NPR Blogs

After Alzheimer's Diagnosis, 'The Stripping Away Of My Identity'

NPR Health Blog - Sat, 01/31/2015 - 5:04pm
After Alzheimer's Diagnosis, 'The Stripping Away Of My Identity' January 31, 2015 5:04 PM ET Rebecca Hersher Listen to the Story 5 min 19 sec  

Greg O'Brien (left), with Colleen, Mary Catherine, Conor, and Brendan O'Brien, has been grappling with Alzheimer's disease for the last five years.

Courtesy Greg O'Brien

This is the second in NPR's series "Inside Alzheimer's," about the experience of living with Alzheimer's. In part one, Greg O'Brien talked about learning that he had the disease.

A diagnosis of Alzheimer's disease, says Greg O'Brien, doesn't mean your life is instantly over. "There is this stereotype that ... you're in a nursing home and you're getting ready to die," he told NPR. "That's not true."

In fact, in the five years since he was diagnosed with early-onset Alzheimer's, O'Brien has taken copious notes about his condition and published a memoir.

"There are times when I, I cry privately. It's an emotional thing, the tears of a little boy because I fear I'm alone and the innings are starting to fade."

Alzheimer's, he says, is like "a death in slow motion."

"It's like a plug in a loose socket," he says. "Think of yourself, wherever you are in the country, and you're sitting down and you want to read a good book, and you're in a nice sofa chair next to a lamp at night. And the lamp starts to blink.

"You push the plug in and it blinks again and you push the plug in. ... Well, pretty soon you can't put the plug back in again because it's so loose, it won't stay there. And the lights go out forever."

When Greg O'Brien was 59 years old he was diagnosed with early-onset Alzheimer's. Now, he's documenting his experience with the disease.

Courtesy of Greg O'Brien Interview Highlights

On putting his assets in his wife's name

The doctors told me that I needed to turn everything that I had over to my wife. I'm not allowed to own anything anymore. That was a difficult thing for me because our house on Cape Cod, which I had built, was exactly the kind of home that I wanted to live in and raise my children in. And now I felt that I was a renter.

And that was the beginning of the stripping away of my identity. And I knew no one got that but me. You know, God bless all the doctors and many of the caregivers in the world, but it's really the people who are fighting through early Alzheimer's who ... who get it.

And ... now I forgot the rest of your question. Can you repeat it?

On waking up confused each morning

I don't have a self-identity; I have to find it. I'm an old-school guy, and I think of a file cabinet and think of the who, where, what, when, why and how of your life, arranged in files in this filing cabinet. Then at night, someone comes in and they take all the files out and they throw them all over the floor.

And then you wake up in the morning and say, "Oh my God, I have to put these files back before I realize my identity."

Additional Information: LISTEN: 'It's 24/7'

What is there to look forward to anymore? What does the future look like to someone with Alzheimer's disease?

"You want an honest answer?" Greg O'Brien says.

"I don't know how long I can keep this fight up."

On labeling everyday objects

Right now I have to label toothpaste because I'll grab for soap or lotion and brush my teeth. I also label mouthwash, because there was a time when I grabbed the rubbing alcohol. Knowing, looking at it — it said rubbing alcohol, Greg!

But I said, "No," and I took a swig. Let me tell you, rubbing alcohol doesn't have a thin, minty taste.

On short-term memory loss

Sixty percent now of my short term memory can be gone in 30 seconds. More and more, I don't recognize people. And now people understand that and, God bless them, they come up and introduce themselves to me. These are people I've known since childhood.

In addition to my short-term memory loss, there are times when I've hurled a phone across the room, a perfect strike to the sink, because in the moment I didn't know how to dial. I'll smash my lawnmower against an oak tree in the backyard in summertime because I don't remember how it works.

Shots - Health News 'How Do You Tell Your Kids That You've Got Alzheimer's?'

I cry privately. It's an emotional thing, the tears of a little boy, because I fear I'm alone and the innings are starting to fade. You know, a fish rots from the head down.

Greg O'Brien will share more of his experience with Alzheimer's in future installments on Weekend All Things Considered.

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

Why Do We Love Football So Much? Theater Tackles Tough Questions

NPR Health Blog - Sat, 01/31/2015 - 5:31am
Why Do We Love Football So Much? Theater Tackles Tough Questions January 31, 2015 5:31 AM ET

fromKQED

April Dembosky

Football rules, uniforms, helmets and protective gear have changed a lot over the years.

Keystone-France/Gamma-Keystone via Getty Images

Football injuries have long been seen by some as a badge of honor. A broken sternum, a busted knee, a pierced kidney: all evidence of tenacity on the field.

But the emerging science around head injuries in football — and the long-term effects of repeated concussions – is forcing players, team owners and football fans to come to grips with the idea that the sport they love may be extracting a much higher price than anyone knew.

"It wasn't scary until some of the prominent players — guys that I knew, some of the guys that I played against — started to have this problem."

X's and O's (A Football Love Story) premieres this month at California's Berkeley Repertory Theater, exploring the tension between these medical discoveries and the insatiable demand from fans to see a hard hit.

"I had a ruptured tendon in this finger. I broke my hand. Rotator cuff, shoulder injuries — but I never missed a game because of an injury," says Dwight Hicks, a former safety for the Super Bowl champion San Francisco 49ers, who plays a retired football player in X's and O's.

Dwight Hicks (#22) psychs up before a 1985 game, flanked by San Francisco 49er teammates. Now a lead actor in X's and O's (A Football Love Story), Hicks played nine seasons in the NFL.

David Madison/Getty Images

It wasn't until the early 2000s, Hicks says, that he realized there might be another injury he needed to worry about. That's when more and more retired players began reporting symptoms of early onset Alzheimer's. Others showed the personality changes, rage and depression that can be signs of a type of brain deterioration called chronic traumatic encephalopathy, first diagnosed in boxers in the 1960s.

"It wasn't scary," Hicks says, "until some of the prominent players — guys that I knew, some of the guys that I played against — started to have this problem."

Violence A Worry From Football's Start

Playwrights KJ Sanchez and Jenny Mercein say the growing number of affected players thrust football into an identity crisis — and not its first.

"Through every generation, we knew, we knew what the risks were," Sanchez says. There have been repeated "intense conversations about the violence of the game, the brutality of the game, and the safety of the players."

Throughout the play, there are breaks in the narrative where the cast marks some of the game's historic moments and controversies.

In 1869, Rutgers and Princeton played the first college football game. In 1905, 19 students died while playing football, spurring Harvard's president at the time, Charles Elliott, to call for an end to the sport. One academic called it "more brutalizing than prizefighting, cockfighting, or bullfighting. The rules of action are hateful. ... Football today is a boy-killing, education-prostituting, gladiatorial sport."

But Teddy Roosevelt, then president of the United States, saw things differently.

Sports Can That Mouth Guard Really Prevent A Concussion?

"The bruising nature of football instills manly virtues and builds strong bodies, when with each passing day America risks becoming less rugged and virile," X's and O's quotes Roosevelt as saying. "Surely we can minimize the danger without having to play the game on too ladylike a basis."

"Through every generation, we knew. We knew what the risks were."

In 1915, American sporting legend Jim Thorpe signed with the Canton Bulldogs, an Ohio powerhouse in the early days of professional football.

Heritage Auctions/Wikimedia

Over the years, the protective gear players wear has improved, in an effort to make the game safer. But Sanchez says making better helmets is part of what led to the progressive brain injuries seen today.

She wrote a team physician into X's and O's to explain how recent research has shown that smaller, subconcussive hits contribute to lasting trauma.

