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Would Doctors Be Better If They Didn't Have To Memorize?

NPR Health Blog - 3 hours 43 min ago
Would Doctors Be Better If They Didn't Have To Memorize? April 26, 2015 5:36 AM ET


John Henning Schumann Katherine Streeter for NPR

Poor old Dr. Krebs. His painstaking Nobel-winning work on cellular metabolism, called the Krebs cycle, has made him the symbol for what's ailing medical education.

"Why do I need to know this stuff?" medical students ask me.

"How many times have you used the Krebs Cycle lately?" senior doctors jokingly reminisce.

For decades, first-year medical students have had to cram the details of the Krebs cycle into their heads. Now the biomedical model of educating doctors, based largely on a century-old document called The Flexner Report, is coming under fire.

From one end, our long-standing medical education model is attacked as out of tune with the information age. By some estimates, our entire body of medical knowledge doubles every three or four years.

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Critics say med students can't possibly master so much information, which quickly becomes outdated anyway. Instead, the new theory goes, students should be taught and evaluated on their ability to find, assess and synthesize knowledge. And they should be educated in teams to help prepare them for what goes on in the real world.

From another angle, critics of the Flexner model correctly point out that Flexner himself, an educational theorist with no medical training, was silent on issues such as poverty, housing, nutrition and other factors that we now call the social determinants of health.

We now know these factors collectively affect our overall health more than even the $3 trillion health care industry.

Many times I've seen patients and found the tools I was trained to use aren't nearly enough to provide help. No physical exam or X-ray can find a homeless person a bed. No lab test or medication can provide a laid-off worker with job training or education.

It took more than a decade for me to learn to ask patients about hunger. I found out that many of the people I've cared for suffer from food insecurity – not knowing where their next meal will come from.

"But what can I do about those problems?" my students ask. "Isn't that just social work?"

The answer may surprise you.

In my role as a medical educator, I attended the Beyond Flexner conference in Albuquerque, N.M., in early April. The main theme of the meeting, sponsored by the W.K. Kellogg Foundation and others, was this question: "What is the social mission of medical education?"

The conference came about as an outgrowth of a 2010 paper that ranked medical schools by their social commitment rather than their research dollars or U.S. News and World Report scores. It began as something of a shot across the bow to organized medicine, challenging orthodoxy, such as making students memorize the Krebs cycle.

Over the years since then, more research has shed light on the economic and health impact of social determinants. The media has caught on to this as well.

Nearly 400 medical educators, activists, policymakers and students turned up to share ideas, hash out strategy and plan a road map for changing medical education.

Our hosts from the University of New Mexico demonstrated that medical schools that are serious about community engagement build strong partnerships that take social determinants into account. We heard how community health workers and a re-imagination of the agricultural extension model for health education are improving the health of New Mexicans.

To me, the most surprising aspect of the meeting was just how many medical schools are now getting serious about the importance of social determinants.

Many of the sessions at the conference explored obstacles that stand in the way of a culture change in medical education. At the top of the list: How to deal with a payment system that still prioritizes the quantity of medical care over quality? A decision by Medicare earlier this year to base a large proportion of future payments on quality and value has convinced many of us that the health system is on the path of change.

I left the conference with new ideas and fresh energy. I also was left wondering what will replace the Krebs cycle in the medical education pantheon.

My bet? It will be a team of students finding ways to break the vicious cycle of poverty that contributes to so much suffering, illness and early loss of life.

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

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CDC Warns More HIV, Hepatitis C Outbreaks Likely Among Drug Users

NPR Health Blog - Fri, 04/24/2015 - 2:19pm
CDC Warns More HIV, Hepatitis C Outbreaks Likely Among Drug Users April 24, 2015 2:19 PM ET Listen to the Story 2 min 22 sec  

The Centers for Disease Control and Prevention warns that the U.S. epidemic of opioid abuse could lead to more severe outbreaks of HIV and hepatitis C nationally, much like the outbreak now seen in Indiana. A health advisory the agency released Friday outlines steps that state health departments and medical providers should take to minimize the risk of that happening.

A public health emergency has been in effect in southern Indiana's Scott County since late March. According to the Indiana State Department of Health, 142 people have been diagnosed with HIV since December. Prior to the outbreak, the rural county hadn't recorded more than five cases of HIV in a given year, and in many years it recorded none.

Indiana's current HIV outbreak has been linked to the intravenous injection of oxymorphone, an oral painkiller sold under the brand name Opana. Abuse of the prescription opioid has been a common problem in southern Indiana for years and has affected many communities across the U.S.

Shots - Health News Indiana's HIV Spike Prompts New Calls For Needle Exchanges Statewide

A CDC report, released at a press conference Friday, shows that 85 percent of patients newly diagnosed with HIV in Scott County also have hepatitis C, which can be hugely expensive to treat.

Around the Nation Indiana Governor Extends Public Health Emergency To Fight HIV Outbreak

The report also indicates that 75 percent of the infected patients are men, and about 25 percent of infected women are commercial sex workers.

Entire families are sometimes using the prescription opioids, the report notes — "with as many as three generations of a family and multiple community members injecting together."

The Indiana State Department of Health says it has developed a multipronged plan for dealing with the current outbreak. It includes a public education campaign, a facility that offers immunizations, and programs that connect patients with addiction treatment centers and job training.

Right now, that approach also includes a controversial needle exchange program, which has reportedly distributed thousands of needles to more than 80 injection drug users. The exchange program became possible when Indiana Gov. Mike Pence temporarily suspended an Indiana law that bans needle exchange programs. Some politicians have called for the ban to be lifted permanently. Neighboring Kentucky approved the use of needle exchange programs last month.

In addition to the recent HIV and hepatitis C outbreaks in Indiana, CDC data have shown a 150 percent increase across four years nationally in new hepatitis C infections. Hepatitis C infections often increase among users of injected drugs; the CDC is asking states to take a closer look at their own health data, to help identify communities that could be at risk for unrecognized clusters of hepatitis and HIV infections.

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To Weather Criticism, It Helps To Think Of The Big Picture

NPR Health Blog - Fri, 04/24/2015 - 10:28am
To Weather Criticism, It Helps To Think Of The Big Picture April 24, 201510:28 AM ET

Think back to the last time you got negative feedback — like when your doctor suggested you lay off the cigarettes or when your mother advised you to get rid of that ridiculous goatee.

Though we all understand the value of constructive criticism, we don't like hearing that we've done something wrong. And the knee-jerk reaction is to act defensive.

But if you focus on the big picture and future goals, you may be able to trick your mind into being a bit more receptive.

That's what researchers at the Ohio State University discovered in a study published Friday in the Personality and Social Psychology Bulletin.

The researchers tried a couple of experiments. First, they divided 85 undergraduate students into two groups. They encouraged half the students think about broad ideas — for example, "sodas are a type of drink." They asked the other half to consider: "A Coke is a type of soda."

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Then they told everyone about the dangers of skin cancer and suggested that students who don't already do so should wear sunscreen and avoid tanning.

The group that was asked to think broadly was more receptive to the suggestions, and said they were more likely to feel motivated to give up tanning.

When people are thinking big, they have an easier time realizing a single critique doesn't define them, says Jennifer Belding, the doctoral student in social psychology who led the study. "It helps them step back, and realize that the person giving them that feedback is just trying to help," she explains.

"But when people are thinking about the nitty-gritty details and they have a narrow mindset, it's easy for them to get caught up in the moment," Belding says. "Instead of focusing on how the feedback can help them in the long run, they think about how much that information is hurting them."

"Every time I submit a research paper to a journal, it invariably comes back with tons of edits and feedback. And every time, it's easy to feel disappointed or even angry."

Believing that change is possible is important as well. In a second experiment, Belding and her colleagues divided 133 students into several groups. Some were asked to think broadly about the importance of maintaining good health, while others were told to think about what they could do in the immediate future to stay healthy. And then, while some read about how skin cancer is easily preventable, others read that it was genetic.

Those who not only thought broadly about their health but also believed that cancer was preventable were the most motivated. This group spent, on average, five extra minutes reading about how to avoid sun damage.

It's all about perspective, says Daniel Molden, a social psychologist at Northwestern University who wasn't involved in the study.

"For most people, the immediate response to criticism is emotional. They might feel threatened or hurt," Molden says. "And people don't like to feel hurt, so they'll try to deflect or undermine the critiques."

A growing body of research suggests that taking a broad perspective helps people deal with perceived threats, Molden notes.

When you're on the receiving end of criticism, Molden's advice is to take a few minutes to think about your long-term goals. And to think about how criticism is simply a part of life.

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"I can tell you, as someone in academia, I deal with negative feedback all the time," Molden says. "I've been doing this for 15 years. And every time I submit a research paper to a journal, it invariably comes back with tons of edits and feedback. And every time, it's easy to feel disappointed or even angry."

Molden says he copes by letting himself feel frustrated for a few minutes. "And then I step back and reflect on how this feedback could be beneficial."

If you're the one delivering negative feedback, before launching into what someone has done wrong, you might want to start with a general statement about what you think of him or her overall, Molden says.

