driving around town in their unmarked black SUV since early this morning. The officers are part of San Antonio's mental health squad — a six-person unit that answers the frequent emergency calls where mental illness may be an issue.

The officers spot a call for help on their laptop from a group home across town.

“ We had absolutely no training 20 years ago in the police academy on how to deal with mental health disturbances.

"A male individual put a blanket on fire this morning," Stevens reads from the blotter. "He's arguing ... and is a danger to himself and others. He's off his medications."

A few minutes later, the SUV pulls up in front of the group home. A thin 24-year-old sits on a wooden bench out back, wearing a black hoodie.

Additional Information: Lessons From San Antonio

Jail is an expensive, ineffective way to treat the mental health problems that underlie some low-level crime, police in San Antonio say. In Part Two of her Morning Edition series, reporter Jenny Gold takes us inside an alternative treatment program.

Listen to the story

"You're Mason?" asks Bandoske. "What happened to your blanket?" Eight years ago, the next stop for someone like Mason would have been a hospital emergency room or jail. (Because of his condition, NPR is not using Mason's last name.) But the Bexar County jail, in San Antonio, was so overcrowded — largely with people with serious mental illnesses — that the state was getting ready to levy fines.

This sort of situation is not unusual: Across the country, jails hold 10 times as many people with serious mental illness as state hospitals do, according to a recent report from the Treatment Advocacy Center, a national nonprofit that lobbies for better treatment options for people with mental illness.

To deal with the problem, San Antonio and Bexar County have transformed their mental health system into a program considered a model for the rest of the nation. Today, the jails aren't full, and the city and county have saved $50 million over the past five years.

The effort has focused on an idea called "smart justice" — basically, diverting people with serious mental illness out of jail and into treatment instead.

San Antonio's new approach starts with the kind of interaction Bandoske and Stevens are having with Mason. The troubled young man is hunched over, and his eyes dart back and forth between the two officers. He mumbles answers to the officers' questions, sometimes stopping to stare at a spot in the distance. For outsiders, it's hard to know what's going on, but the officers say they can tell Mason is hallucinating. Bandoske kneels in front of him, trying to maintain eye contact and get Mason's attention.

Officer Stevens responds to an emergency mental health call in regards to Mason, 24, at a group home in San Antonio.

Jenny Gold/Kaiser Health News

"Are you hearing some voices right now?" Bandoske asks. "You are, aren't you? What are the voices telling you?" Mason is silent, but Bandoske persists. "Hey Mason, you're seeing something that I'm not seeing. What is it?"

These officers seem more like social workers than law enforcers. Stevens says that's a huge change from his early days on the police force.

"We had absolutely no training 20 years ago in the police academy on how to deal with mental health disturbances," recalls Stevens.

Back then, the police were repeatedly arresting the same people; many not only had a serious mental illness but were also addicted to drugs or alcohol, and were often homeless. And whether they went to the jail or the ER, it was expensive for everyone — the jails, the hospitals and the police department that had to pay for overtime while cops waited at the hospital.

San Antonio's response was to require all officers to take a 40-hour course called Crisis Intervention Training, to learn how to handle mental health crises.

But even with strong programs, there's only so much that training alone can do; there's still the problem of where to take patients like Mason.

Around the Nation What Is The Role Of Jails In Treating The Mentally Ill?

San Antonio tackled that problem, too.

People who commit a felony still go to jail, regardless of their mental status. And those who need extensive medical care are taken to the hospital.

Shots - Health News A Son's Death Reveals Chasms In Emergency Mental Health Care

But for patients like Mason, San Antonio built another option: the Restoration Center, a separate facility with a full array of mental and physical health services.

The center was the brainchild of Leon Evans, director of San Antonio's mental health department.

When he took over the department 14 years ago, Evans says not one of the county or city agencies and nonprofits that deal with mental illness was talking to another. The jails, hospitals, courts, police and mental health department all worked in separate silos.

"People who fund these services only look at their little, small piece of the pie and whether there is a return on investment," says Evans.

So, with the help of a county judge, Evans worked to get the funders together to talk about the money they were all spending on mental health. Once they stopped looking at mental health as an isolated expense, the groups realized they were spending enormous sums of money and offering poor care. Pooling their resources instead, they found, could offer significant savings.

Everyone contributed funding to create the Restoration Center. It offers a 48-hour inpatient psychiatric unit; outpatient services for psychiatric and primary care; centers for drug or alcohol detox; a 90-day recovery program for substance abuse; plus housing for people with mental illnesses, and even job training.

More than 18,000 people pass through the Restoration Center each year, and officials say the coordinated approach has saved the city more than $10 million annually.

When Mason arrives at the center, nurse Catherine Riojas checks him in immediately. She gives Mason a physical and helps him get settled in an inpatient psychiatric unit that keeps patients for 48 hours.

And then, about 15 minutes after the police officers walked through the door of the center, they're heading out again, ready to get back on the street.

"OK, Mason, good luck," Stevens calls to the young man, and waves. "OK, buddy? Hope you feel better."

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

Medicare Patients Often See Nurses Instead Of Doctors For Skin Problems

NPR Health Blog - Mon, 08/18/2014 - 1:22pm
Medicare Patients Often See Nurses Instead Of Doctors For Skin Problems August 18, 2014 1:22 PM ET

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Nurse practitioners and physician assistants are taking on more and more responsibility for primary care these days. And an analysis of Medicare data finds many of these health care providers are performing procedures you might not have expected.

More than half of the 4 million procedures that office-based nurse practitioners and physician assistants independently billed Medicare for in 2012 were dermatological surgeries.

That's not surprising to Ken Miller, president of the American Association of Nurse Practitioners. He said older patients, such as those on Medicare, often have skin problems, such as "boils, skin tags and warts."

The study, published in JAMA Dermatology, focused on procedures for which these providers billed more than 5,000 times a year.

"I think that's where you're going to see the majority of procedures that are occurring both in primary care and in some of the other specialties like geriatric clinics," he said.

The study's lead author, Dr. Brett Coldiron, a dermatologist and clinical assistant professor at the University of Cincinnati, said while the "intent for midlevel nurse practitioners was to give primary care," the level of surgical billing implies that they may be doing more.

He said those midlevel providers — PAs and NPs — "are doing invasive procedures and surgery. I'm not sure they were trained to do that."

But practitioners who perform specialized procedures often have received additional training, according to Miller. "If they find something that is out of their scope, they will refer," he said. "It's the same thing that primary care physicians do."

The analysis found that a majority of procedures billed by nurse practitioners and physician assistants relate to dermatology, a trend Coldiron said could stem from the frequency of dermatological procedures being performed in offices rather than hospitals, along with the higher rate of skin cancer among the older patients Medicare covers.