"The brain, it's almost like a yolk inside of an eggshell," says the doctor-character (played by Marilee Talkington) as she paces the stage in a white lab coat. Even with a good helmet, "the yolk is still going to hit on one side of the shell and then the opposite side of the shell."

Are Fans Responsible?

X's and O's isn't a one-note bashing of football — Sanchez considers herself a fan.

And her co-writer, Jenny Mercein, grew up watching her father Chuck Mercein play pro ball; he was a running back for Vince Lombardi's Super Bowl champion Green Bay Packers, and also played for the Redskins, Giants and Jets.

Sanchez and Jenny Mercein say they began developing the idea for the theatrical work after a pivotal milestone in the debate about head injury: the suicide in 2012 of former San Diego Charger and 12-time Pro Bowl linebacker Junior Seau, whose brain was diagnosed after his death as showing the cumulative effects of chronic traumatic encephalopathy.

Shots - Health News High Schools Seek A Safer Path Back From Concussion Michel Martin, Going There Rising Football Star: Prepare For The Worst, Pray For The Best

The playwrights wondered whether, as fans, they had some responsibility to the players — and to the future of football itself.

"We started to talk about how many conflicted feelings we had about loving the game, now understanding the significance of the damage that the game does," Sanchez said.

X's and O's leaves it to a group of fans at a bar to work through this internal debate.

"Me and my dad watched every game together," one fan says. "And to this day, I put on a game, it's like we're back together again." Another adds: "It's like ballet. There's a beauty and a grace to it."

They ponder how long football will last if fans decide to boycott the game, or if parents stop letting their kids play out of fear of head injuries.

"If football goes away ...," another fan says, faltering. "My family, we don't go to church. We're not much for theater or concerts. Football is our way of being part of something bigger. I have to admit I'd be lonely."

The characters question recent rule changes in the game, how violent the game needs to be to be entertaining — and what they really get out of that violence.

"I think I watch it, not for the moment when the guy gets knocked down, but for the moment when he gets back up," the fan says. "I think I need to remember we can get back up."

Sanchez says she hopes to take the play to colleges and high schools. She wants to start conversations like these in the community, especially among young people who will decide whether to play or not — and how much of their future they want to bet on football.

A version of this post originally appeared in KQED's State of Health blog.

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

Why Do We Love Football So Much? Theater Tackles Tough Questions

NPR Health Blog - Sat, 01/31/2015 - 5:31am
Why Do We Love Football So Much? Theater Tackles Tough Questions January 31, 2015 5:31 AM ET

fromKQED

April Dembosky Listen to the Story 3 min 56 sec  

Football rules, uniforms, helmets and protective gear have changed a lot over the years.

Keystone-France/Gamma-Keystone via Getty Images

Football injuries have long been seen by some as a badge of honor. A broken sternum, a busted knee, a pierced kidney: all evidence of tenacity on the field.

But the emerging science around head injuries in football — and the long-term effects of repeated concussions – is forcing players, team owners and football fans to come to grips with the idea that the sport they love may be extracting a much higher price than anyone knew.

"It wasn't scary until some of the prominent players — guys that I knew, some of the guys that I played against — started to have this problem."

X's and O's (A Football Love Story) premieres this month at California's Berkeley Repertory Theater, exploring the tension between these medical discoveries and the insatiable demand from fans to see a hard hit.

"I had a ruptured tendon in this finger. I broke my hand. Rotator cuff, shoulder injuries — but I never missed a game because of an injury," says Dwight Hicks, a former safety for the Super Bowl champion San Francisco 49ers, who plays a retired football player in X's and O's.

Dwight Hicks (#22) psychs up before a 1985 game, flanked by San Francisco 49er teammates. Now a lead actor in X's and O's (A Football Love Story), Hicks played nine seasons in the NFL.

David Madison/Getty Images

It wasn't until the early 2000s, Hicks says, that he realized there might be another injury he needed to worry about. That's when more and more retired players began reporting symptoms of early onset Alzheimer's. Others showed the personality changes, rage and depression that can be signs of a type of brain deterioration called chronic traumatic encephalopathy, first diagnosed in boxers in the 1960s.

"It wasn't scary," Hicks says, "until some of the prominent players — guys that I knew, some of the guys that I played against — started to have this problem."

Violence A Worry From Football's Start

Playwrights KJ Sanchez and Jenny Mercein say the growing number of affected players thrust football into an identity crisis — and not its first.

"Through every generation, we knew, we knew what the risks were," Sanchez says. There have been repeated "intense conversations about the violence of the game, the brutality of the game, and the safety of the players."

Throughout the play, there are breaks in the narrative where the cast marks some of the game's historic moments and controversies.

In 1869, Rutgers and Princeton played the first college football game. In 1905, 19 students died while playing football, spurring Harvard's president at the time, Charles Elliott, to call for an end to the sport. One academic called it "more brutalizing than prizefighting, cockfighting, or bullfighting. The rules of action are hateful. ... Football today is a boy-killing, education-prostituting, gladiatorial sport."

But Teddy Roosevelt, then president of the United States, saw things differently.

Sports Can That Mouth Guard Really Prevent A Concussion?

"The bruising nature of football instills manly virtues and builds strong bodies, when with each passing day America risks becoming less rugged and virile," X's and O's quotes Roosevelt as saying. "Surely we can minimize the danger without having to play the game on too ladylike a basis."

"Through every generation, we knew. We knew what the risks were."

In 1915, American sporting legend Jim Thorpe signed with the Canton Bulldogs, an Ohio powerhouse in the early days of professional football.

Heritage Auctions/Wikimedia

Over the years, the protective gear players wear has improved, in an effort to make the game safer. But Sanchez says making better helmets is part of what led to the progressive brain injuries seen today.

She wrote a team physician into X's and O's to explain how recent research has shown that smaller, subconcussive hits contribute to lasting trauma.

"The brain, it's almost like a yolk inside of an eggshell," says the doctor-character (played by Marilee Talkington) as she paces the stage in a white lab coat. Even with a good helmet, "the yolk is still going to hit on one side of the shell and then the opposite side of the shell."

Are Fans Responsible?

X's and O's isn't a one-note bashing of football — Sanchez considers herself a fan.

And her co-writer, Jenny Mercein, grew up watching her father Chuck Mercein play pro ball; he was a running back for Vince Lombardi's Super Bowl champion Green Bay Packers, and also played for the Redskins, Giants and Jets.

Sanchez and Jenny Mercein say they began developing the idea for the theatrical work after a pivotal milestone in the debate about head injury: the suicide in 2012 of former San Diego Charger and 12-time Pro Bowl linebacker Junior Seau, whose brain was diagnosed after his death as showing the cumulative effects of chronic traumatic encephalopathy.

Shots - Health News High Schools Seek A Safer Path Back From Concussion Michel Martin, Going There Rising Football Star: Prepare For The Worst, Pray For The Best

The playwrights wondered whether, as fans, they had some responsibility to the players — and to the future of football itself.

"We started to talk about how many conflicted feelings we had about loving the game, now understanding the significance of the damage that the game does," Sanchez said.

X's and O's leaves it to a group of fans at a bar to work through this internal debate.

"Me and my dad watched every game together," one fan says. "And to this day, I put on a game, it's like we're back together again." Another adds: "It's like ballet. There's a beauty and a grace to it."

They ponder how long football will last if fans decide to boycott the game, or if parents stop letting their kids play out of fear of head injuries.

"If football goes away ...," another fan says, faltering. "My family, we don't go to church. We're not much for theater or concerts. Football is our way of being part of something bigger. I have to admit I'd be lonely."