"This is relevant when it comes to public health campaigns as well," Molden notes. People tend to avoid screenings for cancer or sexually transmitted diseases because they don't want to risk hearing bad news. But they might be persuaded by campaigns that encourage screenings as part of a broader plan for staying healthy.

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Couples Counseling Catches On With Tech Co-Founders

NPR Health Blog - Thu, 04/23/2015 - 2:56pm
Couples Counseling Catches On With Tech Co-Founders April 23, 2015 2:56 PM ET


April Dembosky Listen to the Story 3 min 28 sec  

Work partners Jon Chintanaroad (left) and Mike Prestano are all smiles now, but founding a tech startup together threatened their friendship — and their business.

April Dembosky/KQED

Startups fail for a lot of reasons: bad product, wrong timing. But sometimes, it's just you.

Relationship problems between co-founders are among the biggest reasons companies don't make it. Increasingly in Silicon Valley, business partners are looking for help before things go downhill — they're signing up for couples counseling.

"It's good to do this work while it's actually unfolding in the organizations, and set these things right before they go horribly wrong."

"It felt like a marriage," Jon Chintanaroad says of his business partnership with his friend, Mike Prestano. They launched a tech recruiting startup, Aspire Recruiting, in 2013.

"My joke was, during the day, Mike was my wife No. 1, and my girlfriend was my wife No. 2," Chintanaroad says. "I would see her at night, and I see him all day."

The two were friends for four years before they went into business together. Chintanaroad says their work styles really complemented one another.

"I'm very transactional-based," Chintanaroad says. "I'm kind of a Type-A personality — I just want to get it done, whereas Mike will listen to their whole life story and really cultivate that relationship. When we had both, we started to win over new clients and things went from there."

The business took off right away, and the money came rolling in. But a year into it, they hit some rough patches. They missed some key customer acquisitions. Revenues dipped.

The Spirit Of Innovation Failure: The F-Word Silicon Valley Loves And Hates

That's when their differences became less complementary and more problematic.

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"It's like any sports team," Prestano says. "If you lose: 'You should have scored this touchdown.' 'You should have scored that basket.' 'You should have passed to here instead of there.' Those aren't easy conversations."

They started fighting a lot. Mike thought Jon spent too much money. Jon thought Mike wasn't pulling his weight.

Prestano says they worried the business problems were starting to threaten their friendship.

"I think we both agree ... no matter what happens with the business," Prestano says, "if we keep doing it, or it stops, we still keep our friendship."

They decided to try couples counseling — though most therapists who work with co-founders call it "partnership coaching."

It's something more and more startup founders are doing. Jonathan Horowitz is a psychologist with offices in San Francisco and San Mateo. He says the number of requests he gets for co-founder counseling has doubled in the last year. A lot of times, people call when things have already gotten really ugly.

"The company's dead, something went horribly wrong in the relationship, and they're picking up the pieces afterwards," Horowitz says.

Many startups, especially in the tech industry, are founded by young guys — friends who met in college, got an apartment together and started working on their laptops around-the-clock to get a business off the ground. When things go well, co-founders can suddenly find themselves in complicated business situations with a lot of money — and power — on the line. They have to decide who's going to be CEO. They have to answer to investors. These pressures test the relationship.

Most of the time, it's usually lawyers who get called in to mediate heated disputes or to force one of the founders out of the company. Or to help the partners declare bankruptcy, if the business failed.

"It's good to do this work while it's actually unfolding in the organizations," Horowitz says, "and set these things right before they go horribly wrong."

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He says in a lot of business partnerships, there's often one founder who is more dominant, even domineering. "You have the other founder who might not feel like they're being heard or respected. An imbalance like that can be insidious."

In cases like that, good ideas get dismissed; opportunities are lost. Horowitz says his job is to help build trust, communication and empathy.

"All those things are important if you're going to run a business with someone for years and years," he says, "just like [in] a marriage."

It's not just startups that have picked up on the idea. Couples counselors say larger companies like Cisco and Google have hired them to work with managers who aren't getting along. Stanford Business School offers a group therapy course, where required reading includes The Seven Principles for Making Marriage Work. The students call it the "touchy-feely" class.

For Jon Chintanaroad and Mike Prestano, a few sessions with a therapist made them both feel like they had permission to talk about their feelings.

"I think, overall, it resulted in both of us being more aware as people, and balanced," Chintanaroad says.

Chintanaroad worked on listening more. Prestano learned when to speak up if something was bothering him.

"Those things that were bottling up, I talked to Jon about it, expressed how I feel, and he took no offense," Prestano says. "And, actually, he's shown some compassion."

Their tech recruiting business is back on track — and that leaves more energy for social recruiting. After a couple drinks on Friday, Chintanaroad asks Prestano to help him scout for a new girlfriend.

"He can be my wingman," Chintanaroad says.

The sales psychology they use at the office, Prestano says, works just as well at the bar.

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Thoughts Can Fuel Some Deadly Brain Cancers

NPR Health Blog - Thu, 04/23/2015 - 12:13pm
Thoughts Can Fuel Some Deadly Brain Cancers April 23, 201512:13 PM ET Listen to the Story 4 min 10 sec  

A color-enhanced cerebral MRI showing a glioma tumor.

Scott Camazine/Science Source

The simple act of thinking can accelerate the growth of many brain tumors.

That's the conclusion of a paper in Cell published Thursday that showed how activity in the cerebral cortex affected high-grade gliomas, which represent about 80 percent of all malignant brain tumors in people.

"This tumor is utilizing the core function of the brain, thinking, to promote its own growth," says Michelle Monje, a researcher and neurologist at Stanford who is the paper's senior author.

In theory, doctors could slow the growth of these tumors by using sedatives or other drugs to reduce mental activity, Monje says. But that's not a viable option because it wouldn't eliminate the tumor and "we don't want to stop people with brain tumors from thinking or learning or being active."

Even so, the discovery suggests other ways to slow down some of the most difficult brain tumors, says Tracy Batchelor, who directs the neuro-oncology program at Massachusetts General Hospital and was not involved in the research.

Dr. Michelle Monje wanted to figure out how tumors hijacked the myelination process.

Steve Fisch/Courtesy of Stanford School of Medicine

"We really don't have any curative treatments for high-grade gliomas," Batchelor says. The discovery of a link between tumor growth and brain activity "has opened up a window into potential therapeutic interventions," he says.

The discovery came from a team of scientists who studied human glioma tumors implanted in mouse brains. The scientists used a technique called optogenetics, which uses light to control brain cells, to increase the activity of cells near the tumors.

The team wanted to know whether this high level of activity would make the glioma grow more quickly. "And it turns out that it did,"

The discovery of a link between tumor growth and brain activity is a byproduct of Monje's career-long quest to help to help children with a rare and deadly form of brain cancer.

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The cancer is called diffuse intrinsic pontine glioma, or DIPG. Monje saw her first case when she was still in medical school. "I cared for a little girl who had diffuse intrinsic pontine glioma and I was just so struck by our failure to treat this disease," she says.

DIPG strikes about 200 children a year, often at around age 6. It can't be treated with surgery because the tumor cells become entwined with healthy cells in the brain stem. Children with DIPG typically live about nine months after they are diagnosed.

"This is a disease with a terrible prognosis," Monje says. "And it's one that unfortunately we haven't been able to touch with interventions for decades."

Monje wanted to change that. So after receiving her M.D. and Ph.D. from Stanford in 2004, she began studying DIPG tumor cells as well as the part of the brain in which they grow, the brain stem.

Shots - Health News No Rest For Your Sleeping Brain

She began to suspect that this cancer was somehow hijacking a process called myelination, which happens in the brains of healthy kids. Myelination creates a layer of insulation around nerve fibers, which allows them to carry signals more quickly and efficiently.

Last year, Monje and a team of researchers showed that the cells responsible for myelination began to grow rapidly in response to high levels of brain activity. "That was an intriguing finding and it was consistent with our idea that activity in the brain, thinking, planning, using your brain, might be promoting the cancer arising within it," she says.

The mouse experiment confirmed Monje's suspicion. Another experiment showed that the glioma cells were indeed growing in response to the chemical signals that usually lead to myelination.

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One striking finding, though, was that the link between brain activity and tumor growth wasn't limited to DIPG, the rare childhood tumor Monje had been studying since medical school. Her team found that a range of deadly gliomas grow faster when they're near highly active nerve cells.

"This work has much broader implications for brain tumors," says Batchelor. "It's not just pediatric tumors, it's pediatric and adult. And it's not just one particular type of glioma. This has potential implications across the entire family of gliomas in the brain."

Batchelor says Monje's research suggests a new way to slow down these tumors — by interrupting the pathways linking brain activity to tumor growth.

Monje says she is encouraged that her work has led to a better understanding of DIPG and other deadly childhood tumors. But she says it's still hard to feel gratified.

"It will be gratifying when we make some difference for these kids," she says.

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More Whistleblowers Say Health Plans Are Gouging Medicare

NPR Health Blog - Thu, 04/23/2015 - 5:08am
More Whistleblowers Say Health Plans Are Gouging Medicare April 23, 2015 5:08 AM ET Fred Schulte

Privately run Medicare plans, fresh off a lobbying victory that reversed proposed budget cuts, face new scrutiny from government investigators and whistleblowers who allege that plans have overcharged the government for years.