The nurse practitioners performing specialized dermatological procedures often have received extra training, Miller said, and they often attend "the same symposiums and conferences dermatologists actually attend."

"If they're in the same subspecialty of dermatology, they may be doing these procedures because that's how they've been trained," he said.

He thinks no more than 3 or 4 percent of nurse practitioners actually end up specializing in a specific area of care. But all nurse practitioners will often see patients with dermatological conditions, and the treatments they require are usually not "extraordinary," he said.

Coldiron said while the midlevel providers may have received extra training within a relevant specialty, many likely lack the expertise of doctors who have done a residency within the field. "If nurses are going to practice surgery, that's not [nursing] — that's medicine," he said.

Nurse practitioners and physician assistants have been suggested as a potential solution to shortages of primary care physicians.

The study cautioned that a boost in midlevel providers performing surgical procedures could lead to more cases of malpractice, a concern Coldiron said suggested a need for greater regulatory oversight of nurse practitioners and physician assistants.

But that kind of argument is a "red herring," Miller argued.

"There have been no real studies out there that show nurse practitioners are less safe than physicians," he said. "What we're all trying to do," he added, is "trying to provide the best care and the best quality of care."

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

The Power Of The Peer Group In Preventing Campus Rape

NPR Health Blog - Mon, 08/18/2014 - 3:51am
The Power Of The Peer Group In Preventing Campus Rape August 18, 2014 3:51 AM ET Listen to the Story 8 min 14 sec   Maria Fabrizio for NPR

Many forces can drive a male college student to commit sexual assault. But one of the most important may be the company he keeps.

A number of studies, on college campuses and elsewhere, have shown that having friends who support violence against women is a big risk factor for committing sexual assault. Now prevention efforts are exploring the idea that having male friends who object to violence against women can be a powerful antidote to rape on college campuses.

"One of the things that matters most to boys and emerging adult men is the opinion of other men," says John Foubert, a researcher at Oklahoma State University who studies rape prevention among young men.

One of the most well-known studies on perpetrators of campus sexual assault is psychologist David Lisak's 2002 "undetected rapists" study. Because few campus rapes are ever reported, much less prosecuted, Lisak looked for sex offenders hiding in plain sight at University of Massachusetts in Boston.

“ There is a small percentage of college students who are sex offenders. They are behaving like sex offenders. They are sex offenders.

He surveyed about 1,800 men, asking them a wide range of questions about their sexual experiences. To learn about sexual assault, he asked things like, "Have you ever had sex with an adult when they didn't want to because you used physical force?" When the results came back, he was stunned.

All told, 120 men in the sample, or about 6 percent of the total, had raped women they knew. Two-thirds of those men were serial rapists, who had done this, on average, six times. Many of the serial rapists began offending before college, back in high school.

Other studies at colleges and in the military have since found similar numbers — usually somewhere around 10 percent of men admitting to either an attempted rape or a rape, with a significant proportion of them reporting a history of repeated offenses.

"I was forced, really, to accept that these are college students, but there is this small percentage of college students who are sex offenders," says Lisak. "They are behaving like sex offenders. They are sex offenders."

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Together, the 120 men in Lisak's study were responsible for 439 rapes. None was ever reported.

But Lisak had no problem getting details about how the men carefully planned and executed their assaults. They'd often ask a girl to come to a party, saying it was invite-only, a big deal to a nervous freshman. Then they'd get her drunk to the point of incapacitation so they could have sex with her.

In an excerpt from one of Lisak's interview transcripts, a college student using the pseudonym Frank talks about how his friends would help him prep for an assault:

“ This idea that getting somebody intoxicated so you can have sex with them is an idea we just simply have to confront and erode.

"We always had some kind of punch, you know, like our own home brew. We'd make it with a real sweet juice, and just pour in all kinds of alcohol. It was really powerful stuff. The girls wouldn't know what hit them."

Alcohol was the weapon of choice for these men, who typically saw themselves as college guys hooking up. They didn't think what they had done was a crime.

"Most of these men have an image or a myth about rape, that it's some guy in a ski mask wielding a knife," says Lisak. "They don't wear ski masks, they don't wield knives, so they don't see themselves as rapists."

In fact, they'd brag about what they had done afterwards to their friends. That implied endorsement from male friends — or at the very least, a lack of vocal objection — is a powerful force, perpetuating the idea that what these guys are doing is normal rather than criminal.

But in a group of guy friends, Oklahoma State's Foubert says, the opinions that can end up influencing behavior are often just what a guy thinks his friends think.

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"Let's say you have a peer group of 10 guys," says Foubert. "One or two are constantly talking about, 'Oh, I bagged this b- - -h.' Many of the men listening to that are uncomfortable, but they think that the other men support it through their silence."

What if that silence could be broken before college — as early as high school?

At a few high schools in Sioux City, Iowa, students are starting to find out what that might look like.

MVP, or Mentors in Violence Prevention, matches upperclassmen with groups of incoming freshmen. Throughout the school year, the older kids facilitate discussions about relationships, drinking, sexual assault and rape.

Xavier Scarlett, a rising senior and captain of the football, basketball and track teams, says he tries to get inside the heads of the freshmen guys he mentors. They talk through various scenarios. What does it mean to hook up with a drunk girl when you're sober? Would you be letting down your guy friends if you didn't hook up in that situation?

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And they spend a lot of time on that scenario Lisak heard about over and over in his U-Mass Boston study. You're at a big party. You see a guy you know with an extremely drunk girl, and he's trying to leave with her.

Scarlett says he talks through all the options with the freshmen in his group. "Do I let them just leave? Or do I grab him, or do I grab her? Or do I get some friends? If I say something, then will my friend judge me?"

These conversations are tough, often awkward, in high school. A lot of the mentors still haven't confronted this kind of situation in real life by the time they graduate. But once they get to college, says Iowa State University junior Tucker Carrell, a former MVP mentor, the scenarios come to life.

Tucker says that he's not afraid to confront his Delta Tau Delta fraternity brothers when they talk about women in a way that makes him uncomfortable. He'll sit down with them, sometimes even bringing a woman they've hit on into the conversation.

The day we talked, Tucker said he'd used his MVP training to intervene in a situation just the night before.

This was at a going-away party at a bar in Ames, Iowa. Tucker noticed that a friend's female cousin was pretty drunk. She was over by the jukebox with two guys who weren't part of the party. They were strangers. Tucker says he was paying attention to her body language, and something didn't look right. She looked almost cornered.

So Tucker grabbed a buddy, and they went over to the jukebox together.