The characters question recent rule changes in the game, how violent the game needs to be to be entertaining — and what they really get out of that violence.

"I think I watch it, not for the moment when the guy gets knocked down, but for the moment when he gets back up," the fan says. "I think I need to remember we can get back up."

Sanchez says she hopes to take the play to colleges and high schools. She wants to start conversations like these in the community, especially among young people who will decide whether to play or not — and how much of their future they want to bet on football.

A version of this post originally appeared in KQED's State of Health blog.

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

By Impersonating Her Mom, A Comedian Grows Closer To Her

NPR Health Blog - Fri, 01/30/2015 - 4:39pm
By Impersonating Her Mom, A Comedian Grows Closer To Her January 30, 2015 4:39 PM ET Listen to the Story 8 min 19 sec  

Think of human relationships as entanglements. How do they bind you; how do they reveal who you really are?

Daniel Horowitz for NPR

In this episode of Invisibilia, NPR's new show about human behavior, we wanted to explore entanglements: the invisible ways we're entangled with each other. So we called a comedian.

I'm a fan of Maria Bamford, who has done impressions of her mother throughout her career:

"My mom told me before I went to my first girl-boy party in the eighth grade: 'OK, remember what we talked about — gonorrhea, syphilis, herpes, 1, 2. Watch the cold sores. Date rape is a lot more common than people think! You look so gorgeous! Oh, Jenny's mom's here to pick you up. Well, have a good time!' "

Sometimes the version of her mom she plays is just funny, because the mom can be so charmingly upbeat about the horrors of the world that it's hilarious. But sometimes it feels like it's about elements in their relationship that have a darker side. Like in this YouTube bit:

" 'Sweetie, you taking a shower? Can I just get in there a little bit and just show you something? Oh, I didn't know you were naked. Oh sweetie — listen — if you want to get breast implants we will support you. Not financially — but emotionally.' "

So what happens when you mess in a very public way with an entanglement that's pretty complicated already: the emotional entanglement between mother and daughter? How does that affect things?

And I was really interested, most honestly, in her mother's experience.

How does it feel when your body's been overtaken by someone else?

So on two different days, in two different states, with the blessing of both, we spoke to Maria and her mom, whose name is Marilyn Bamford.

We started with Maria, who said her mom imitations were some of the very first comedy bits she ever did. In the beginning, she did them to get a kind of distance or control over her relationship with her mother.

Maria: For me it was a time in life of detaching from my family, or detaching from what I think they want me to be. So it was more like this way I could express frustration.

" 'Honey, when you don't wear makeup, you look mentally ill.' So now when I go home I'm certain to wear thick green eye shadow and a line of lipstick around my lips. 'Baby look pretty now, Mommy?' "

Maria Bamford and her mother, Marilyn, onstage during The Marilyn Bamford Collective at the RIOT Festival in Los Angeles.

Courtesy of Julie Seabaugh

Marilyn: She's got me down, perfectly. In terms of voice, cadence, vocabulary, pretty much.

Alix: And what about the things you say?

Marilyn: Quite a bit of that is not exactly what I say. The one I think about was the one where she has me saying, when you don't wear lipstick you look mentally ill. She and I have gone back and forth on that because I know I didn't say it that way. I said you looked depressed. I mean that's my memory of it. On the other hand, she remembers what she remembers.

But still, Marilyn doesn't seem disturbed at all by her daughter's impression of her, even by the things that she feels are misrepresentations of what she said or how she is. She sees the impression as helpful.

Marilyn: I've recognized that when she talks about things in her comedy that those are issues for her, some issue that she's been interested in. It helps us to understand one another. But I know there are times where I've chosen not to discuss it, or have the energy to discuss it.

" 'You know, I think the real reason you're down is because you're 36 — and you look 36, and that's hard.' "

Alix: Did you learn anything about yourself from watching her imitation of you?

Marilyn: Oh, yes. I kind of remind myself of my mother. My mother was a believer that you put your lipstick on and you powdered your nose, and I see that in myself and say, "Oh no, I don't want to be that way." But what can you do?

And speaking of the inevitable gravity of being your mother, though Maria Bamford started her imitations to detach from her mom, it ended up having the reverse effect. It brought her closer.

A still from Maria Bamford's Web series "Ask My Mom."

Courtesy of Maria Bamford

Maria: It cheers me up to think about what she would say about things. I like the idea that she has a certain point of view on life and things are certain. Or if she's not around, I can make her be around, you know; what would she say in this situation? I would like to be more like her as I get older. Like I'm hoping that my impersonation just bleeds into, I'm her!

Alix: Are you really hoping that?

Maria: Yeah. I could just be the full-on Marilyn Bamford. She's a very likable person. She's always bright-eyed and bushy-tailed.

And Marilyn Bamford, in her own way, has experienced an unanticipated benefit of her daughter's impressions.

Marilyn: I think that many women my age who are, you know, catching up with 70, feel kind of invisible. So when you have your daughter doing these really wonderful and gifted impressions of you, it makes you kind of immortal in some way. And that's kind of a lovely thing to happen at this age.

Maria had actually never heard this. When we told her, she made these three noises:

Maria: Ohhh! Ohhh. Ack. That's really sweet. 'Cause my mom is such a delight.

For us, those three noises summed up the entire messy relationship between children and their well-meaning parents.

You, the child, feel deep affection and gratitude. But sometimes something else mixes in — frustration, maybe, at the imposition of those first emotions.

Because to love your parents and to feel frustrated by the complexity and obligation of those relationships are two realities that are forever entangled.

More on Maria and Marilyn Bamford and other stories of entanglement are going live on Invisibilia, NPR's new show about human behavior. You can hear the program on many public radio stations this weekend. The podcast is available for download on NPR.org and on iTunes.

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

Obama Wants Funding For Research On More Precise Health Care

NPR Health Blog - Fri, 01/30/2015 - 1:23pm
Obama Wants Funding For Research On More Precise Health Care January 30, 2015 1:23 PM ET

Harvard University student Elana Simon introduces President Obama before he spoke at the White House Friday about an initiative to encourage research into more precise medicine.

Mandel Ngan/AFP/Getty Images

You may soon be able to donate your personal data to science. There are plans afoot to find 1 million Americans to volunteer for a new Precision Medicine Initiative that would anonymously link medical records, genetic readouts, details about an individual's gut bacteria, lifestyle information and maybe even data from your Fitbit.

The idea is that medical science can learn a lot more about diseases if researchers can tap into a wide spectrum of information about people who get sick and those who stay healthy.

Medicine has been moving haltingly in that direction. For example, some cancer patients get a genetic test to help doctors identify the best drug to treat their particular subset of tumor. A National Academy of Sciences report in 2011 suggested that there's vastly more potential here for understanding and treating disease. And that idea has taken hold.

Today President Obama asked Congress to fund a $215 million initiative, which would build around those million volunteers. Participants would be assured privacy, and they'd also have a say in how the overall effort is designed.

"Ultimately this has the possibility of not only helping us find new cures, but it also helps us create a genuine health care system as opposed to just a disease-care system," Obama said at a White House ceremony Friday. "Part of what we want to do is to allow each of us to have sufficient information about our particular quirks, that we can make better life decisions. And that ultimately is one of the most promising aspects about this. "

Don't expect this to happen overnight. When this idea was a gleam in the National Academy of Science committee's eye, the scientists said this idea would take decades to mature.

There are already efforts afoot to bring together medical data to advance research. The i2b2 center at Partners HealthCare System in Boston is one federally funded effort to integrate medical records and genetic information on a large scale. Kaiser Permanente in Oakland, Calif., also collaborates with University of California, San Francisco in a similar effort.