Federal court records show at least a half dozen whistleblower lawsuits alleging billing abuses in these Medicare Advantage plans have been filed under the False Claims Act since 2010, including two that just recently surfaced. The suits have named insurers from Columbia, S.C., to Salt Lake City to Seattle, and plans that have together enrolled millions of seniors. Lawyers predict more whistleblower cases will surface. The Justice Department also is investigating Medicare risk scores.

Though specific allegations vary, the whistleblower suits all take aim at these risk scores. Medicare uses the scores to pay higher rates for sicker patients and less for people in good health. But officials were warned as early as 2009 that some plans claim patients are sicker than they actually are to boost their payments.

Privately run Medicare Advantage plans have signed up more than 17 million members, about a third of the people eligible for Medicare, and are poised to get bigger. Earlier this month, the industry overturned proposed cuts sought by the Obama administration for a third straight year, instead winning a modest raise in payment rates for the programs.

Medicare Advantage resonates with many seniors for its low out-of-pocket costs. It's also winning favor with some health policy experts who argue these managed care plans can offer higher quality care than standard Medicare, which pays doctors and hospitals on a fee-for-service basis.

Karen Ignagni, the chief executive officer of America's Health Insurance Plans, the industry's trade group, called the government's change of heart "a notable step to provide stable funding."

"It shows the incentives provided for whistleblowers are working well, and all the other controls and detection systems are failing miserably."

But the whistleblower suits argue that it's too easy for health plans to gouge the government.

Malcolm Sparrow, a health care fraud expert at Harvard's John F. Kennedy School of Government, said the number of these cases suggests government oversight is too lax.

"It shows the incentives provided for whistleblowers are working well, and all the other controls and detection systems are failing miserably," Sparrow wrote in an email.

Ray Thorn, a spokesman for the federal Centers for Medicare and Medicaid Services, disagreed. He said CMS "is taking steps to protect taxpayers, Medicare beneficiaries and the Medicare program." Thorn cited an increase in CMS audits and said health plans have identified overpayments and given back about $1.1 billion to the government.

Still, critics want to step up accountability as the health plans bite off bigger chunks of Medicare business. Annual taxpayer costs for Medicare Advantage exceed $150 billion

"CMS could save billions of dollars by improving the accuracy of its payments to Medicare Advantage programs."

"CMS could save billions of dollars by improving the accuracy of its payments to Medicare Advantage programs," the Government Accountability Office wrote in its just-released 2015 annual report.

On another front, the Justice Department is widening the scope of an investigation into whether exaggerated risk scores are jacking up costs improperly.

Humana Inc., based in Louisville, Ky., which counts more than 3 million seniors in its plans, wrote in a March Securities and Exchange Commission filing that the investigation "includes a number of Medicare Advantage plans, providers and vendors."

On April 14, DaVita Healthcare Partners Inc., headquartered in Denver, disclosed that it had received a Justice Department subpoena. Investigators sought Medicare Advantage billing data and other records.

Shots - Health News Humana Discloses Widening Justice Dept. Probe Of Medicare Advantage Plans

In the latest lawsuit to surface, a pair of whistleblowers allege that Blue Cross of South Carolina submitted inflated claims between 2006 and 2010, then "acted to cover up and hide the false submissions so that they would be able to retain the wrongly paid reimbursements," according to an April 3 filing.

The South Carolina suit also names the Deseret Mutual Insurance Co., a Utah plan formed by the Church of Jesus Christ of Latter-day Saints, which contracted with Blue Cross to process Medicare Advantage billings.

"We deny the allegations and are vigorously defending the case," responded Blue Cross of South Carolina spokeswoman Patti Embry-Tautenhan.

Deseret Mutual could not be reached despite repeated calls and emails to the health plan's Utah office and its South Carolina attorney.

The suit was filed by Catherine Brtva, a former Blue Cross computer billing specialist, and Jerald R. Conte, a former contractor.

The case targets flaws in computer programs that Blue Cross says were used to submit to Medicare millions of health insurance claims by hundreds of thousands of members.

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In court filings, Blue Cross does not deny that some overcharges occurred. But it says underpayments also happened and that it worked with CMS to correct the problems.

The whistleblowers argue that the plans set out to repay only about $2 million in overpayments — just 10 percent of what they actually owed. CMS officials declined to discuss the matter.

Several attorneys said in interviews they expect more cases to surface, particularly as Medicare Advantage grows. Risk scoring fraud "has popped up on our radar," said Joseph E.B. White, a Philadelphia lawyer specializing in whistleblower cases.

One suit, which the Center for Public Integrity only recently discovered, was filed in 2012 by Lisa Parker, a former clinic supervisor at The Polyclinic in Seattle, who sued the clinic and Essence Healthcare, a Medicare Advantage plan.

Parker cited a 2010 memo that asked doctors' staff to talk hundreds of elderly people into coming in for a medical visit. The clinic was to receive about $250,000 to $500,000 in 2011 from increased risk scores from the visits.

Shots - Health News Feds Knew About Medicare Advantage Overcharges Years Ago

The lawsuit alleges the visits "were not dictated by patient concern, nor for the treatment or diagnosis of specific illnesses, symptoms, complaints or injuries, but were designed and performed to maximize the opportunity to bill Medicare."

Joel Andersen, vice president of marketing for Essence Healthcare, said in an email statement: "The government did not find any wrongdoing or any cause to intervene and thus the case was quickly dismissed. We consider the matter closed and have no additional commentary to add. We strongly advise that this matter not be characterized in any other fashion than a frivolous lawsuit based on unfounded claims."

Tracy Corgiat, vice president of marketing and development at The Polyclinic, said that CMS requires that a patient's "clinical history and medical diagnoses be newly documented each year during an in-person visit." The Polyclinic has a "rigorous process for validating the diagnoses of our patients and we are fully confident in that process," she said.

At least one doctor was taken aback.

"Let me see if I've got this right. In order to get more $$$ for the Polyclinic, we have to bring patients in for a visit they didn't need or initiate?" the doctor, Scott Stevens, wrote in an email that's part of the court file.

"They would get more from a movie and popcorn!" Stevens wrote.

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. To follow CPI's investigations into Medicare and Medicare Advantage waste, fraud and abuse, go here. Or follow the organization on Twitter.

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Critics Lash Out At Chinese Scientists Who Edited DNA In Human Embryos

NPR Health Blog - Thu, 04/23/2015 - 5:06am
Critics Lash Out At Chinese Scientists Who Edited DNA In Human Embryos April 23, 2015 5:06 AM ET Listen to the Story 3 min 39 sec   iStockphoto

For the first time, scientists have edited DNA in human embryos, a highly controversial step long considered off limits.

Junjiu Huang and his colleagues at the Sun Yat-sen University in Guangzhou, China, performed a series of experiments involving 86 human embryos to see if they could make changes in a gene known as HBB, which causes the sometimes fatal blood disorder beta-thalassemia.

The report, in the journal Protein & Cell, was immediately condemned by other scientists and watchdog groups, who argue the research is unsafe, premature and raises disturbing ethical concerns.

Shots - Health News Scientists Urge Temporary Moratorium On Human Genome Edits

"No researcher should have the moral warrant to flout the globally widespread policy agreement against modifying the human germline," Marcy Darnovsky of the Center for Genetics and Society, a watchdog group, wrote in an email to Shots. "This paper demonstrates the enormous safety risks that any such attempt would entail, and underlines the urgency of working to forestall other such efforts. The social dangers of creating genetically modified human beings cannot be overstated."

George Daley, a stem cell researcher at Harvard, agreed.

"Their data reinforces the wisdom of the calls for a moratorium on any clinical practice of embryo gene editing, because current methods are too inefficient and unsafe," he wrote in an email. "Further, there needs to be careful consideration not only of the safety but also of the social and ethical implications of applying this technology to alter our germ lines."

Scientists have been able to manipulate DNA for years. But it's long been considered taboo to make changes in the DNA in a human egg, sperm or embryo because those changes could become a permanent part of the human genetic blueprint. One concern is that it would be unsafe: Scientists could make a mistake, which could introduce a new disease that would be passed down for generations. And there's also fears it this could lead to socially troubling developments, such as "designer babies," in which parents can pick and choose the traits of their children.

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The Chinese researchers say they tried this to try to refine a new technique called CRISPR/Cas9, which many scientists are excited about it because it makes it much easier to edit DNA. The procedure could enable scientists to do all sorts of things, including possibly preventing and curing diseases. So the Chinese scientists tried using CRISPR/Cas9 to fix a gene known as the HBB gene, which causes beta thallasemia.

The work was done on 86 very early embryos that weren't viable, in order to minimize some of the ethical concerns. Only 71 of the embryos survived, and just 28 were successfully edited. But the process also frequently created unintended mutations in the embryos' DNA.

"Taken together, our data underscore the need to more comprehensively understand the mechanisms of CRISPR/Cas9-mediated genome editing in human cells, and support the notion that clinical applications of the CRISPR system may be premature at this stage," the Chinese scientists wrote.