"We were like, 'Hey, let's pick a song.' So we picked a song. And then we were like, 'Do you want to go to the table and see your cousin?' "

They steered her back toward their group of friends.

And that was it. The night went on as if nothing had happened.

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Lisak says by the time 18-year-olds leave for college, they need to be hearing this kind of challenge from their guy friends.

"This idea that getting somebody intoxicated, plastered, so that you can have sex with them is an idea we just simply are going to have to confront and erode," he says. "Just like we have eroded the idea that it's fine to get drunk and get in your car."

There are only a few dozen high schools around the country that offer the MVP program. It's been used in high schools around Sioux City, Iowa, for over a decade now. Surveys of participating students suggest their attitudes about sexual assault, and intervening in dangerous situations, shift after they go through the program, but researchers have yet to evaluate how effective it is in reducing incidents of sexual violence.

John Foubert, the psychologist in Oklahoma, says it's important to remember that 90 percent of men have never committed a rape. The key is opening their eyes to what's going on with the other 10 percent, so they can see it and intervene.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

When Patients Read What Their Doctors Write

NPR Health Blog - Sun, 08/17/2014 - 5:29am
When Patients Read What Their Doctors Write August 17, 2014 5:29 AM ET Katherine Streeter for NPR

The woman was sitting on a gurney in the emergency room, and I was facing her, typing. I had just written about her abdominal pain when she posed a question I'd never been asked before: "May I take a look at what you're writing?"

At the time, I was a fourth-year medical resident in Boston. In our ER, doctors routinely typed visit notes, placed orders and checked past records while we were in patients' rooms. To maintain at least some eye contact, we faced our patients, with the computer between us.

But there was no reason why we couldn't be on the same side of the computer screen. I sat down next to her and showed her what I was typing. She began pointing out changes. She'd said that her pain had started three weeks ago, not last week. Her chart mentioned alcohol abuse in the past; she admitted that she was under a lot of stress and had returned to heavy drinking a couple of months ago.

As we talked, her diagnosis — inflammation of the pancreas from alcohol use — became clear, and I wondered why I'd never shown patients their records before. In medical school, we learn that medical records exist so that doctors can communicate with other doctors. No one told us about the benefits they could bring when shared with patients.

In fact, before the Health Insurance Portability and Accountability Act, a federal law enacted in 1996, patients generally had to sue to see their records. HIPAA, as that mouthful is abbreviated, affirmed that patients have a right to their medical information. But the process for obtaining records was often so cumbersome that few patients tried to access them.

In 2010, Tom Delbanco, an internist, and Jan Walker, a nurse and researcher, started an experiment called OpenNotes that let patients read what their primary care providers write about them. They hypothesized that giving patients access to notes would allow them to become more engaged in their care.

Many doctors resisted the idea. Wouldn't open medical records inhibit what they wrote about sensitive issues, such as substance abuse? What if patients misunderstood the notes? Would that lead to more lawsuits? And what would patients do with all the information anyway?

After the first year, the results were striking: 80 percent of patients who saw their records reported better understanding of their medical condition and said they were in better control of their health. Two-thirds reported that they were better at sticking with their prescriptions. Ninety-nine percent of the patients wanted OpenNotes to continue, and no doctor withdrew from the pilot. Instead, they shared anecdotes like mine. When patients see their records, there's more trust and more accuracy.

That day in the Boston ER was a turning point for me. Since I started sharing notes with my patients, they have made dozens of valuable corrections and changes, such as adding medication allergies and telling me when a previous medical problem has been resolved. We come up with treatment plans together. And when patients leave, they receive a copy of my detailed instructions. The medical record becomes a collaborative tool for patients, not just a record of what we doctors do to patients.

The OpenNotes experiment has become something of a movement, spreading to hospitals, health systems and doctors' offices across the country. The Mayo Clinic, Geisinger Health System and Veterans Affairs are among the adopters so far. (The OpenNotes project has received funding from the Robert Wood Johnson Foundation, which also provides financial support to NPR.)

But there are new controversies arising. Should patients receiving mental health services obtain full access to therapy records, or should there be limits to open records? What happens if patients want to share their records on social media? Will such "crowdsourcing" harm the doctor-patient relationship? What if patients want to develop their own record and videotape their medical encounter? Are doctors obligated to comply?

Delbanco tells me that he considers OpenNotes to be "like a new medication." Just like any new treatment, it will come with unexpected side effects. In the meantime, patients and doctors don't need to wait for the formal OpenNotes program to come to town. Patients can ask their doctors directly to look at their records. Doctors can try sharing them with patients, in real time, as I do now. It's changed my practice, and fundamentally transformed my understanding of whom the medical record ultimately belongs to: the patient.

Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. She is the author of "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Care," and founder of Who's My Doctor, a project to encourage transparency in medicine. On Twitter: DrLeanaWen

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

When Patients Read What Their Doctors Write

NPR Health Blog - Sun, 08/17/2014 - 5:29am
When Patients Read What Their Doctors Write August 17, 2014 5:29 AM ET Listen to the Story 3 min 54 sec   Katherine Streeter for NPR

The woman was sitting on a gurney in the emergency room, and I was facing her, typing. I had just written about her abdominal pain when she posed a question I'd never been asked before: "May I take a look at what you're writing?"

At the time, I was a fourth-year medical resident in Boston. In our ER, doctors routinely typed visit notes, placed orders and checked past records while we were in patients' rooms. To maintain at least some eye contact, we faced our patients, with the computer between us.

But there was no reason why we couldn't be on the same side of the computer screen. I sat down next to her and showed her what I was typing. She began pointing out changes. She'd said that her pain had started three weeks ago, not last week. Her chart mentioned alcohol abuse in the past; she admitted that she was under a lot of stress and had returned to heavy drinking a couple of months ago.

As we talked, her diagnosis — inflammation of the pancreas from alcohol use — became clear, and I wondered why I'd never shown patients their records before. In medical school, we learn that medical records exist so that doctors can communicate with other doctors. No one told us about the benefits they could bring when shared with patients.

In fact, before the Health Insurance Portability and Accountability Act, a federal law enacted in 1996, patients generally had to sue to see their records. HIPAA, as that mouthful is abbreviated, affirmed that patients have a right to their medical information. But the process for obtaining records was often so cumbersome that few patients tried to access them.

In 2010, Tom Delbanco, an internist, and Jan Walker, a nurse and researcher, started an experiment called OpenNotes that let patients read what their primary care providers write about them. They hypothesized that giving patients access to notes would allow them to become more engaged in their care.

Many doctors resisted the idea. Wouldn't open medical records inhibit what they wrote about sensitive issues, such as substance abuse? What if patients misunderstood the notes? Would that lead to more lawsuits? And what would patients do with all the information anyway?