And the nation of Iceland (with one-thousandth the population of the United States) has centralized medical information for its citizens, which has proven to be a treasure trove for scientists who want to link genes and disease — at least in this largely homogeneous population. A company headquartered in Iceland, deCODE genetics, has tapped into the nation's health data, and that of half a million people from around the world, to draw links between genes and disease. (deCODE is a subsidiary of biotech giant Amgen.)

A sample of a million volunteers across the United States could expand that effort – helping to connect the dots between diet, environment, genes, behavior and health. That could help guide more effective disease-prevention strategies and it could help improve treatment in people who do get sick.

The initiative's immediate focus is on cancer. It seeks $70 million for the National Cancer Institute, to accelerate efforts to understand how changes in the genome can be tapped to improve cancer treatment. Another $10 million would go to the Food and Drug Administration to help it grapple with approving tests and drugs based on these new approaches to medicine.

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

Experiments With Coordinating Medical Care Deliver Mixed Results

NPR Health Blog - Fri, 01/30/2015 - 11:42am
Experiments With Coordinating Medical Care Deliver Mixed Results January 30, 201511:42 AM ET

Partner content from

Jay Hancock

Medical homes are a simple, compelling idea: Give primary-care doctors resources to reduce preventable medical crises for diabetics, asthmatics and others with chronic illness, and it will reduce hospital visits, improve lives and save money.

But it's not so easy in practice.

Two big experiments run by the Center for Medicare & Medicaid Innovation have delivered mixed early results in enhancing primary care, two studies find. The programs reduced expensive hospital visits in some cases, but struggled to show net savings after accounting for their cost.

Consultants evaluated the first year's results for the Comprehensive Primary Care Initiative, a four-year program in Colorado, New Jersey and several other states; and the Multi-Payer Advanced Primary Care Practice Demonstration, a three-year test in eight states including New York and Pennsylvania. The experiments are part of the Affordable Care Act.

The CPC initiative cut costs by $168 per participating Medicare beneficiary, thanks largely to declines in hospital admissions and emergency visits, compared with results from practices that are not part of the initiative. Results were "more favorable than might be expected" in the test's first year, said a report by Mathematica Policy Research.

Shots - Health News Early Test Of An Obamacare Experiment Posts Little Progress

But that wasn't enough to cover the extra $240 per patient that the Department of Health and Human Services paid practices to hire extra nurses, improve electronic records, set up 24-hour call lines and make other adjustments. The goal was to identify high-risk patients, keep them on the right medicines and diets and steer them to lower-cost treatments.

"As a taxpayer — are we really making a difference?" said Dr. David Nash, dean of Thomas Jefferson University's School of Population Health and an authority on improving care quality. "I can't tell from this report."

Nor was there a big change in quality-of-care indicators, such as follow-up visits after a hospital discharge or making sure patients got recommended diabetes tests. The reports gave little information on whether the added resources improved patients' health, saying it was too soon to tell.

But those who believe medical homes are one answer to America's expensive, uncoordinated health system found encouraging spots in the evaluation.

"The numbers don't take your breath away," said Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, a consortium of payers and caregivers. But, she added, "The fact that the early results look as good as they do we take to be very good news."

"The numbers don't take your breath away."

Almost all of the medical practices that signed up were still participating in the $322 million CPC test at the end of the first year. The complex tasks of identifying patients who could benefit from extra management "proceeded relatively smoothly in the first program year," Mathematica said.

Other payers, including state Medicaid programs and commercial insurers, joined Medicare in giving primary care doctors extra resources to coordinate care. That made for substantial extra revenue — $70,045 per clinician for a median practice — for about 500 participating primary practices.

Another innovation-lab model, the multi-payer primary care demo, or MAPCP, did produce a small savings for Medicare — $4.2 million — after counting extra patient-management fees, according to an evaluation by RTI International.

State Medicaid programs and numerous insurance companies also participated in this experiment, which pays primary care doctors for care management.

Although private insurers' results aren't included in the MAPCP evaluation, the report said some are unhappy with the program. Commercial insurers may be more impatient than government agencies to see their investment in care coordination pay off with lower overall costs.

"Payers are noticeably frustrated with the lack of data showing either a positive return on investment or an improvement in health outcomes for participants," said the evaluation.

Shots - Health News Small Businesses Drop Coverage As Health Law Offers Alternatives

Both MAPCP and the CPC initiative had start-up challenges involving training, communication and data management, the evaluations said.

Patrick Conway, HHS' top innovation and quality officer, called the results "promising" in a blog post, and said the cost reductions in the CPC program "were nearly enough" to cover agency fees paid to doctors for care management.

There has been little information released by HHS on another medical-home test, a three-year, $57 million experiment involving federally qualified health centers that ended last year.

The latest reports follow other research showing mediocre results for medical homes. A widely discussed study last year in JAMA, the journal of the American Medical Association found that a medical-home pilot in Pennsylvania didn't cut the overall cost of care.

But many of the medical-home experiments evaluated so far, including the Pennsylvania pilot, MAPCP and CPC, don't include potent-enough incentives for doctors, say some reform advocates.

Rather than simply giving primary doctors extra funds to manage care, payers need to reward them for cost and quality improvements and possibly penalize them for missing goals, they say. Similar incentives are found in accountable care organizations or bundled-payment arrangements that involve groups of caregivers working under a budget.

"If you change the economic incentives, you will change physicians' practice behavior."

"If you change the economic incentives, you will change physicians' practice behavior," said Nash.

The CPC program intends to offer "shared savings" of cost efficiencies with primary physicians in its third year.

A medical-home program run by CareFirst BlueCross BlueShield in Maryland and the D.C. region that includes shared savings has more than paid for itself in total cost cutting while improving care, the company says.

After launching the arrangement for privately insured members, CareFirst got a $24 million grant from the HHS innovation lab to include Medicare patients. The company has hired outside evaluators to try to confirm its results, said Nielsen.

But she argues that cost savings aren't the ultimate measure of medical-home success.

"If you put in incentives to save money you're going to see practices save money," she said. "But if all we do is save money and we don't improve care, we'll be cutting off our noses to spite our face."

CPC and MAPCP are among dozens of experiments being run by HHS' innovation center, which has a 10-year, $10 billion budget.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

Diabetes Technology Inches Closer To An Artificial Pancreas

NPR Health Blog - Fri, 01/30/2015 - 11:22am
Diabetes Technology Inches Closer To An Artificial Pancreas January 30, 201511:22 AM ET Miriam E. Tucker

Every person who uses insulin to manage diabetes wants what they don't have — a replacement for their malfunctioning pancreas. And though the technology isn't yet to the point of creating an artificial pancreas, it's getting a lot closer.

Just last week, the U.S. Food and Drug Administration approved a mobile app-based system that can monitor a person's sugar levels remotely. Parents can monitor a child's sugar while she or he is in school, for example, providing greater peace of mind.

That technology is the latest step in an evolution aimed at letting people manage diabetes without the burden of calibrating insulin doses themselves. So far we have devices that deliver insulin and devices that continuously monitor blood sugar. Getting those two pieces of equipment to talk to each other would make the process safer and simpler. That's the technology that people really want. And that's starting to happen.

Because that technology is rolling out bit by bit rather than all at once, it makes more sense to call it an artificial pancreas "system," according to Aaron Kowalski, chief mission officer and vice president for research at the Juvenile Diabetes Research Foundation (JDRF), a top funder of research into the systems. The devices are "trying to replace mechanically what's lost in diabetes," Kowalski tells Shots.

The Dexcom Share device is designed to help monitor glucose levels remotely.