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Rumors about this research have been circulating for weeks, prompting several prominent groups of scientists to publish appeals for a moratorium on doing this sort of thing.

In the wake of the report from the Chinese scientists, several of these researchers reiterated their call for a moratorium. Some said they hoped the difficulties that Huang and his colleagues encountered might discourage other scientists from attempting anything similar.

"The study simply underscores the point that the technology is not ready for clinical application in the human germline," Jennifer Doudna, the University of California, Berkeley, scientist who developed CRISPR, wrote in an email. "And that application of the technology needs to be on hold pending a broader societal discussion of the scientific and ethical issues surrounding such use."

But there are already reports that Huang's group and possibly others in China continue to try editing the genes in human embryos.

"We should brace for a wave of these papers, and I worry that if one is published with a more positive spin, it might prompt some IVF clinics to start practicing it, which in my opinion would be grossly premature and dangerous," Daley says.

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Why Do Mosquitoes Like To Bite You Best? It's In Your Genes

NPR Health Blog - Wed, 04/22/2015 - 4:08pm
Why Do Mosquitoes Like To Bite You Best? It's In Your Genes April 22, 2015 4:08 PM ET Listen to the Story 3 min 3 sec  

Mmm. Smells just like your identical twin.


A study that asked a few dozen pairs of twins to brave a swarm of hungry mosquitoes has revealed another clue to the cluster of reasons the insects are more attracted to some people than others: Genes matter.

"Twins that were identical were very similar in their level of attractiveness to mosquitoes, and twins that were [not identical] were very different in their level of attractiveness," says James Logan, a medical entomologist at the London School of Hygiene & Tropical Medicine who led the study. "So it suggests that the trait for being attractive or unattractive to mosquitoes is genetically controlled."

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It's long been known that female mosquitoes, which need the proteins in a blood meal to make their eggs, are more drawn to certain people than others, and that various factors are involved.

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Women who are pregnant seem to attract the insects more than women who aren't, for example, and people infected with the malaria parasite seem to be most attractive during the period when the parasite is most transmissible.

In their own previous research, Logan and his colleagues found that people who are bitten less frequently seem to "smell differently to mosquitoes." It's almost as if they produce a natural repellent, he says.

The most recent study, published Wednesday in the journal PLOS ONE, indicates that there are likely specific genes behind those differences in people — genes that affect the way each person smells to the insects.

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To figure that out, the researchers brought 18 pairs of identical twins and 19 pairs of fraternal twins into the lab. Each person stuck a hand in one of the short arms of a Y-shaped plexiglass tube, as air was blown past the hand, toward 20 female Aedes aegypti mosquitoes clustered at the long end of the Y. Once released, the insects could choose between the twins — to fly upwind, along either side of the Y, presumably following the odor of the person they were most attracted to. (The scientists used a new batch of hungry mosquitoes in each trial, and also compared the results to trials that involved "clean air" and nobody's hand.)

There was essentially no difference in the mosquitoes' response to genetically identical twins, the scientists found, but quite a bit of difference in their response to fraternal twins, who are as genetically different from each other as any other pair of siblings. Logan now wants to try to identify which genes exactly influence attractiveness.

"If we could work out which genes are involved, we could develop new repellents," Logan says — which could be much more than a boon to backyard barbeques. Mosquitoes spread lots of terrible diseases.

"The mosquito tested here, Aedes aegypti, is the main transmitter of the yellow fever virus, and the dengue virus, and some other infectious agents," says Richard Pollack, a public health entomologist at the Harvard School of Public Health. "So the more we learn about what causes a mosquito to find a person, the better we'll be able to design better strategies to protect people."

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Can A Person With Dementia Consent To Sex?

NPR Health Blog - Wed, 04/22/2015 - 3:34pm
Can A Person With Dementia Consent To Sex? April 22, 2015 3:34 PM ET Listen to the Story 3 min 40 sec   iStockphoto

Sexual relationships in long-term care facilities are not uncommon. But the long-term care industry is still grappling with the issue.

There's no greater evidence of that than a criminal case in Iowa. On Wednesday, a jury in Iowa found a 78-year-old man not guilty of raping his wife, who had Alzheimer's disease. Henry Rayhons' wife lived in a nursing home. The staff there told Rayhons that because of her dementia, his wife was no longer capable of consenting to sex. He had been charged with sexual assault for allegedly having sex with her after that.

But at the Hebrew Home in Riverdale, N.Y., the fact that some people with dementia still have sex lives isn't news. That facility has had a written policy to help staff manage such relationships for 20 years.

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"It was controversial in 1995 and it's controversial today," says Daniel Reingold, the CEO of RiverSpring Health, the nonprofit that runs the Hebrew Home.

"We knew that there was intimacy occurring, and we considered it to be a civil right and a legal right," says Reingold. "We also felt that intimacy was a good thing, that touch is one of the last pleasures we abandon and lose as we age."

Reingold says the policy protects residents from unwanted sexual contact. And he argues that people with dementia are indeed capable of giving consent.

"People who have Alzheimer's disease or dementia are asked on a daily basis to make decisions about their desires," says Reingold, "from what they eat to activities they may want to engage in," including intimacy with another person.

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But even with a written policy, it's not that easy for nursing homes to figure out when consent to sex is really valid, says Evelyn Tenenbaum, a professor of law at Albany Law School and bioethics professor at Albany Medical College.

"For example, suppose you have a couple and the woman believes that the man she's seeing is her husband," says Tenenbaum. "Then she consents to a sexual relationship. Is that really consent if she doesn't understand who he is and that she's not married to him?"

Sometimes in such cases, nursing homes will defer to the wishes of the resident's family, says Tenenbaum.

"On the other hand, nursing homes are required to take care of the psychosocial needs of their residents," says Tenenbaum. "Whether psychosocial needs would include sexual relationships is a question."

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And it's a question with no commonly accepted answer. The American Health Care Association, a trade group representing the majority of nursing homes, only suggests that its member facilities develop their own policies. Patricia Bach, a geriatric psychologist, says when she started looking into the topic she didn't find much.

"There was very, very little empirical evidence, little data, few research studies and it really was a lower priority issue for long-term care providers," she says.

So with a colleague, Bach surveyed members of the American Medical Directors Association, which represents physicians who work in long-term care facilities.

Bach found that "only 25 to 30 percent actually had formal training in the area of intimacy and sexuality, as it would pertain to older adults. Thirty percent had no training at all." The survey also found that only about 30 percent of nursing homes where the respondents worked had formal policies.

That's something that needs to change, and fast, says Reingold.

"We are dealing with the arrival of my fellow baby boomers," he says. They've "grown up in an environment where sexuality was a much more open conversation and activity."

And there's no reason to think that will change, Reingold says, even when those boomers are in long-term care.

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Why Many Doctors Don't Follow 'Best Practices'

NPR Health Blog - Wed, 04/22/2015 - 12:14pm
Why Many Doctors Don't Follow 'Best Practices' April 22, 201512:14 PM ET Listen to the Story 3 min 33 sec  

For all their talk about evidence-based medicine, a lot of doctors don't follow the clinical guidelines set by leading medical groups.

Consider, for example, the case of cataract surgery. It's a fairly straightforward medical procedure: Doctors replace an eye's cloudy lens with a clear, prosthetic one. More than a million people each year in the U.S. have the surgery — most of them older than 65.

"The procedure itself is relatively painless and quick," says Dr. Catherine Chen, an anesthesiologist and researcher at the University of California, San Francisco. She calls it the "prototypical low-risk surgery."

And since at least 2002, Chen says, clinical guidelines have stipulated that no preoperative testing is needed before cataract surgery. A large study showed that procedures like chest X-rays, blood tests and EKGs — tests sometimes recommended when older people undergo more complicated surgeries — do not benefit someone who is simply having a cataract removed.

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But Chen noticed that a lot of patients are having these preoperative tests done anyway. How many? Digging into the numbers, she discovered that half the ophthalmologists who performed cataract surgery on Medicare patients in 2011 ordered unnecessary tests. That's the same percentage as in 1995.

"In about 20 years, nothing has really changed in terms of physician performance," Chen says. She recently published those findings in the New England Journal of Medicine.

Dr. Steven Brown, a professor of family medicine at the University of Arizona, has studied doctors' reasons for ordering unnecessary tests before a scheduled surgery. A lot of it has to do with perceived safety, he says.

"They think, somehow, that this is going to make the patient more likely to do well in surgery," he says. "It's not."

Brown says some doctors don't know the latest guidelines, which is somewhat understandable, since there can be hundreds to follow.

But often, he says, doctors order extra tests because they think someone down the line — another surgeon or anesthesiologist — will require them.

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"[It becomes] this game of tag," he says, "where you're doing something because you think somebody else wants it, even if you don't really want it."

So, even in the midst of good science and a clear consensus on what should be done, a lot of physicians don't follow the "best practice" guidelines.

Now, imagine what happens when the science isn't clear.

That was the case Monday, when the U.S. Preventive Services Task Force updated its guidelines for breast cancer screening. After analyzing the best studies, the influential panel now suggests most women get a mammogram every other year, beginning at age 50. Guidance from this task force largely determines which tests will be covered by Medicare, Medicaid and insurance companies.