After the first year, the results were striking: 80 percent of patients who saw their records reported better understanding of their medical condition and said they were in better control of their health. Two-thirds reported that they were better at sticking with their prescriptions. Ninety-nine percent of the patients wanted OpenNotes to continue, and no doctor withdrew from the pilot. Instead, they shared anecdotes like mine. When patients see their records, there's more trust and more accuracy.

That day in the Boston ER was a turning point for me. Since I started sharing notes with my patients, they have made dozens of valuable corrections and changes, such as adding medication allergies and telling me when a previous medical problem has been resolved. We come up with treatment plans together. And when patients leave, they receive a copy of my detailed instructions. The medical record becomes a collaborative tool for patients, not just a record of what we doctors do to patients.

The OpenNotes experiment has become something of a movement, spreading to hospitals, health systems and doctors' offices across the country. The Mayo Clinic, Geisinger Health System and Veterans Affairs are among the adopters so far. (The OpenNotes project has received funding from the Robert Wood Johnson Foundation, which also provides financial support to NPR.)

But there are new controversies arising. Should patients receiving mental health services obtain full access to therapy records, or should there be limits to open records? What happens if patients want to share their records on social media? Will such "crowdsourcing" harm the doctor-patient relationship? What if patients want to develop their own record and videotape their medical encounter? Are doctors obligated to comply?

Delbanco tells me that he considers OpenNotes to be "like a new medication." Just like any new treatment, it will come with unexpected side effects. In the meantime, patients and doctors don't need to wait for the formal OpenNotes program to come to town. Patients can ask their doctors directly to look at their records. Doctors can try sharing them with patients, in real time, as I do now. It's changed my practice, and fundamentally transformed my understanding of whom the medical record ultimately belongs to: the patient.

Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. She is the author of "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Care," and founder of Who's My Doctor, a project to encourage transparency in medicine. On Twitter: DrLeanaWen

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Has Health Law Helped Young People Get Mental Health Treatment? Maybe

NPR Health Blog - Fri, 08/15/2014 - 1:55pm
Has Health Law Helped Young People Get Mental Health Treatment? Maybe August 15, 2014 1:55 PM ET Ceneri/iStockphoto Shots - Health News For New College Grads, Finding Mental Health Care Can Be Tough Shots - Health News More Young Adults Get Inpatient Psychiatric Care After Health Law

Mental health issues like depression, anxiety and substance abuse often start in adolescence, then peak in young adulthood. But for young people who don't have steady jobs or stable paychecks, getting help can be tough.

A popular provision of the Affordable Care Act that took effect in 2010 aimed to make it easier for young adults to get access to health care, by allowing them to stay on their parents' insurance until they turn 26.

So, are more young adults getting help with mental health issues because of the provision? Maybe, suggests a study published in the September issue of Health Affairs.

Before 2010, just over 30 percent of young adults with mental health issues said they were getting treatment. And that went up by about 2 percent in the two years after the ACA provision took effect, the study found, based on data from the National Survey on Drug Use and Health.

That's not much of an increase, and researchers can't say exactly why the rate went up. But, they say, there's evidence that the ACA provision is at least partly responsible.

Once it took effect, uninsured visits to mental health care providers went down by 12.4 percent, while the number of visits paid by private insurance increased by 12.9 percent. And among older adults in the 26-to-35 age group, who weren't affected by the provision, the number seeking care went down.

One thing that didn't change during this time period was the number of young people getting treatment for substance abuse.

"This is a first glimpse — an early look at what's happening," says Brendan Saloner, an assistant professor at the Johns Hopkins Bloomberg School of Public Health who led the study.

We asked Saloner about the work and what's keeping young adults from getting the mental health care they need. The conversation has been edited for length and clarity.

Were you surprised at all by what the study found?

What really surprised us was that the stories were not consistent for substance abuse and mental health treatment. We had expected both mental health and substance abuse treatment to go up after the ACA provision passed.

We're still trying to make sense of why that is.

I think that speaks to the fact that there are probably very different systems in play for mental health and substance abuse. People with substance abuse problems are more likely to come into contact with the criminal justice system, in many cases. When people get arrested, do they get care when they're in jail and prison?

Colleges and universities are also places where a lot of young adults with substance use problems are right now. Are they getting the services that they need?

The numbers for mental health care didn't seem to budge that much either.

If you just focus on the trend among young adults, then the uptick is indeed rather modest. But we made the assumption that were it not for the ACA provision, the trends for the young adults would be the same as the trend for the older adults. And that went down — the economy was bottoming out and a lot of people were losing their insurance.

So it's important that young adults were able to maintain some modest improvement while treatment for older adults was going down. The policy can be successful even if it only has a modest effect in improving access.

Even so, only about a third of young adults who need help are actually getting it. Why is that?

That's consistent with what we know from national data. We know that at any point in time, among individuals who screen positive for mental health problems fewer than half of them get any kind of care. And when you look at substance abuse, that number is much lower — around 10 percent.

Some of what's going on is people don't have the resources to pay for treatment.

The Mental Health Parity Act does a lot to make sure the costs for mental health and substance abuse care is on par with the costs for other medical treatments. It was passed in 2008, but it's really starting to be implemented now. Historically, people have had to pay a lot more out of pocket for these treatments.

Even so, copays that might look small to people who are more established and affluent are going to be a real financial burden for a young person who is working part time or who's a student with limited financial resources.

And it's also hard to find treatment providers. We need to have the manpower and womanpower — or rather, physician power — to meet the needs of this diverse population of young adults.

So even though more young adults have access to care now, they're not necessarily seeking treatment for mental issues.

Access to health care can help indirectly. One of the most powerful agents for getting people into mental health treatment is the primary care provider. A young person might go to their doctor just for a physical exam, and then it comes up in the conversation with the doctor that, "Oh by the way, I'm feeling really down lately."

A primary care provider can at least help these patients recognize they could benefit from some treatment, and even refer the patient to a psychiatrist. And better-trained primary care providers have some awareness of mental health issues and try to screen for them.

What would help more young people who need treatment seek it out?

One thing is making sure there's an adequate network of providers who are in health insurance plans. And the other thing is making sure people who have transitory health insurance — like young adults who are using their parents' plans — can maintain continuity with their providers over time. That way people get access to a mental health provider, they can stay with the treatment.

But I think this is something that's going to involve changes within the health insurance system, but it's also going to require a lot of effort even outside the health care system.