Dexcom, Inc.

The healthy human pancreas is an awesome machine, secreting the exact right amount of insulin into the bloodstream to allow the glucose from your food to enter your cells and be used for energy. When you eat, your pancreas secretes more insulin. When you exercise, it dials back the insulin. And if you don't eat for a long time, it makes another hormone called glucagon that tells your liver to put more sugar into your bloodstream. If you don't have diabetes, that system keeps your blood sugar within a very tight range.

In people with Type 1 diabetes and some with longstanding Type 2 diabetes, that system is broken and the insulin has to be replaced manually, by shots or a pump.

Insulin pumps, which have been available for decades, deliver insulin via a small catheter inserted under the skin throughout the day, but the wearer has to tell it how much and when. Getting it right all the time can be extremely difficult, because pump wearers have to check their blood sugar, make educated guesses about the amount of carbohydrates they're eating and how much they exercise, and set the pump accordingly.

Essentially, it's trial and error. And even if you get an on-target blood sugar value once, the next day might turn out differently because you exercise or eat more or less or get sick or stressed or, as one patient quipped, "the moon was full."

Shots - Health News Tight Control Of Type 1 Diabetes Saves Lives, But It's Tough

Enter continuous glucose monitors. Available for home use for the past decade, these devices are a huge advance. They automatically measure the wearer's glucose level every few minutes and wirelessly display the value, so wearers can see their sugar level trends at all times. The CGMs can also send out alarms when sugar levels go too high or too low.

Many people now wear both a CGM and a pump, but that's not a true artificial pancreas system because the user still has to be the brain. New devices are starting to take on more of that responsibility.

A system that shuts off the pump if the wearer's glucose level hits a preset low threshold was approved by the FDA in 2013. The Minimed 530G with Enlite from Medtronics Diabetes helps people avoid low sugars that can cause brain damage or death, and has allowed many parents of a child with diabetes to finally be able to sleep through the night without waking every few hours to check their child's levels.

Even better would be a device that predicts when a person's blood sugar will get too low, and intervenes. That's exactly what 4-year-old Xavier Hames of Perth, Australia, got earlier this month. The device shuts off the pump when the CGM predicts that the blood sugar is about to drop too low, reducing the total number of dreaded low blood sugar episodes by almost 80 percent.

That device, Medtronic's Minimed 640G with Smartguard, was hyped in news accounts as an "artificial pancreas," but it's not a fully automated system that will keep the boy's blood sugar normal all the time without any input from his parents. Yet Kowalski says the device's ability to prevent low blood sugars is "pretty huge." So far, the 640G is only available in Australia, but it's being tested in the United States, with the aim of future FDA approval.

Shots - Health News What Diabetes Costs You, Even If You Don't Have The Disease

Still, neither of these systems addresses high blood sugars, which over time can damage the eyes, kidneys, heart and nerves in people with diabetes. In 2017, Medtronic plans to add a feature to dose insulin if glucose levels rise above a certain threshold.

Further improvements on the technology are in clinical trials. These include: "hybrid" systems that are automated except that the wearer has to signal that he or she is about to eat; "closed-loop" systems that don't require such input; and a fully automated system that adds glucagon in addition to insulin.

This last one, which the investigators call a "bionic pancreas," is a bit controversial in the field; some doctors think a functional artificial pancreas system can be achieved without adding the extra hormone, which is less stable than insulin.

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

In the meantime, some tech-savvy members of the Type 1 diabetes community aren't waiting for trials or FDA approvals, having figured out how to "hack" their devices to create their own artificial pancreas systems.

All of this is happening rapidly, but challenges still need to be overcome: For one, the insulin needs to be redesigned to work faster in order to prevent post-meal sugar spikes — after all, it's still being deposited under the skin, rather than directly into the bloodstream the way a healthy pancreas does it.

Also, CGM accuracy needs to improve. Because the devices measure sugar in the tissues rather than the blood, it's not an exact match. Progress is being made on both fronts.

And there's progress on the payment side, too. A Medtronic rep tells Shots that both the MiniMed 640G and the MiniMed 530G are priced similarly to previous systems. Insurance coverage varies greatly by country, of course, and also within the U.S. by insurance plan. The company contracts with more than 600 insurance plans nationwide.

There is one glaring coverage gap: Medicare currently doesn't reimburse for CGMs, meaning that wearers have to give up the devices when they hit 65 or pay for them out of pocket. The JDRF and other organizations are lobbying for legislation to fix that. (Medicare does cover insulin pumps, but largely for people with Type 1.)

Shots - Health News Scientists Coax Human Embryonic Stem Cells Into Making Insulin

Ultimately, though, even if artificial pancreas technology evolves to the point of full automation, it's still a machine. It can break. And it's not a cure.

Last October, researchers at Harvard announced that they had found a way to coax human embryonic stem cells into making insulin. The researchers are now working on encapsulating those cells so that they won't be attacked by the patient's immune system, the process that causes Type 1 diabetes in the first place. Other research is also focused on finding biological "cures."

Kowalski sees artificial pancreas systems as a bridge until a biological cure becomes available. "Ultimately, we want to get rid of the devices. But in the meantime, we want to keep people healthy and ease the burden. So that's what we're trying to do: make smarter pumps until we have more nature-made solutions."

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

Could This Virus Be Good For You?

NPR Health Blog - Fri, 01/30/2015 - 4:17am
Could This Virus Be Good For You? January 30, 2015 4:17 AM ET Listen to the Story 3 min 56 sec  

Augustine Goba (right) heads the laboratory at Kenema Government Hospital in Sierra Leone. He and colleagues analyzed the viral genetics in blood samples from 78 Ebola patients early in the epidemic.

Stephen Gire/AP

Viruses are usually thought of as the bad guys — causing everything from Ebola and AIDS to hepatitis and measles. But scientists have been following the curious story of a particular virus that might actually be good for you.

The virus is called GB Virus-C, and more than a billion people alive today have apparently been infected with it at some point during their lives, says Dr. Jack Stapleton, an infectious disease specialist at the University of Iowa.

At first, the scientists who named the virus thought it caused hepatitis in a surgeon (whose initials were "GB"). But it turns out the virus actually came from a small monkey — a marmoset — that had been used in an experiment to diagnose the surgeon. GBV-C had nothing to do with the surgeon's illness, but that serendipitous finding has led researchers on a globe-trotting investigation of the life and times of this microbial hitchhiker.

Goats and Soda Is HIV Evolving Into A Weaker Virus? Goats and Soda Ebola Is Rapidly Mutating As It Spreads Across West Africa

Some studies in recent years have hinted that persistent infection with this virus might slow disease progression in some people infected with HIV — leading Stapleton to suggest that maybe the "GB" in the virus's name should stand for Good Boy.

The latest chapter in this saga involves Ebola.

In a widely reported study last summer, Pardis Sabeti, a computational biologist at Harvard, collaborated with colleagues who collected plasma from Ebola patients in West Africa (at great personal expense to the scientists — five of them died while carrying out this research). Sabeti's team sifted through that material looking for RNA (the genetic material in Ebola viruses). And they posted the genetic sequence of all the RNA they found in a public database at the National Institutes of Health.

Some blood plasma samples collected from Ebola patients in West Africa also contained GB Virus-C.

Stephen Gire/AP

David O'Connor, a pathology professor at the University of Wisconsin in Madison, realized that digital treasure trove might also include information about GBV-C. And sure enough, he found the genetic fingerprints of that virus in the records of 13 samples of blood plasma from the Ebola study. Though six of the 13 people who were co-infected with Ebola and GBV-C died, seven survived.