Meanwhile, the American Cancer Society and the American College of Radiology still recommend annual screening mammograms for women beginning at age 40.

"There's really a lot more ambiguity about what is the right thing — what's appropriate [and] what's not appropriate," says Dr. Albert Wu, an internist and professor at the Johns Hopkins Bloomberg School of Public Health.

In cases like these, Wu says, doctors are more likely to follow their gut instincts. And when that happens, fear often comes into play.

Imagine, for example, that a healthy, 40-year-old woman walks into your office and asks about a mammogram.

"If that woman were to develop breast cancer or to have breast cancer, you can imagine what might happen to you if you didn't order the test," Wu says. "Maybe you'd get sued."

Doctors often hear stories like this, he says, and that can affect their judgment.

"Emotion and recent events do influence our decision-making," he says. "We are not absolutely rational, decision-making machines."

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Is It Time To Make Medical And Family Leave Paid?

NPR Health Blog - Wed, 04/22/2015 - 7:56am
Is It Time To Make Medical And Family Leave Paid? April 22, 2015 7:56 AM ET

Partner content from

Michelle Andrews

It's been more than 20 years since passage of the landmark Family and Medical Leave Act, which allows workers to take up to 12 weeks of unpaid time off for medical or family reasons without losing their jobs.

Some workers' advocates and politicians say it's time to plug a big hole in the law by requiring that workers get paid while they're on leave. But the change faces stiff opposition from some small business and other groups that argue that it would be too expensive and an unnecessary government intrusion.

Saying the reality for many families is that both parents must work, President Obama has pushed for paid family leave, calling it an "economic necessity" in his State of the Union address. He proposed $2.2 billion in next year's federal budget to help five states get paid leave programs up and running, and an additional $35 million for states to conduct planning and startup activities.

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Meanwhile, Democrats have reintroduced the Family and Medical Insurance Leave Act that would create a national paid leave program to cover two-thirds of people's wages for up to 60 days a year. With Republicans in control of Congress, however, there's little chance it will pass.

Supporters say that many workers can't afford to take unpaid leave and others aren't eligible for leaves because they work for small employers. The law allows workers to take time off to care for a newborn or adopted child, or if they or family members have a serious health condition. But it doesn't apply to companies with fewer than 50 workers, and workers have to have worked for at least a year and logged at least 1,250 hours in the previous year to qualify for the benefit.

Only 13 percent of workers had access to paid family leave in 2013, according to the Department of Labor's 2014 national compensation survey. Meanwhile, 59 percent of workers were eligible for unpaid leave under the FMLA in 2012.

Four states have implemented paid family leave programs, and their experience may provide guidance for a national paid family leave law.

Three of them — California, New Jersey and Rhode Island — fund the programs entirely by withholding employee wages. The programs are administered by states' unemployment insurance agencies in conjunction with temporary disability insurance programs, according to human resources consultant Mercer. (Washington state has a paid leave program on the books, but it has never been implemented because legislators haven't approved funding.)

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California's program is well established after more than a decade. It allows workers up to six weeks of leave annually at 55 percent of their weekly pay, up to a cap of $1,104 weekly in 2015.

When Allison Guevara's children, now aged 5 and 2, were born, she twice took paid time off from her half-time job as a field representative for the American Federation of Teachers-affiliated union that represents librarians and lecturers at the University of California.

Guevara, 36, says that getting just 55 percent of her salary might have been problematic, but she was able to negotiate with her employer to use accrued vacation and sick time to make up the other 45 percent of her pay.

Altogether, she took off at least three months with pay for each baby. Her husband, who works for the city of Santa Cruz, was not so lucky. The law typically doesn't apply to public sector employees.

"The time off was very necessary," says Guevara. In addition to bonding with her kids, "breastfeeding was very difficult with my first one, it took eight weeks to get that going."

Guevara stumbled upon the information about her paid leave options by accident. That's not surprising. A survey conducted last fall for the California Center for Research on Women and Families found that just 36 percent of Californians knew about the state's paid leave program, a decline from three years earlier when 43 percent said they knew about the law.

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"Those who know about it are those who disproportionately work for employers who already do it," says Vicki Shabo, a vice president at the National Partnership for Women and Families. "That leaves out many lower-paid workers."

California employers are generally positive about the paid family leave law, according to a study prepared for the U.S. Department of Labor last year. Ninety percent of employers in a 2010 survey said the law had either a positive effect on productivity, profit and morale, or it had no effect.

California, New Jersey and Rhode Island have built their programs around existing short-term paid disability program infrastructures; only five states have such disability programs in place, says Catherine Stamm, a senior consultant at Mercer.

"It's not as difficult or momentous for these employers," Stamm says.

Under the Democrats' bill, workers and employers would split the cost of the program, which would be administered by the Social Security administration.

But that's a problem for small business owners, says Jack Mozloom, national media director for the National Federation of Independent Business, a trade group. Many of their members have fewer than 10 employees, Mozloom says, and if someone's out on leave, it's likely that they have to hire a temporary worker or pay someone overtime to do the job.

Financing a paid leave program would "represent a real expense that some of them cannot absorb," he says. "When it's mandated, it puts them in a hole."

Copyright 2015 Kaiser Health News. To see more, visit
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Screening Tests For Breast Cancer Genes Just Got Cheaper

NPR Health Blog - Tue, 04/21/2015 - 3:54pm
Screening Tests For Breast Cancer Genes Just Got Cheaper April 21, 2015 3:54 PM ET Listen to the Story 3 min 26 sec   iStockphoto

A new California company announced Monday it is offering a much cheaper and easier way for women to get tested for genetic mutations that increase their risk for breast and ovarian cancer.

Color Genomics of Burlingame, Calif., has begun selling a $249 test that it says can accurately analyze a saliva sample for mutations in the breast cancer genes BRCA1 and BRCA2, as well as check for 17 other genetic variants that have been associated with a somewhat increased risk for cancer of the breast or ovaries.

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"Color's goal is to democratize access to genetic testing, starting with breast and ovarian cancer risk testing," says Elad Gil, one of the company's co-founders.

But the announcement has sparked mixed reactions, with some scientists and patient advocates praising the option of cheaper genetic testing, while others say it might not be useful, and could be harmful.

Until now, such testing has typically cost thousands of dollars. Gil says his company slashed the cost in a variety of ways, including using the latest technology to automate much of the process. The firm also recruited software engineers from leading companies, including Google and Twitter, to develop computer programs that streamline the analysis. In addition, Gil tells Shots, the company saves money by making the price so low that women don't need to get their insurance companies involved.

Test-kit-in-a-box, from Color Genomics.

Color Genomics

People interested in taking the test can either ask their doctor to order it for them or can contact the company directly through its website, so that Color Genomics can arrange for a physician to place the order. A test kit containing a small plastic tube will then arrive in the mail; the patient just spits into the tube and mails it back to the company, which then analyzes the DNA from cells in the saliva.

The company validated the accuracy of its test in a variety of ways, Gil says, including using it to analyze about 500 samples provided by leading breast cancer researchers. Color Genomics published the results on its website and plans to submit them to a peer-reviewed journal, Gil says.

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The announcement produced mixed reactions. Some researchers welcome the new test as a way for more women to get tested. Currently, only women with a family history of cancer of the breast or ovaries are routinely urged to get a BRCA test, and typically only these women can get their insurance company to pay for it. But Mary-Claire King, a University of Washington geneticist who discovered BRCA1, says many more women carry one of the mutations in BRCA1 and BRCA2 that significantly increase their risk for cancer.

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"We need to be able to offer all women the opportunity to be sequenced for BRCA1 and BRCA2 — and, indeed, their sister genes — when a woman is young enough to make a plan if [it turns out] she does have the misfortune of having a mutation," says King, who is an unpaid advisor to the Color Genomics.

Still, some other geneticists, cancer researchers and women's health advocates are alarmed by the new test. They question whether the results have been studied enough to provide women with reliable information. The test, they say, may produce ambiguous or misleading results that frighten women into taking drastic action that may be unnecessary, such as getting mastectomies or having their ovaries removed

"I worry it will give women information that we really don't know what it means — and that women will make very difficult choices that turn out to be incorrect," says Frances Visco of the National Breast Cancer Coalition.

"If we have more women who believe they are at increased risk," Visco says, "we will have more women removing healthy body parts. We really do not have enough information to base this kind of expansion of this kind of testing."

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Young Adults With Autism More Likely To Be Unemployed, Isolated

NPR Health Blog - Tue, 04/21/2015 - 2:31pm
Young Adults With Autism More Likely To Be Unemployed, Isolated April 21, 2015 2:31 PM ET

The transition to adulthood marks a big turning point in life for everyone, but for young people on the autism spectrum that transition can be really tough.

Young adults with autism had lower employment rates and higher rates of complete social isolation than people with other disabilities, according to a report published Tuesday by the A.J. Drexel Autism Institute.

Additional Information: Disconnection after high school

Percentage of young adults with autism who never worked or continued education after graduating high school.