There's a lot of stigma. We need to do everything that can be done so people feel less ashamed of saying "I have depression" or "I have an anxiety disorder" or "I have bipolar disorder."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Wide Range Of Hospital Charges For Blood Tests Called 'Irrational'

NPR Health Blog - Fri, 08/15/2014 - 12:24pm
Wide Range Of Hospital Charges For Blood Tests Called 'Irrational' August 15, 201412:24 PM ET

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Explaining the charges for simple blood tests isn't all that simple.

David Romero Corral/iStockphoto

One California hospital charged $10 for a blood cholesterol test, while another hospital that ran the same test charged $10,169 — over 1,000 times more.

For another common blood test called a basic metabolic panel, the average hospital charge was $371, but prices ranged from a low of $35 to a high of $7,303, more than 200 times more.

The wide disparity in hospitals' listed charges for routine blood tests at California hospitals was revealed in a study published in the August issue of BMJ Open. The study examined the listed charges for routine blood tests performed in 2011.

Researchers said their analysis found no rational explanation for the stark variation in listed prices, though teaching hospitals and government hospitals generally set lower charges than other facilities.

"People say our health care system needs to be more marketplace-driven, but the charging system and payment system are irrational," said Dr. Renee Hsia, the paper's lead author, an associate professor of emergency medicine at University of California, San Francisco. "When people try to understand why prices are the way they are, we have no ability to explain it. That is the take-home message. That is what is so disturbing."

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Other industries don't work this way. "If you ask an automotive maker, they will know how much it costs to make a Honda," Hsia said. "If you ask a hospital CEO how much an appendicitis admission costs, they will not be able to tell you. They have never been asked to determine prices that way."

Officials with the California Hospital Association dismissed the report as irrelevant, saying that the vast majority of patients pay discounted rates that have been negotiated by their insurance plans.

"Charges are meaningless data — virtually no one pays charges," said Jan Emerson-Shea, the association's vice president for external affairs.

"It is true that an uninsured person will receive a hospital bill based on charges," she said, but California law requires the bill to "include text referencing the availability of free or discounted care to persons who meet income guidelines." Those discounted fees must be based on what government programs pay for services, under California law, she said.

But researchers say the list prices are a starting point for negotiations with insurers and patients, so they play a role in driving up health care costs. Some uninsured patients, as well those with insurance who have gone out of network, may also be billed for the full charges.

Earlier studies by Hsia identified variations in listed charges for labor and deliveries and for appendectomies in California, with labor and delivery charges varying eight to 11-fold between hospitals, and charges for a routine appendectomy ranging from $1,500 to $182,955.

But, she said, she did not expect to see so much variation on a single line item like a blood test.

"This was even more surprising to me," Hsia said. "There is always some variation in patients, even among young healthy adults, and there are variations in physician practice. But these are very basic, standard blood tests. It doesn't matter if you're sick or not, a complete blood count is a complete blood count. You draw the blood, send it to the lab and put it in a machine."

In addition, she said, patients are increasingly being asked to play a role in keeping health care costs down by being smart shoppers, but it is almost impossible to get prices of health care services in advance and comparison shop. The study's findings suggest that price setting for many services is arbitrary, since there is little difference between standard blood tests done at different institutions.

While the disparities in charges for cholesterol tests were the most extreme, they were not an aberration. Charges for a complete blood cell count and a thyroid stimulating hormone assay ranged from as low as $20 in some hospitals to as much as $7,439 and $8,392, respectively.

The smallest discrepancy in charges was for a creatine kinase assay, often used to diagnose a heart attack; the lowest listed charge was $10 but some hospitals charged as much as $628.

The researchers obtained the hospital charges for blood tests from reports that non-federal hospitals in California are required to submit each year to the Office of Statewide Health Planning and Developmen

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

What The U.S. Health Care System Can Learn From Ebola Outbreak

NPR Health Blog - Fri, 08/15/2014 - 10:35am
What The U.S. Health Care System Can Learn From Ebola Outbreak August 15, 201410:35 AM ET

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Health workers at the district hospital in Biankouma, Ivory Coast, practice handling potential patients with Ebola.

Issouf Sanogo/AFP/Getty Images

Jeanine Thomas is a well-known patient advocate and active member of ProPublica's Patient Harm Facebook Community. But this week, she contributed in another forum: the World Health Organization.

The WHO selected Thomas to serve on the ethics committee that recommended making experimental drugs available to Ebola patients in West Africa. Thomas was the sole patient representative on the international panel, which decided that offering experimental drugs is ethical if patients give fully informed consent and data are gathered to track the safety and effectiveness of the medications used.

Thomas has a unique perspective. She nearly died from a bacterial infection acquired in the hospital during routine surgery in 2000. Since then, she has committed her life to speaking out on behalf of patients as founder and president of the MRSA Survivors Network.

Here she discusses why the Ebola decision has relevance for the U.S. health care system.

Do you think patients should have access to experimental drugs in situations other than the Ebola outbreak?

I think that should always be an option on the table. There is no drug for the pathogen CRE (carbapenem-resistant Enterobacteriaceae), which can be caught by patients in health care settings, and like Ebola it's got a high mortality rate. If there's a drug out there that could possibly save somebody's life, and there's informed consent from the patient or the family member, there should be an option to use it. It's compassionate care. On the downside, it could cause harm, and that's why it could only be done in dire situations, and on a limited case-by-case basis.

How is the recommendation made by the World Health Organization ethics committee about Ebola in West Africa relevant to the rest of us?

This will be an issue we face in the future. With CRE, for example, there's no antibiotic for it, and there will be breakouts. There will also be outbreaks of other superbugs that can't be treated by known methods because of all the antimicrobial resistance that's occurred because of the overuse of antibiotics. Who knows what's going to burst out next? We're going to need some protocols in place in the future. This is the world we live in now. It's proven that these pathogens are going to evolve and there will be no drugs for them.

Why is it important to have a patient advocate on this type of panel?

Patients have a unique perspective that healthcare industry experts or academics might not have. They know personally what it is to experience a bacterial or viral infection and what happens to the person and how it impacts the family. I've personally experienced septic shock, multiple-organ failure and a temperature of 105 degrees. I know how bad these infections can be, and if you survive, it is a very long road to recovery and you are never the same. The pain is unbearable and goes on for months, sometimes years with lasting effects to your organs and immune system.

The industry and academic experts are more clinical. They're looking at data, statistics and some have a little detachment. There has to be a voice there that's a champion for the patient.

Ebola isn't a threat here, but how worried should we be about these drug-resistant infections in our medical facilities?

The public should not feel secure in what government health officials say about their ability to control outbreaks here. For decades we have not controlled MRSA (Methicillin-resistantStaphylococcus aureus) and staph infections in U.S. health care facilities, and now also Clostridium difficile. We are at epidemic levels of MRSA and C. diff infections in many health care facilities.