Had the GBV-C virus helped to improve the odds of the Ebola patients who survived? The numbers studied are far too tiny to know. But the question is worth pursuing, say O'Connor and his colleagues in their description of the work, published in the February issue of the Journal of Virology.

"We're very cautious about over-interpreting these results," O'Connor tells NPR. He's now waiting to get a bigger sample, to see if there really is a strong connection between GBV-C infection and survival. It could simply be that people ages 20 to 40 are more likely to be infected with GBV-C — and more likely to survive Ebola.

But there is a theoretical reason why the virus might be helpful: It infects a type of white blood cell, and (when an infection is active) it apparently damps down part of the immune system. With HIV, the thought is that the virus helps reduce inflammation, and that in turn helps slow the onset of AIDS.

Shots - Health News Scientists Debate If It's OK To Make Viruses More Dangerous In The Lab

"It's not severe — it's not enough that it makes people immune-suppressed," Stapleton says, "but it does reduce the inflammatory response of immune cells."

Hypothetically, this virus might also reduce inflammation in some people fighting off a roaring Ebola infection. "It's something you would predict," Stapleton says. "Although often what you predict doesn't happen, so I wouldn't have predicted it." But if that's the case, perhaps drugs that act in a similar manner would help as well.

And beyond the possible implications for HIV and Ebola, O'Connor says, "we're getting to some of these greater questions about ... other situations where this might be beneficial."

There's been some talk about deliberately infecting people with GBV-C in instances where doctors want to turn down the immune system. "That might be something worth testing in a clinical trial," O'Connor says.

"The thinking is," he says, "this infects hundreds of millions of people around the world today; we knowingly transmit it in blood transfusions. It's essentially a safe virus."

But it may not be entirely harmless.

Last October, Stapleton and collaborators at the National Institutes of Health published a study suggesting that people with a cancer of the lymphatic system, non-Hodgkin lymphoma, were more likely to be infected with GBV-C. If the virus actually increases the risk of this disease, it must be by only a small amount; having the virus is much more common than having the cancer.

Again, the evidence of a cancer link is only suggestive. "If it turns out there is actually a risk for cancer, that would provide another reason to find out more about this virus," O'Connor says.

"We always have a bias," he says — assuming that viruses are bad for us. "But now, with new technologies, we're finding there are viruses like GBV-C ... that don't seem to cause disease."

How many more viruses like this might be lurking?

"I actually think it's not that many," Stapleton says, "and I wouldn't have said that 10 years ago." Because the technology that helped identify this virus in Ebola blood samples is so powerful, he reasons, it should also reveal other lurking viruses — if they're there — in similar studies of human tissue.

"At least if you look at the many, many [types of virus] that we now know about," he says, "not many are showing up."

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

Rise In Measles Cases Marks A 'Wake-Up Call' For U.S.

NPR Health Blog - Thu, 01/29/2015 - 7:21pm
Rise In Measles Cases Marks A 'Wake-Up Call' For U.S. January 29, 2015 7:21 PM ET $(function() { var pymParent = new pym.Parent( 'responsive-embed-measles-national-cases', 'http://apps.npr.org/dailygraphics/graphics/measles-national-cases/child.html', {} ); });

After a few cases here and there, measles is making a big push back into the national consciousness.

An outbreak linked to visitors to the Disneyland Resort Theme Parks in Orange County, Calif., has sickened 67 people in California and six other states according to the latest count from the Centers for Disease Control and Prevention.

So far this year there have been 84 measles cases in 14 states. That's already more cases than the U.S. typically sees in a year, the CDC's Dr. Anne Schuchat told reporters on a conference call Thursday. "This is a wake-up call to make sure measles doesn't get a foothold back in our country."

Measles is highly contagious. Ninety percent of people who aren't immune get sick after being around an infected person. Vaccination against the virus is highly effective. Schuchat said the current outbreak is happening because people haven't been vaccinated — not because the measles vaccine isn't working.

The latest wave of cases and potential infections to be identified is in Arizona. Health officials there said 1,000 people may have been exposed to measles from seven people confirmed to have been sick with measles there. Four of those cases were in an unvaccinated family that visited Disneyland.

"This is a critical point in this outbreak," wrote Will Humble, director of the Arizona Department of Health Services, in a blog post Wednesday. "If the public health system and medical community are able to identify every single susceptible case and get them into isolation, we have a chance of stopping this outbreak here. However, if we miss any potential cases and some of them go to a congregate setting with numerous susceptible contacts, we could be in for a long and protracted outbreak."

Widespread vaccination led to a decline in measles, and the disease was declared eliminated in the U.S. in 2000. Vaccination has kept the illness at bay. But the disease remains common in many countries, and travelers bring cases back to the U.S. A big bump in 2014 was tied to Amish missionaries who traveled to the Philippines when a measles epidemic was underway.

Schuchat told reporters that measles outbreaks have been much harder to control in recent years.

Children are supposed to receive their first dose of measles vaccine at a year to 15 months of age, followed by a second dose between 4 and 6. But 1 in 12 kids isn't getting the first dose on time, Schuchat said.

The "overall picture has been getting better, not worse" for vaccination, Schuchat said. But pockets where many people haven't been vaccinated, such as the Amish communities in Ohio back in 2014, provide fertile ground for the measles virus.

$(function() { var pymParent = new pym.Parent( 'responsive-embed-measles-national-exemptions', 'http://apps.npr.org/dailygraphics/graphics/measles-national-exemptions/child.html', {} ); });

One issue is schoolchildren whose parents seek nonmedical exemptions from vaccine requirements. The proportion of children receiving those exemptions varies widely — from 7 percent of kindergartners in Oregon to none in Mississippi and West Virginia where they aren't allowed.

Schuchat said medical exemptions are needed. Some children, such as Rhett Krawitt, a 6-year-old boy in California boy whose immune system was compromised by leukemia treatment, can't be vaccinated. But Rhett relies on what's called herd immunity to keep him safe. His father and mother have asked the school district to bar unvaccinated children, who could pass on diseases such as measles, from attending school.

Research published Monday in the journal Pediatrics finds that people who seek personal-belief exemptions for their children often live near one another. "We think it's the microcommunities that are the problem," CDC's Schuchat said of the way that measles has erupted recently.

Data from Arizona show that the rate of nonmedical vaccination exemptions has been on the rise in recent years and varies quite a bit depending on the type of school a child attends.

$(function() { var pymParent = new pym.Parent( 'responsive-embed-measles-az-exemptions', 'http://apps.npr.org/dailygraphics/graphics/measles-az-exemptions/child.html', {} ); }); Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Cleveland Hospitals Grapple With Readmission Fines

NPR Health Blog - Thu, 01/29/2015 - 11:44am
Cleveland Hospitals Grapple With Readmission Fines January 29, 201511:44 AM ET

fromWCPN

Sarah Jane Tribble

Cleveland Clinic pharmacist Katie Greenlee talks with Morgan Clay about how he should take his prescriptions when he leaves the hospital.

Sarah Jane Tribble/WCPN/Ideastream

At the Cleveland Clinic's sprawling main campus, Morgan Clay is being discharged early one Tuesday afternoon.

Clay arrived a couple of weeks earlier suffering from complications related to acute heart failure. He's ready to go home. But before he can leave, clinic pharmacist Katie Greenlee stops by the room.

"What questions can I answer for you about the medicines?" Greenlee asks as she presents a folder of information about more than a dozen prescriptions Clay takes.

"I don't have too many questions," Clay says. "I've been on most of that stuff for a long time."

Clay, 62, has been taking the medicines since he was in his 20s, when he developed heart problems.