Credit: NPR; Source: National Longitudinal Transition Study-2/A.J. Drexel Autism Institute

Two-thirds of young people with autism had neither a job nor educational plans during the first two years after high school. For over a third of young adults with autism, this continued into their early 20s, the report found.

And 20-somethings with autism were less likely to be employed than their peers with other disabilities, with 58 percent employed. In comparison, 74 percent of young people with intellectual disabilities, 95 percent with learning disabilities, and 91 percent with a speech impairment or emotional disturbance were employed in their early 20s.

The results are based on data gathered for two large longitudinal studies: the National Longitudinal Transition Study-2, which followed young people in special education programs; and the Pathways survey of children with physical, developmental, mental and behavioral disorders.

"We don't really know at this point why that's happening," says Paul Shattuck an associate professor at Drexel University's School of Public Health, who led the study.

The economic shift in the United States to more service sector jobs hasn't helped, he notes. "Starting in the early to mid-1970s, there's been a historic shift in the balance of jobs in the manufacturing sector to the service sector. And those types of jobs, which require lots of social interaction, are exactly the types of jobs that people with autism have difficulty with."

At the end of high school there's also what Shattuck refers to as the "services cliff." Though the 12th grade, public school students with autism can get tutoring, mental health services and other support through their school's special education program.

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"Then, all of a sudden, when you graduate high school, the special ed services go away. What you're left with is a hodgepodge patchwork of different public services that are pretty difficult to access," Shattuck says. Community programs for adults with autism generally have the capacity to help only the most severely impaired.

"Federal law for special education requires that high schools help students and families develop a transition plan," Shattuck adds. But that doesn't always happen. Only 58 percent of high school students with autism had a transition plan by age 14, as required by federal law. "That's a big accountability problem," Shattuck says.

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Further complicating the issue, he says, is the fact that many people with autism also have an intellectual disability, a seizure disorder or mental health issues. "Although the core of the disability is an inability to relate easily to other people, the majority of people on the spectrum do have some amount of social appetite," Shattuck says.

But many of them lack social support. The study found that 1 in 4 young people with autism was completely isolated — meaning he or she had not seen or spoken with friends in the past year.

Most autism research is focused on children with autism or on preventing the development of autism, he adds. "But autism doesn't go away when people turn 18. We need to figure out how to help adults on the spectrum as well."

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Californians Can Now Pay Cash For Health Insurance At 7-Eleven

NPR Health Blog - Tue, 04/21/2015 - 11:06am
Californians Can Now Pay Cash For Health Insurance At 7-Eleven April 21, 201511:06 AM ET

Partner content from

Sarah Varney

The largest publicly run health plan in the nation, L.A. Care, will allow customers who do not have traditional bank accounts to pay their health insurance premiums with cash.

One in four Americans who were previously uninsured and eligible for federal insurance subsidies don't have a bank account, relying instead on prepaid debit cards, money orders and cash to pay bills, according to a study by Jackson Hewitt Tax Service.

After advocates for low-income consumers raised concerns to the Department of Health and Human Services over how so-called unbanked households would pay their monthly insurance premiums, the Obama administration ordered health plans to accept payment methods that didn't require a credit card or checking account.

"It's as quick as buying a Slurpee."

Starting this week, customers of L.A. Care Covered, one of the health plans for sale on Covered California, the state's insurance marketplace, can pay monthly premiums in cash at more than 680 locations, including 7-Eleven and Family Dollar stores. At the register, customers scan a bar code sent to their smartphone and hand over their cash. The payment posts to L.A. Care within 24 hours, and the service is free to customers.

"It's as quick as buying a Slurpee," said Danny Shader, the founder and CEO of PayNearMe, the for-profit company that established the electronic cash transaction network.

L.A. Care, like most health insurers around the country, pays fees to Visa, MasterCard and banks to process debit and credit card transactions. Laura Jaramillo, director of commercial and group plan operations at L.A. Care, said the health plan negotiated a similar surcharge to PayNearMe for cash payments.

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"It should not increase our administrative costs," Jaramillo said. L.A. Care estimates that up to 25 percent of its marketplace customers mail in money orders each month. Now, members who don't have a bank account can pay in cash, said Jaramillo, "instead of sending us money orders."

Some low- and moderate-income households shun bank accounts because checking account and overdraft fees can wreak havoc on their precarious finances. These same households, however, rely heavily on cellphones — 68 percent of unbanked households have mobile phones.

L.A. Care is the first health plan to use the PayNearMe network, although the company's method of cash collection is already in use in other ways elsewhere. In Nebraska, parents can use the network to pay child support. Pittsburgh water customers and bike share riders in Philadelphia can pay cash at local convenience stores to settle their bills.

"What goes in is cash, and what comes out is an electronic payment," said Shader. "We think everybody ought to do it."

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What's At Stake If Supreme Court Eliminates Your Obamacare Subsidy

NPR Health Blog - Tue, 04/21/2015 - 3:56am
What's At Stake If Supreme Court Eliminates Your Obamacare Subsidy April 21, 2015 3:56 AM ET


Jeff Cohen Listen to the Story 5 min 40 sec  

Carlton Scott pays $266.99 per month for his subsidized health insurance plan. He worries he and his neighbors would lose their insurance without the subsidy.

Jeff Cohen/WNPR

The Affordable Care Act requires all Americans to get health insurance or pay a penalty. To help coax people to buy a health plan, the federal government now subsidizes premiums for millions of Americans.

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In just a couple of months, the Supreme Court will rule on a major case concerning those subsidies. The question to be decided is whether the law authorized that financial help nationwide or just in the minority of states that set up their own insurance exchanges. A decision to take away those subsidies could leave millions without insurance.

Attorney Tom Goldstein, who runs SCOTUSblog, has closely followed the case and says the law is ambiguous. "This is a real, serious question," he says. "The law doesn't tell you whether Congress wanted to limit the subsidies only to those states where the state itself went to the trouble of setting up the exchange, or whether Congress wanted everybody who needed the help to be able to get the subsidies."

In my home state of Louisiana, a lot of people could be affected by the upcoming court decision. About 186,000 people there have used to buy insurance, and nearly 90 percent of them get subsidies. Here are the stories of a few of the people I spoke with.

Carlton Scott

Carlton Scott: "You never know what's going to happen to you."

Carlton Scott is 63. Sitting at the kitchen table of his home in Prairieville, La., near Baton Rouge, Scott tells me he worked at a chemical plant for 30 years before he retired. Last fall his company let him know it was scaling back his retirement benefits.

"Around October," he says, "they wrote me a letter saying [that] in December we'll no longer be covered."

Those reduced benefits included Scott's health insurance, which he was really counting on.

"I thought they would take me to my grave," he says. "I really thought the company would take me to my grave."

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He was deeply angry, and in a bind. At 63, Scott is too young for Medicare, and Louisiana hasn't expanded Medicaid. Obamacare, he says, was a good option for him.

He pays $266.99 per month, "to the penny," for his plan from BlueCross BlueShield of Louisiana. Like a lot of people I spoke with, Scott could rattle off the exact amount. Money is tight and people track their expenses carefully.

If Scott loses his subsidy, he may eventually lose his health insurance, too. He could pay more for a little while if he has to, he says. He gets $2,600 a month between Social Security and his pension. But he worries about friends who don't make as much.

"I got a friend of mine ... down the street," Scott says. "He gets Social Security and pension too. But it's not as much as mine — not half as much."

When asked about the case soon to be decided by the justices of the Supreme Court, Scott laughs.

"They all got insurance, too," he says. "I guarantee you that. They all got insurance."

He thinks the court should "leave it like it is. I mean, what are people going to do? Get sick, go to the hospital [and say], 'I don't have insurance. Won't you please help me anyway?' " It just won't happen, he says.

LaTasha Perry

LaTasha Perry says she couldn't afford the health plan offered by the community health center where she works. But with a subsidized plan, she has insurance and money left over "to buy food for my kids."

Jeff Cohen/WNPR

LaTasha Perry is at the other end of her career. She's 31 and works at the front desk of a community health center in Plaquemine, La. She's healthy and rarely needs a doctor, she says, but bought coverage under Obamacare because it was cheaper than paying the penalty.

Perry's children have Medicaid as their health coverage. Her job offers health insurance, but she doesn't buy it. Like a lot of people who work but don't make a lot of money, she says she can't afford the insurance her company offers.

"I would pay at least $100 a month for the insurance here," Perry says. "With my subsidy, I pay $13."

That leaves her money for other necessities, she says. "Food for my kids. I'm a single parent. It's hard."

Charles Dalton

Retired paramedic Charles Dalton is now disabled. He pays $149 each month for his subsidized health insurance. "If you get a helping hand," he says, "the last thing you need is for it to be snatched out from under you."

Jeff Cohen/WNPR

Charles Dalton: "Losing my insurance is not an option."

Charles Dalton, of Shreveport, was very glad to get Obamacare coverage. He's 64, and after retiring as a paramedic he didn't have any health insurance. Then he got sick.

"I'm disabled," Dalton says. "But I would be totally incapacitated without seeing this doctor."

Before the Affordable Care Act became law, insurance companies could take a person's health status into account when setting the price of the monthly premium and even refuse an applicant for health reasons. That used to make insurance unavailable or unaffordable for many sick people. And now — with subsidies — Dalton says he pays $149 a month. He hopes the Supreme Court doesn't touch the subsidies.