What steps are the medical community and regulators taking to protect the public from drug-resistant healthcare-acquired infections?

The Centers for Disease Control and Prevention only gives recommendations — and they're lax. The CDC has acted for years like hand washing could control health care-acquired infections, and we know that's not true. The CDC standards are way below those of northern European countries, such as the Netherlands and the Scandinavian countries. In those countries they screen patients before they enter the hospital and after they're transferred from one department to another in a facility, and before they're discharged, to be sure the patient hasn't been colonized by a bacteria that could be transmitted to another patient or health care facility. They examine clinical cultures to track where the transmissions are happening. They call the method "search and destroy."

This approach has been proven to work in our country, too. The Veterans Affairs Department hospitals have been screening for MRSA since 2007. They do universal screening, and they have studies that show the method dramatically reduces MRSA infection rates. If the VA is doing it, and it's a federal agency, why isn't the CDC strongly recommending this? There is proof! But this screening approach, called active detection and isolation, is still a second-tier recommendation by the CDC. Other places in the world it's a first-level recommendation. It should be mandatory here.

Editor's Note: Our request for comment from the CDC is pending. To prevent the spread of MRSA in health care facilities, the CDC recommends hand washing; identifying patients who are colonized and infected to prevent contact with others; rapidly reporting lab results; and educating providers. The agency's website says screening of patients to detect bacteria should be considered.

Updated 11:07 a.m.: According to the CDC, the actual effectiveness of the type of screening promoted by Thomas is a subject of ongoing scientific controversy, said Dr. John Jernigan, director of the agency's Office of Health Associated Infections Prevention Research and Evaluation. Other independent agencies, including the Agency for Healthcare Research and Quality, have reviewed the research on the subject and agree with the CDC's recommendations, he said.

Copyright 2014 ProPublica. To see more, visit http://www.propublica.org/.
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A Virtual Outbreak Offers Hints Of Ebola's Future

NPR Health Blog - Thu, 08/14/2014 - 5:56pm
A Virtual Outbreak Offers Hints Of Ebola's Future August 14, 2014 5:56 PM ET Listen to the Story 3 min 57 sec  

Kenyan health officials take the temperatures of passengers arriving at the Nairobi airport on Thursday. Kenya has no reported cases of Ebola, but it's a transportation hub and so is on alert.

Simon Maina/AFP/Getty Images

While the Ebola outbreak continues to rage in West Africa, it is also unfolding — in a virtual sense — inside the computers of researchers who study the dynamics of epidemics.

Policymakers look to these simulations to get a sense of how the outbreak might spread. They also can use them to run experiments to see which public health measures should take priority.

"I've spent a lot of time doing computer models of disease transmission, but rarely does it involve something in Africa. Africa is often overlooked," says Bryan Lewis, a computational epidemiologist at Virginia Tech.

Goats and Soda The Ebola Outbreak: 'A Dress Rehearsal For The Next Big One'

So when a defense agency called him a few weeks ago and asked him to model the Ebola outbreak, he was excited by the challenge.

Lewis started plugging data into his computer. He uses the official numbers of how many people have died or gotten infected, even though those are probably underestimates. And he says health officials really don't have a handle yet on other important stuff that's going on — like how many infected people stay at home versus go to a hospital, or how burial practices spread infection.

"Some of those factors are the ones that are hard to measure," he says. "You've got to choose how much of this complexity you care to explicitly represent."

What's more, they can't assume this will play out like past Ebola outbreaks — those hit much smaller populations in more isolated, rural areas.

Despite all this uncertainty, Lewis says his models have been able to predict the course of the epidemic so far.

"At the moment, these models — at least for Sierra Leone and Liberia — we aren't putting in any mitigating factors. We're just letting these things run unthrottled," Lewis says. "And they've just been surging up. And they've been, unfortunately, accurate in the last couple of weeks in terms of the number of cases coming out."

Goats and Soda Ebola Is A Deadly Virus — But Doctors Say It Can Be Beaten

He says if you just kept this simulation going on and on, it shows Ebola spreading across the continent. But this scenario he's constructed doesn't include all the public health measures starting to ramp up now.

Goats and Soda Liberians In America Help Dispel Ebola Myths Back Home

"We know in the real world there are efforts being directed out there, there are resources being allocated," says Lewis. "Until we understand that better and can incorporate that into the model, I don't think it's very useful to speculate out past a week or two."

Some computer simulations focus on the risk of Ebola spreading to other countries. Alessandro Vespignani, at Northeastern University, creates those models, using information about air travel and other kinds of transportation.

His work suggests that Ebola could find its way to African nations like Ghana, Gambia, and Senegal. "There is a tangible risk of spreading in the region to other countries," says Vespignani, "probably in the ballpark of 20 to 30 percent in the next few weeks."

He notes poor countries might have trouble keeping an imported case from spreading. And the larger this outbreak gets, the harder it will be to contain.

So while his model currently suggests that the risk of Ebola reaching the U.S. or Europe in the next six weeks or so is very small — just a small percentage — that could change if the outbreak in Africa continues to grow.

Vespignani says we need "to extinguish the fire," so that Ebola doesn't really become a threat to the rest of the world in the next months.

Given that all this modeling is as much an art as a science, different groups working on the problem have been comparing notes. They've also been fielding calls from government officials and policymakers.

Martin Meltzer, who heads up the unit at the Centers for Disease Control and Prevention that's been creating computer models of the outbreak, says that people always ask him the same two questions: "How many people are going to die, and when is this going to end?"

He tells them too much is unknown to give any reliable answer.

Mostly, he says, the models just illustrate the need for old, tried-and-true methods for disease control, such as quickly identifying patients and isolating them.

"Modeling won't stop this disease," says Meltzer. "We know how to stop this disease. It's fairly simple and it's a matter of getting the simple activities and practices in action — in place, on the ground."

That's the struggle now, he says. Because while it's easy to change a line of computer code in a simulated epidemic and, say, reduce a transmission rate by 80 percent, it's a lot harder to do that in the real world.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Heads Still Dry, Scientists Try New Approach With ALS

NPR Health Blog - Thu, 08/14/2014 - 5:19pm
Heads Still Dry, Scientists Try New Approach With ALS August 14, 2014 5:19 PM ET

Houston Texans Coach Bill O'Brien (center) Chief Operating Officer Cal McNair (right) and Houston Chronicle reporter Brian Smith take the ALS Ice Bucket Challenge Thursday to raise money for the ALS Association.

David J. Phillip/AP

While your Facebook friends douse themselves with buckets of ice-cold water to raise money to fight amyotrophic lateral sclerosis, an international team of scientists said they'd taken a small step toward drowning out the deadly disease.