Still, Greenlee wants to make sure Clay understands the importance of taking his pills at the right time and at their full dosage. Taking medicine incorrectly is a big reason patients return to the hospital, and research has found that as many as 30 percent of prescriptions are never filled.

Since it began sending pharmacists into the rooms of patients with heart problems when they are being discharged, the Cleveland Clinic has seen a big drop in the number of patients who need to be readmitted.

But it has proved hard for other Cleveland hospitals that serve many of the area's poor patients to achieve the same results.

This month, the National Quality Forum began a two-year trial that adjusts Medicare's metrics to account for poorer patient populations. NQF is a not-for-profit advisory group that works with federal regulators on the penalty metrics.

NQF's Chief Scientific Officer Dr. Helen Burstin says there's a big question that needs to be answered: "How much should these issues around socioeconomic status (and) poverty be considered as well for the readmission program?"

The NQF plans to analyze the readmissions data for signs of poverty affecting the outcomes and figure out how the measurement should be risk-adjusted to account for poverty's influence, Burstin says.

"Socioeconomic status may be a proxy for some other really important factors, such as whether somebody has social support at home, whether somebody has the ability to come back and have a follow up appointment with their doctor after hospitalization," Burstin says.

The key, she says, is to understand which factors hospitals can be held accountable for and which they can't.

"So we would also like to begin to understand what's underlying those differences, and, ultimately begin to understand which of those lend themselves towards improvement strategies, like making sure somebody does in fact have what they need to make sure they don't bounce back into the hospital," says Burstin.

Burstin says federal regulators at the Centers for Medicare and Medicaid Services are taking part in the discussions and are "willing to participate in the trial going forward."

For now, Cleveland may be the perfect place to help answer this question.

On the near west side of Cleveland, Dr. Alfred Connors is chief quality officer at county-owned MetroHealth System. About half of the hospital's patients are uninsured or on Medicaid, which is government coverage for the poor and disabled.

"So we take care of people who are homeless, people who don't have places to go when they leave, people who really don't have family supports." Connors says. "They are living by themselves on a very limited income."

Unlike the Cleveland Clinic, MetroHealth has seen its Medicare fines increase since the program began. MetroHealth had a 0.83 percent cut in Medicare reimbursement for 2015, as compared with a 0.45 percent in 2013.

The clinic's main hospital is more likely to have privately insured patients, like Clay. Since 2013, the clinic's main campus has seen its penalty drop to 0.38 percent of Medicare payments from 0.74 percent.

There are several factors at play in the numbers.

First, the maximum Medicare penalties increased. A hospital could lose as much as 3 percent cut in Medicare funding starting in the fall of 2014, up from 1 percent when the program started in 2012.

In addition, federal regulators began tracking two new conditions. The penalties were originally based on readmissions of Medicare patients who went into the hospital with a heart attack, heart failure or pneumonia and returned within 30 days.

Now, federal regulators are also including readmissions for hip and knee replacement surgery and chronic obstructive pulmonary disease.

Still, the Cleveland Clinic's Chief Quality Officer Dr. Michael Henderson says socioeconomic issues like poverty are an important factor. "One of the real benefits of some of these programs that have come in place is it's really put coordination of care on the map for patients," Henderson says.

Leaders at all three systems say that regardless of the amount of care and coaching a patient gets in the hospital, a patient's home environment is critical.

University Hospitals — the city's other big hospital system — also serves a high proportion of the region's low-income patients at its main campuses. It reported a 0.59 percent penalty in Medicare reimbursements for 2015 up from a 0.11 percent hit in 2013.

Dr. William Annable, chief quality officer at University Hospitals, is skeptical about the measurement and penalties: "There are some people in the health care industry who see it as the government trying to solve society's problems on the back of the hospitals."

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

Copyright 2015 Cleveland Public Radio. To see more, visit http://www.wcpn.org.
Categories: NPR Blogs

Insurance Choices Dwindle In Rural California As Blue Shield Pulls Back

NPR Health Blog - Thu, 01/29/2015 - 4:12am
Insurance Choices Dwindle In Rural California As Blue Shield Pulls Back January 29, 2015 4:12 AM ET

fromKXJZ

Pauline Bartolone Listen to the Story 3 min 32 sec  

Lori Lomas, an insurance agent with Feather Financial in Quincy, Calif., has noticed that her clients in San Francisco have many more health carrier options than her mountain neighbors.

Pauline Bartolone for KXJZ

After the insurance exchanges set up under the Affordable Care Act first went live in late 2013, Lori Lomas started combing the website of Covered California on a hunt for good deals for her clients. Lomas is an agent at Feather Financial, in the Sierra Nevada town of Quincy, Calif.; she's been selling health policies in rural communities for more than 20 years.

Areas Where Blue Shield Of California Stopped Selling Policies To Individuals In 2014 Notes This map does not include zip codes inside forest/park areas. You can look up specific zip codes via Capital Public Radio.

Source: California Department of Managed Health Care

Credit: Alyson Hurt/NPR

But in 2013, she noticed a troubling change that surprised her: For many clients, insurance options decreased.

"I just started running quotes for people," Lomas says, "and began realizing that in [some] zip codes, the only thing that shows up is Anthem [Anthem Blue Cross]."

In addition to Anthem, Blue Shield of California used to sell policies to individuals in every county in the state, according to the Department of Managed Health Care, one of California's two teams of health insurance regulators. But by 2014's open enrollment period, Blue Shield had pulled out of 250 zip codes throughout the state, including four entire counties: Alpine, Monterey, Sutter and Yuba.

Shots - Health News Limited Insurance Choices Frustrate Patients In California

The gaps are particularly felt in the top third of the state, where thousands of residents now have only one choice of insurer if they want to buy a health policy on the exchange.

That's in contrast, Lomas says, to other spots, like the San Francisco Bay Area, where she's also been helping clients find policies on the state exchange. "I'd do it for them," she says, "and, wow, there are six insurance companies or seven insurance companies. I think that was when I first realized how, truly, we were getting the shaft up here."

"Competition in the marketplace is a good thing, in that it does keep companies, in some sense, honest."

Blue Shield of California declined an interview with NPR. But in a written statement, the company reported that it's not selling in certain areas of California because it could not find enough health providers willing to accept a level of payment that would keep premiums low. According to the statement, the company also is not selling in areas where there is no contracted hospital within 15 miles.

Because of the broad changes in the individual health insurance market under the Affordable Care Act, "there is no accurate apples-to-apples comparison between the individual market in 2013 and the individual market in 2014 and beyond," Blue Shield said, adding that "coverage areas were designed to meet regulatory guidance and with patient access to care in mind."

Blue Shield of California is acting within the law, says Shana Alex Charles, director of health insurance studies at UCLA's Center for Health Policy Research. She says Blue Shield could have offered to pay health care providers more. But, at the same time, she adds, insurance companies can't be forced to operate at a loss.

Shots - Health News Two Doctors Weigh Whether To Accept Obamacare Plans

"There's no public charge that says they have to be in those zip codes," she says. "If they determine that it's not within their company's best interests to remain there and sell their product there, then they won't be there."

That's generally allowed under the federal health law — plans don't have to sell throughout an entire state, for example. Consumer advocates say there is often a lack of doctors in rural areas, and agree that insurers shouldn't sell plans where there isn't a good network. But UCLA's Charles says consumers lose when there are not many insurers to choose from.

"Competition breeds choice," she says, "and people that are competing against each other, work to keep the consumer as happy as possible, so that the consumer will choose them. Competition in the marketplace is a good thing, in that it does keep companies, in some sense, honest."