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"They're just going to make a difficult situation more difficult," Dalton says. The Affordable Care Act, he says, has helped make his existence "more livable."

"You're not asking for a handout," Dalton says. "But if you get a helping hand, the last thing you need is for it to be snatched out from under you."

Attorney Goldstein says the Supreme Court justices have a particularly tough job, trying to balance the specifics of the law with its human dimensions.

"The consequences are so real and so powerful," Goldstein says, "that, if the challengers win here — and maybe they deserve to win, maybe it's what Congress intended — but it's hard to avoid the conclusion that millions of people would lose access to health insurance."

This story is part of NPR's reporting partnership with WNPR and Kaiser Health News.

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Federal Panel Revisits Contested Recommendation On Mammograms

NPR Health Blog - Mon, 04/20/2015 - 5:08pm
Federal Panel Revisits Contested Recommendation On Mammograms April 20, 2015 5:08 PM ET Katherine Hobson Listen to the Story 4 min 2 sec  

In 2009, I was among the scrum of reporters covering the controversial advice from the U.S. Preventive Services Task Force that women in their 40s think twice about regular mammograms. The task force pointed out that the net benefits in younger women were small and said women should weigh the pros and cons of screening before making a decision.

Those guidelines kicked off a heated debate about the benefits and harms of mammography that is rekindled with every new study.

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I wasn't yet 40 back then, but what I learned about mammograms stuck with me: I haven't yet had the test. I took to heart the warnings of the task force and of many other physicians that mammography has minuses as well as pluses. I wasn't so worried about a false positive result. But I was very concerned about overdiagnosis, or being diagnosed with and treated for a cancer that would never have caused me any harm.

I'm now 43 and am thinking that I should get a mammogram. So when I found out the USPSTF was doing a routine update of its breast cancer screening recommendations, I hoped it would help me decide.

As it turns out, the suggested changes to the recommendations — which are in draft form and may be altered after a public comment period — are small ones.

What is new? For the first time, the task force looked at the evidence behind 3-D mammography, also known as tomosynthesis. The USPSTF said there's not enough evidence to make a recommendation for or against using the technology to screen women. It also said there was insufficient evidence to say whether women with dense breasts should have screening with MRI, ultrasound or other methods in addition to mammography.

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But the task force's basic advice has not changed. The group recommends that women ages 50-74 get a screening mammogram every two years. And women between 40 and 49 should make their own decision, in consultation with their doctors, based on "health history, preferences and how they value the different potential benefits and harms of screening." (Women with a family history of breast cancer may benefit more from screening in their 40s, the task force says.)

The task force reiterates that there isn't enough evidence to say whether or not women 75 and older should be routinely screened.

Screening mammography means looking for potential cancer in women who are healthy and who don't have any symptoms. People with symptoms should be seen by a doctor, no matter their age. And these recommendations don't apply to women who have previously been diagnosed with the disease or who are at higher risk because of a genetic mutation or other condition.

"We want to reaffirm the importance of mammography to help prevent death from breast cancer," Kirsten Bibbins-Domingo, a physician and vice chairwoman of the USPSTF, told Shots.

And mammograms do save lives in women between 40 and 49 — it's just that there's a disproportionate level of harm.

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The USPSTF's draft includes statistical models estimating the lifetime consequences of screening women from ages 50-74 and also from 40-74. For every 1,000 women screened, the model finds that screening women in their 40s means an estimated one additional breast cancer death averted (from eight to seven), but with 576 additional false positive tests (1,529 vs. 953), 58 unnecessary biopsies (204 vs. 146) and two additional overdiagnosed tumors (20 vs. 18).

The draft recommendations also repeat the USPSTF's earlier advice that women be screened every other year rather than annually, said Bibbins-Domingo. That time frame provides "most of the benefits while minimizing the harm," she said.

Guidelines from medical groups differ on when a woman should start regular screening.

The American Cancer Society, for example, recommends yearly mammograms starting at age 40. Richard Wender, chief cancer control officer of the ACS, says there's much common ground between the guidelines, however. "The task force reconfirmed its conclusion that mammography reduced breast cancer deaths for women in their 40s," he said. The ACS is reviewing its own breast cancer screening guidelines this year.

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As for my fear of overdiagnosis? Wender said it's an issue, but the exact extent of the problem is unknown. And, he added, much of overdiagnosis happens in women with ductal carcinoma in situ, which is Stage 0 cancer that hasn't yet become invasive.

In the not-so-far future, molecular tools may help physicians give those women a more accurate prognosis, Wender says, so those at lower risk can opt for less aggressive treatments — or simply watchful waiting. "The next 10 years are going to be good news for helping women really make decisions about treatment, not just about screening," he said.

So why am I planning to get a mammogram this year? In part, simply because I'm a few years older. The 50-year cutoff isn't a clear line in the sand, and as Bibbins-Domingo told me, the value of the test increases with age.

But to be honest, the main change has little to do with the numbers. I now have a young daughter, and my fear of dying prematurely has become far, far stronger than my fear of getting chemo or even a mastectomy I might not need. I understand the statistics, but I'd feel like a total jerk if I didn't get screened and that unlucky statistic were me.

And on the flip side, if my mammogram did show breast cancer and I was treated successfully, I'd probably be grateful I'd been screened, even if there was no way to know whether the treatment was necessary.

In other words, then and now, I weighed the benefits and the risks and made my own decision, which is exactly what the USPSTF suggests.

NPR's Richard Harris discussed the recommendations on All Things Considered.

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Doctors Don't Always Ask About Pet-Related Health Risks

NPR Health Blog - Mon, 04/20/2015 - 3:07pm
Doctors Don't Always Ask About Pet-Related Health Risks April 20, 2015 3:07 PM ET

Reptiles like leopard geckos can bring Salmonella along with them.


If you're being treated for cancer, an iguana might not be the pet for you.

Ditto if you're pregnant, elderly or have small children at home.

Pets can transmit dozens of diseases to humans, but doctors aren't always as good as they should be in asking about pets in the home and humans' health issues, a study finds.

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And that goes for people doctors and animal doctors. "The fact that they're equally uneducated is concerning," says Jason Stull, an assistant professor of veterinary preventive medicine at Ohio State University and lead author of the review, which was published Monday in the Canadian Medical Association Journal. "There hasn't been a great dialogue between the veterinary community, the human health community and the public."

The people doctors aren't asking their patients what kind of pets they have, Stull says, and veterinarians aren't asking owners about health issues that might increase their risk of acquiring unpleasant, even life-threatening, infections. His paper includes a long list of possibilities, including:

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  • Dog and cats can transmit bacteria like Campylobacter jejeuni that cause nasty intestinal problems, as well as antibiotic-resistant bugs like MRSA. Pets might pick up MRSA while visiting people in the hospital, the report notes.
  • Amphibians, reptiles, rodents and young poultry can spread Salmonella. Back in 2013 the Centers for Disease Control and Prevention warned of an outbreak of a rare strain of Salmonella among people who had pet hedgehogs, and suggested that people lay off cuddling the adorable creatures.
  • Parasites like giardia and Cryptosporidium cause diarrheal disease and can be spread by dogs and cats. Those are nasty but treatable. Rarer parasites like Echinococcus tapeworms can cause liver failure and death.

People should be sure to let their human health-care providers know that they have pets, Stull says, and let the vet know if there are family members who are at greater risk of animal-borne infections. That includes children under age 5, pregnant women, older people, and anyone with a weakened immune system due to things like chemotherapy, HIV/AIDS or organ transplants.

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If you're intrigued by the notion of Fluffy as disease vector, you've got friends at Worms and Germs, a blog from the University of Guelph. They're closely following the new outbreak of canine flu, for example.

"People don't even think of their pets as a possible source of disease," Stull says. "I'm not saying that people should be overly concerned, for the vast majority of the public." Good hand-washing habits can go a long way toward reducing risk in many cases, he adds.

"We're not saying get rid of pets. We're not saying stop getting pets. We're just saying make good choices."

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Humans' Use Of Pain-Relief Creams Proves Fatal To Felines

NPR Health Blog - Mon, 04/20/2015 - 11:39am
Humans' Use Of Pain-Relief Creams Proves Fatal To Felines April 20, 201511:39 AM ET Poncie Rutsch

Contact between cats and their owners may have exposed the animals to toxic levels of medication.


Veterinarians have long warned that pain medications like ibuprofen are toxic to pets. And it now looks like merely using a pain relief cream can put cats at risk.

That's what happened in two households, according to a report issued Friday by the Food and Drug Administration. Two cats in one household developed kidney failure and recovered with attention from a veterinarian. But in a second household, three cats died.

When the veterinarians performed necropsies on the three dead cats, they found physical damage in the cats' intestines and kidneys, evidence of the toxic effects of nonsteroidal anti-inflammatory drugs, or NSAIDs. NSAIDs include ibuprofen, like Advil and Motrin, and naproxen, which is in Aleve.