Researchers from the Scripps Research Institute and the Mayo Clinic developed a new drug that combats molecular contributors to ALS, which currently afflicts more than 30,000 Americans.

Commonly known as Lou Gehrig's disease, ALS gradually damages nerve cells that control muscles. Early symptoms may include difficulty walking and slurred speech. Over time, people lose the ability to stand and walk. As muscles in the chest weaken, breathing becomes difficult. The disease is fatal. Many people die from respiratory complications.

There is no cure for ALS and only one FDA-approved drug treatment, which only slows its advances a little.

"ALS is one of the worst diseases you can get," says Matthew Disney, a chemist at the Scripps Research Institute in Florida, and an author of the study. "If we don't understand its biology, we can't make a therapeutic treatment."

Recently, scientists identified a mutated gene called C90RF72 that is linked with ALS. That gene can produce a toxic protein, which scientists think may contribute to the disease.

The team is working on a potential drug treatment that would disrupt production of the protein, reducing it by half in some lab experiments. The interdisciplinary group published their work Thursday in the journal Neuron.

Though other researchers are also working on ways to combat ALS, Disney says that his team is the first to focus on a pill that could be taken to block the potentially dangerous protein.

"Given the severity of this disease, it's important that as many possible approaches are brought to the table," Disney tells Shots.

The team also found that they could detect within a patient's cerebrospinal fluid a previously known marker for the toxic protein. That finding, Disney said, would allow scientists and doctors to assess how well a drug aimed at shutting down the protein is working in patients.

"It's very exciting because it's such an important leap forward to a developmental approach," said Lucie Bruijn, chief scientist for the ALS Association. Although she also cautions, "We can't be too definitive yet. It's in an early stage, but it's fantastic that we've come this far."

The experiments with the drug are at a very early state. So far, the medicine has only been tested in cells grown in the lab. Also, the biomarker the researchers developed does not indicate how advanced the ALS is in someone who shows signs of the disease.

Still, Disney says, the clinical implications of this work could be both a way to identify if someone has ALS and then a targeted way to treat it.

But Disney says the work, hasn't resulted in any licensing agreements or partnerships with drug companies. It's too early for that, he says, underscoring how the approach, even if successful, is a very long way from resulting in a medicine that could be put into clinical practice.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Who Gets First Dibs On Transplanted Liver? Rules May Change

NPR Health Blog - Thu, 08/14/2014 - 3:34am
Who Gets First Dibs On Transplanted Liver? Rules May Change August 14, 2014 3:34 AM ET Listen to the Story 5 min 42 sec  

Surgeons at Methodist University Hospital in Memphis prepare to transplant a liver in 2010.

Karen Pulfer Focht/The Commercial Appeal/Landov

Vicki Hornbuckle used to play the piano at her church. But that was before her liver started failing.

"I had to give it up because I couldn't keep up," says Hornbuckle, 54, of Snellville, Georgia. "I didn't have the energy to do three services on Sunday. You're just too tired to deal with anything. And so, it's not a life that you want to live."

“ Either it's a jackpot and you have very, very easy access to a lifesaving liver — if you lived in Indiana or if you lived in Louisiana or Florida. But if you live in California or New York or New England the chances are significantly worse.

But Hornbuckle hasn't given up. She's fighting to stay alive long enough to get a liver transplant.

"I would like to see my grandchildren grow up," she says. Plus, she adds, her mother is still alive, and "it's not fair to have to bury your children. It's not supposed to work that way."

About 900 miles north, in East Hartford, Connecticut, Woody Wright is also on the transplant list. He's 38 and used to work as a pharmacy technician — until his failing liver made him too sick.

"I do I feel horrible," Wright says. "Some of my bones are hurting really bad. I'm anxious ... waiting and just waiting for this liver."

Hornbuckle and Wright are among more than 12,000 Americans waiting for a liver transplant because their own is failing, because of conditions such as hepatitis, cancer or cirrhosis. But only about 6,000 livers are donated each year. So, each year, hundreds of patients like Hornbuckle and Wright die while waiting. And not everyone has the same chance to get a liver. It depends a lot on where you live.

'We Have This Huge Disparity.'

"Either it's a jackpot and you have very, very easy access to a lifesaving liver — if you lived in Indiana or if you lived in Louisiana or Florida," says Dr. David Mulligan, a transplant surgeon at Yale University. "But if you live in California or New York or New England the chances are significantly worse."

That's because the country is divided into 11 regions and some regions have more livers for transplant than others.

"So in the Southeast, for example, or in parts of the Midwest, where there's a higher death rate," Mulligan says, "there are more donor organs."

“ I'm worried about dying before I get my new liver. Any time you have to wait behind somebody else and your life depends on it ... you worry.

And the sickest patients in each region get the first crack at every liver, which means patients in the parts of the country that have the most livers don't have to be as sick to get a transplant as people who live in other places.

"We have this huge disparity," Mulligan says.

He chairs a committee assembled by the United Network for Organ Sharing, which manages the nation's organ transplant system, to come up with some ideas for making the system fairer. One possibility would be to divide the country into much bigger districts — perhaps only eight or even four. That way that livers could be distributed across a much wider area, making the chances of getting one about the same no matter where you live.

"Our goal is to save lives and to be fair, and to take this scarce resource and to spread it in a way that will allow us to save lives," Mulligan says.

But the proposal is raising a lot of concerns. Some patients in regions that currently have the most livers to offer would have to wait longer to get a transplant than they do now. That's because more organs from their area would end up going to sicker patients in other regions.

"The impact on patients in our area would be that it would increase their likelihood of dying while waiting for a liver transplant," says Dr. Marty Sellers, a transplant surgeon at the Piedmont Hospital in Atlanta.

Sellers and others argue that a better solution is to get more people to donate livers in places that need them.

"We don't have enough livers here in Georgia to transplant all the patients that are in need here," Sellers say.

And some worry the change could end up backfiring by making people less willing to donate organs. Many people say they donate because they want to help someone in their community, transplant teams say.

"People who live in Texas would prefer for their organs to be transplanted into people who live in Texas rather than to go to New York or Chicago," says Dr. Michael Charlton at the Intermountain Medical Center in Utah. "People feel like that."

People who favor changing the system agree that more needs to be done to increase donations. But that takes time. And they dispute the idea that rejiggering priorities would end up costing lives.

"There are patients that are currently receiving liver transplants that could easily wait a little longer so that patients who don't have the option to live can live," Mulligan says.

When you ask patients about this, how they feel tends to depend on where they live.

"I don't think it's fair how they're doing it right now," says Woody Wright in Connecticut. "You should not take it all for yourself. Share it around," he urges. "Let it be fair. There are a lot of sick people out there."