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Ibuprofen is the most common drug that pets eat, according to the American Veterinary Medical Association, perhaps since many of the pills are candy-coated. In pets, the drugs can cause stomach or intestinal ulcers and kidney failure.

But these cats died by flurbiprofen, another NSAID. In the case of its most recent victims, the cat owner applied a lotion or cream containing flurbiprofen to treat muscle or arthritis pain. And it's highly unusual for a cat to show up at the vet's office; usually it's the dogs that get into trouble from exposure to NSAIDs.

"I can't even remember the last cat I've seen that got into ibuprofen or an NSAID," Erica Reineke, an assistant professor at the University of Pennsylvania's School of Veterinary Medicine, tells Shots. "We've seen more cats that get into antidepressants."

Reineke says that she probably treats a pet for some sort of ingestion problem every day, but usually it's chocolate or chewing gum, or the owner's medication. As little as 50 milligrams of ibuprofen for every kilogram a cat weighs can cause problems; for dogs, it's 100 milligrams for every kilogram. Reineke says she's never seen flurbiprofen toxicity in her office and would have a hard time estimating how much would be toxic to a cat or dog.

This isn't an animal mistreatment issue — none of the cats died because owners were applying their medications to the cats. The owners reported using the product on their necks or feet, and somehow the animals were exposed. The third cat died after the owner had stopped using the medication.

The FDA recommends that pet owners store all medications away from pets and to discard anything used to apply the medication. If any furniture or carpeting becomes contaminated, clean it immediately.

And keep an eye on those pets – if they show signs of lethargy, vomiting or lack of appetite, go see a vet immediately.

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Mellow Pastimes Can Be Good For Your Health, Too

NPR Health Blog - Mon, 04/20/2015 - 3:48am
Mellow Pastimes Can Be Good For Your Health, Too April 20, 2015 3:48 AM ET Listen to the Story 1 min 46 sec  



This makes total sense: When you're engaged in an activity you truly enjoy, you're happy. And, when you're happy you're not dwelling on all the negative things in life, nor are you stressed about obligations or problems. Certainly this is a good thing from an emotional point of view, but it also has physical benefits.

We know exercise reduces stress, but it turns out that more simple stationary things, like doing puzzles, painting or sewing can help, too.

To find that out, Matthew Zawadzki, an assistant professor of psychology with the University of California, Merced, looked at how the body reacts to leisure activities, defined as anything a person does in his or her free time.

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In the study, 115 men and women from different racial groups, ages 20 to 80, were asked to wear little electrodes attached to their chest which measured heart rate throughout the experiment. They were then monitored over the course of three consecutive days, taking surveys at random times throughout the day. The survey questions included what they were doing at that very moment and how they felt about it.

Virtually all the participants reported reduced stress and had a lower heart rate during leisure activities, as compared to parts of the day when they weren't involved in leisure. Leisure could include exercise and socializing, but in many cases it was simple stationary things like listening to music, doing puzzles, sewing, even watching movies or TV. The people said they were 34 percent less stressed, 18 percent less sad and their heart rate dropped, on average, by 3 percent.

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The positive benefits of leisure activities even appeared to persist for hours after the activity itself ended.

"We're still talking about the short term, but there was a definite carryover effect later in the day," says Zawadzki, "and if we start thinking about that beneficial carryover effect day after day, year after year, it starts to make sense how leisure can help improve health in the long term."

When a person is stressed, "their body is worked up – heart rate, blood pressure, hormones – so the more we can prevent this overworked state, the less of a load it builds up," he says.

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You could think of this as a sort of mental escape. When you're totally engaged in and enjoying what you're doing, you don't have time to ruminate and worry. You also don't have time to get bored. And boredom, says Zawadzki, can be dangerous.

"There's something called 'boredom eating'," he says, "where people just binge on junk food as a way to distract themselves. We'll often watch TV passively for hours at a time, rather than actively engage or really think about it. People smoke, drink, do drugs when they're bored."

So the next time you're absorbed in a good book or a good movie, or even just listening to your favorite music, remember you're not only enjoying yourself. You're helping your health.

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FDA Ponders Putting Homeopathy To A Tougher Test

NPR Health Blog - Mon, 04/20/2015 - 3:46am
FDA Ponders Putting Homeopathy To A Tougher Test April 20, 2015 3:46 AM ET Listen to the Story 4 min 51 sec   Katherine Streeter for NPR

It's another busy morning at Dr. Anthony Aurigemma's homeopathy practice in Bethesda, Md.

Wendy Resnick, 58, is here because she's suffering from a nasty bout of laryngitis. "I don't feel great," she says. "I don't feel myself."

The traditional treatments just weren't helping me at all.

Resnick, who lives in Millersville, Md., has been seeing Aurigemma for years for a variety of health problems, including ankle and knee injuries and back problems. "I don't know what I would do without him," she says. "The traditional treatments just weren't helping me at all."

Aurigemma listens to Resnick's lungs, checks her throat and then asks detailed questions about her symptoms and other things as well, such as whether she's been having any unusual cravings for food.

Aurigemma went to medical school and practiced as a regular doctor before switching to homeopathy more than 30 years ago. He says he got disillusioned by mainstream medicine because of the side effects caused by many drugs. "I don't reject conventional medicine. I use it when I have to," Aurigemma says.

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Throughout his career, homeopathy has been regulated differently from mainstream medicine.

In 1988, the Food and Drug Administration decided not to require homeopathic remedies to go through the same drug-approval process as standard medical treatments. Now the FDA is revisiting that decision. It will hold two days of hearings this week to decide whether homeopathic remedies should have to be proven safe and effective.

There is no question that it helps patients.

When Aurigemma is finished examining his patient, instead of pulling out a prescription pad, he uses a thick book to come up with a homeopathic diagnosis. He then searches through heavy wooden drawers filled with rows of small brown glass vials filled with tiny white pellets. They're homeopathic remedies. He pulls out two.

"So this will be the first dose," he says. "Then I'll give you a daily dose, to try to get underneath into your immune system to try to help you strengthen your energy, basically."

Homeopathic medicine has long been controversial. It's based on an idea known as "like cures like," which means if you give somebody a dose of a substance — such as a plant or a mineral — that can cause the symptoms of their illness, it can, in theory, cure that illness if the substance has been diluted so much that it's essentially no longer in the dose.

Homeopathy is an excellent example of the purest form of pseudoscience.

"We believe that there is a memory left in the solution. You might call it a memory. You might call it energy," Aurigemma says. "Each substance in nature has a certain set of characteristics. And when a patient comes who matches the physical, mental and emotional symptoms that a remedy produces — that medicine may heal the person's problem."

Critics say those ideas are nonsense, and that study after study has failed to find any evidence that homeopathy works.

"Homeopathy is an excellent example of the purest form of pseudoscience," says Steven Novella, a neurologist at Yale and executive editor of the website Science-Based Medicine. "These are principles that are not based upon science."

Novella thinks consumers are wasting their money on homeopathic remedies. The cost of such treatments vary, with some over-the-counter products costing less than $10.

Some of the costs, such as visits to doctors and the therapies they prescribe, may be covered by insurance. But Novella says with so many people using homeopathic remedies, the costs add up.

There's also some concern that homeopathic remedies could be dangerous if they're contaminated or not completely diluted, or even if they simply don't work.

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Somebody who's having an acute asthma attack, for example, who takes a homeopathic asthma remedy, "may very well die of their acute asthma attack because they were relying on a completely inert and ineffective treatment," Novella says.

For years, critics like Novella have been asking the FDA to regulate homeopathy more aggressively. The FDA's decision to revisit the issue now was motivated by several factors, including the growing popularity of homeopathic remedies and the length of time that has passed since the agency last considered the issue.

The FDA is also concerned about the quality of remedies, according to Cynthia Schnedar, director of the FDA's Center for Drug Evaluation and Research Office of Compliance. The agency has issued a series of warnings about individual homeopathic products in recent years, including one that involved tablets being sold to alleviate teething pain in babies.

"So we thought it was time to take another look at our policy," Schnedar says.

The FDA's decision to examine the issue is making homeopathic practitioners like Aurigemma and their patients nervous. "It would be a terrible loss to this country if they were to do something drastic," he says.

He also disputes claims that homeopathy doesn't work and is unsafe.

The potential risk to consumers is if any change in regulation were to limit access to these products.

"There's no question that it helps patients. I have too many files on too many patients that have shown improvements," Aurigemma says, although he acknowledges some homeopathic products sold over the counter make misleading claims.

Companies that make homeopathic remedies defend their products as well.

"Homeopathic medicines have a very long history of safety," says Mark Land, vice president of operations and regulatory affairs for Boiron USA, which makes homeopathic products. "One of the hallmarks of homeopathic medicines is safety," says Land, who is also president of the American Association of Homeopathic Pharmacists.

"The potential risk [of greater FDA regulation] to consumers is if any change in regulation were to limit access to these products," says Land.

That's what worries Resnick. She says homeopathic remedies have helped alleviate a long list of health problems she's experienced over the years. "Why would they want to take that away from us?" she says. "Let us have the freedom to decide what works the best for us."

The FDA says this week's hearing is just a chance to start gathering information to decide what — if anything — the agency should do about homeopathy.

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