But Vicki Hornbuckle in Georgia isn't convinced.

"I'm worried about dying before I get my new liver," she says. "Any time you have to wait behind somebody else and your life depends on it ... you worry."

UNOS is holding a public hearing in Chicago on Sept. 16 to discuss how best to distribute the limited supply of livers for transplantation.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Schoolchildren Who Add Hand Sanitizer To Washing Still Get Sick

NPR Health Blog - Wed, 08/13/2014 - 12:36pm
Schoolchildren Who Add Hand Sanitizer To Washing Still Get Sick August 13, 201412:36 PM ET

If a kid is already washing his hands well, adding sanitizer in school doesn't appear to help reduce illnesses and absences.

Juanmonino/iStockphoto

Schools can be a great breeding ground for colds, stomach viruses, the flu and other bugs kids (and their parents) would rather not get.

Researchers wanted to know whether the transmission of those baddies could be reduced by telling elementary school children to use hand sanitizer in addition to the usual hand washing. But their study, conducted in 68 primary schools in New Zealand, found putting sanitizer in classrooms might not be worth the money and effort in higher-income countries, where soap and clean water are readily available.

Half the schools were randomly assigned to get the sanitizer. In those schools, the kids had a 30-minute educational session on hand hygiene and were also told to use the hand sanitizer dispensers after coughing or sneezing and when they left the classroom for recess or lunch. (The active ingredient in the hand sanitizer was plain old alcohol, not the antibacterial triclosan, which is controversial for its potential to create antibiotic-resistant bacteria.) Kids in the other schools just got the session on hand hygiene.

After the 20-week study was over, the researchers followed up with caregivers of a randomly selected sample of 2,443 students. The absence rates due to illness in the sanitizer and nonsanitizer groups were similar. Nor was there a difference in absence rates due to a specific illness, say, a gastrointestinal bug. And the family members of those kids in the soap-only group didn't get sick more often either.

The study was conducted in 2009 and began right before the H1N1 flu pandemic began. So the researchers cautioned that kids might have been more careful about hand hygiene in general, thanks to public health efforts aimed at curtailing the spread of the flu. Still, they conclude that this study and others conducted in high-income countries "show that the addition of hand sanitizer to existing hand hygiene facilities does not result in important benefits."

But Dr. Aaron Glatt, executive vice president at Mercy Medical Center in Rockville Centre, N.Y., and a spokesman for the Infectious Diseases Society of America, emphasizes that this doesn't mean there's any harm in using alcohol-based hand sanitizers in schools. It's only that they don't seem to help much there. (Of course, this research can't say anything about the effectiveness of sanitizers in other settings, like the hospital.)

But Glatt notes that schools, like the workplace or other places where people gather together in close proximity, are "absolutely" sites of disease transmission. So whether or not a kid uses sanitizer, basic hand hygiene is essential to cutting back on those sick days.

The findings appear in PLoS Medicine.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Many Big Employers Plan To Offer Skimpy Health Options Despite Law

NPR Health Blog - Wed, 08/13/2014 - 11:23am
Many Big Employers Plan To Offer Skimpy Health Options Despite Law August 13, 201411:23 AM ET

Partner content from

Quite a few big businesses plan to offer workers health insurance options that have so few benefits that they don't comply with the Affordable Care Act.

iStockphoto

Nearly 1 in 6 companies plans to offer health coverage that doesn't meet the Affordable Care Act's requirements for value and affordability, a national survey of employers finds.

Many thought such skimpy coverage would be history once the health law was fully implemented this year. Instead, 16 percent of large employers in a survey released Wednesday by the National Business Group on Health said they will offer in 2015 these so-called skinny plans along with at least one insurance option that does qualify under ACA standards.

The results weren't entirely unexpected. Last year, it became clear that ACA regulations would allow skinny plans and even make them attractive for some employers. But this survey gives one of the first looks at how many companies followed through.

"It is a little higher than I would have expected but does not surprise me," says Timothy Jost, a law professor who specializes in consumer health at Washington and Lee University in Virginia. "It would be interesting to know what sectors of the economy these employers are in." Low-benefit plans traditionally have been offered by hotels, restaurant chains and other lower-wage industries, Jost said, "but this may be spreading."

The survey compiled responses from 136 large employers but didn't specify which industries made up the 16 percent offering low-benefit plans.

"My guess is that they are probably in those industries with low-wage employees where they have historically not been attracted to taking a lot of their paycheck for coverage and wanted something smaller," said Steve Wojcik, vice president of public policy at the National Business Group on Health.

Skinny plans are part of a two-step strategy that lets workers and employers avoid health law penalties but may not produce substantial coverage. Some skinny plans cover preventive care and nothing else — no inpatient or outpatient hospital treatment, says Edward Fensholt, a benefits lawyer with Lockton Cos., a large insurance brokerage and consulting firm.

It works like this. Employers can shield themselves from health law penalties by offering insurance that meets tests for affordability and value — regardless of whether anybody signs up. At the same time, workers can avoid the ACA's individual penalty by enrolling in a company skinny plan, which qualifies as "minimal essential coverage" for individuals under the health law by the mere fact that it's employer-sponsored.

In practice, employees in low-pay industries often decide that the substantial plan is too expensive even though it meets ACA standards, Fensholt said. (The ACA says coverage is affordable if the employee's contribution is 9.5 percent of household income or less.)

So workers sign up for the skinny plans, which shield them from the individual mandate penalty (the greater of $95 or 1 percent of their income) but offer little coverage.

"Employees need to know that if they choose one of these plans, it may be cheap and may satisfy the individual mandate requirement, but it may offer little protection if they actually get sick," said Jost.

Even so, at Las Vegas hotels and elsewhere, employees are asking for skinny plans and employers are offering them to stay competitive, Fensholt said.

"Some of these employers are doing it because their competitors are doing it," he said. "They don't want to lose these employees."

Potentially large medical bills aren't the only disadvantage for workers at companies using the two-step strategy. By offering an ACA-compliant plan, their employers disqualify them from getting subsidized insurance through HealthCare.gov or other online exchanges — even if they don't sign up for the company policy.

The survey also showed a continued move by large companies toward high-deductible, "consumer-directed" health plans and tools for workers to shop around for care. Consumer-directed plans, often paired with a tax-favored health savings account, feature deductibles of thousands of dollars. Deductibles are what consumers pay for care before the insurance kicks in.

Next year, 32 percent of companies surveyed intend to offer a consumer-directed plan and nothing else — "larger than I would have expected," said Karen Marlo, a vice president at National Business Group on Health. "We were really surprised at how much the survey over and over again pointed the finger at consumerism."

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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