Two other companies — Assurant Health and Moda Healthare selling health policies in Northern California, but not on the state exchange. So if consumers choose to buy those plans, they can't get the subsidies offered under the federal health law.

Assurant Health says it sells individual policies in every California zip code, and covers out-of-state care. Moda Health just started selling individual policies in California for 2015.

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

Copyright 2015 Capital Public Radio. To see more, visit http://www.capradio.org.
Categories: NPR Blogs

Florida Health Officials Hope To Test GMO Mosquitoes This Spring

NPR Health Blog - Wed, 01/28/2015 - 5:28pm
Florida Health Officials Hope To Test GMO Mosquitoes This Spring January 28, 2015 5:28 PM ET Listen to the Story 4 min 5 sec  

A couple of male, genetically modified Aedes aegypti mosquitoes take flight.

Dr Derric Nimmo/Oxitec

The FDA is considering whether to approve the experimental use of genetically modified mosquitoes in the Florida Keys to help stop the spread of dengue fever and other diseases. Mosquito control officials in the region say they hope to get approval to begin releasing the insects in the Keys as soon as this spring.

There are few places in the United States where mosquito control is as critical as the Florida Keys. In this southernmost county of the continental U.S., mosquitoes are a year-round public health problem and controlling them is a top priority.

Michael Doyle, an entomologist who oversees the Mosquito Control District in the Keys, is worried about one species in particular: Aedes aegypti.

"They love people," Doyle says. He puts his hand near a fine-meshed cage full of the insects, in one of the district labs, to demonstrate his point. The mosquitoes immediately respond, clustering at Doyle's side of the cage. They've clearly noticed him, and they're interested.

"I'm not going to touch them," he says, "because these are wild types and they could be carrying something. But if you put your hand up, they'll fly over and land on the screen to try to bite you through the screen."

These are the mosquitoes that carry dengue fever and chikungunya, another tropical disease that's swept through the Caribbean and is now showing up in Florida.

Goats and Soda Painful Virus Sweeps Central America, Gains A Toehold In U.S. Shots - Health News Houston, We Have Dengue Fever

After years of spraying, local health officials say, A. aegypti mosquitoes in the Keys have developed a resistance to most chemical pesticides. Now, the Mosquito Control District wants to become the first in the U.S. to try something new: genetically modified mosquitoes. The strain of insects was developed more than a decade ago by a British company, Oxitec.

Experiments already conducted in Malaysia, Brazil and the Cayman Islands have found that releasing bioengineered male mosquitoes can reduce the A. Aegypti population by 90 percent. For the past five years, officials in the Keys have been working with Oxitec to get approval from the U.S. Food and Drug Administration for similar experimental trials in Florida.

Derric Nimmo, Oxitec's head of mosquito research, says only male A. aegypti are released in these experiments. "It mates with the females in the wild," he explains, "and passes on that gene to all the offspring. The female goes off and lays her eggs. The eggs hatch. But then they die before reaching adulthood."

Science Biotech Firms Caught In Regulatory No Man's Land Joe's Big Idea A Scientist's 20-Year Quest To Defeat Dengue Fever

The district says surveys it has commissioned of area residents suggest that 60 percent are OK with the trials, and 10 to 20 percent are opposed. In public meetings, though, opposition to the bioengineered mosquitoes has been strong. Some residents question whether dengue is enough of a problem in the Keys to warrant such an experiment.

"It makes no sense to me," Deb Curley, a resident of Cudjoe Key, said at a recent public meeting. "We don't want to be guinea pigs."

In 2009 and 2010, Key West was hit with an outbreak of dengue fever, the first in 75 years. There haven't been any cases since. But Doyle compares the situation to a smoldering fire. "We've got 2.5 to 3 million people that visit the Keys every year," he says. "We're very popular. So the likelihood of it arriving at any given time is good."

Other residents say they're concerned by how a bioengineered mosquito may affect them and the environment. Patty Crimmins, a resident of Key West, says her concerns go beyond mosquitoes. "We're not particularly thrilled with genetically modified anything," she says.

Oxitec's Nimmo says that since A. Aegypti mosquitoes are nonnative, removing them would actually be an environmental plus. He says the bioengineered mosquitoes don't live long after they're released. "And then," he says, "the offspring will die. We've shown that after trials where we stop releasing, [this strain of mosquito] doesn't last very long in the environment. So, we've got a very self-limiting, safe, species-specific technology."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Why Teens Are Impulsive, Addiction-Prone And Should Protect Their Brains

NPR Health Blog - Wed, 01/28/2015 - 2:03pm
Why Teens Are Impulsive, Addiction-Prone And Should Protect Their Brains January 28, 2015 2:03 PM ET Listen to the Story 38 min 12 sec  

Teens can't control impulses and make rapid, smart decisions like adults can — but why?

Research into how the human brain develops helps explain. In a teenager, the frontal lobe of the brain, which controls decision-making, is built but not fully insulated — so signals move slowly.

"Teenagers are not as readily able to access their frontal lobe to say, 'Oh, I better not do this,' " Dr. Frances Jensen tells Fresh Air's Terry Gross.

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A Neuroscientist's Survival Guide to Raising Adolescents and Young Adults

by Frances E., M.D. Jensen and Amy Ellis Nutt

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Jensen, who's a neuroscientist and was a single mother of two boys who are now in their 20s, wrote The Teenage Brain to explore the science of how the brain grows — and why teenagers can be especially impulsive, moody and not very good at responsible decision-making.

"We have a natural insulation ... called myelin," she says. "It's a fat, and it takes time. Cells have to build myelin, and they grow it around the outside of these tracks, and that takes years."

This insulation process starts in the back of the brain and heads toward the front. Brains aren't fully mature until people are in their early 20s, possibly late 20s and maybe even beyond, Jensen says.

"The last place to be connected — to be fully myelinated — is the front of your brain," Jensen says. "And what's in the front? Your prefrontal cortex and your frontal cortex. These are areas where we have insight, empathy, these executive functions such as impulse control, risk-taking behavior."

This research also explains why teenagers can be especially susceptible to addictions — including drugs, alcohol, smoking and digital devices.

Interview Highlights

On why teenagers are more prone to addiction

Addiction is actually a form of learning. ... What happens in addiction is there's also repeated exposure, except it's to a substance and it's not in the part of the brain we use for learning — it's in the reward-seeking area of your brain. ... It's happening in the same way that learning stimulates and enhances a synapse. Substances do the same thing. They build a reward circuit around that substance to a much stronger, harder, longer addiction.

"The effects of substances are more permanent on the teen brain. They have more deleterious effects and can be more toxic to the teen than the adult."

Just like learning a fact is more efficient, sadly, addiction is more efficient in the adolescent brain. That is an important fact for an adolescent to know about themselves — that they can get addicted faster.

It also is a way to debunk the myth, by the way, that, "Oh, teens are resilient, they'll be fine. He can just go off and drink or do this or that. They'll bounce back." Actually, it's quite the contrary. The effects of substances are more permanent on the teen brain. They have more deleterious effects and can be more toxic to the teen than the adult.

On the effects of binge drinking and marijuana on the teenage brain

Binge drinking can actually kill brain cells in the adolescent brain where it does not to the same extent in the adult brain. So for the same amount of alcohol, you can actually have brain damage — permanent brain damage — in an adolescent for the same blood alcohol level that may cause bad sedation in the adult, but not actual brain damage. ...

Dr. Frances Jensen is a professor and chair of the Department of Neurology at the University of Pennsylvania Perelman School of Medicine.

Courtesy of Harper Collins

Because they have more plasticity, more substrate, a lot of these drugs of abuse are going to lock onto more targets in [adolescents'] brains than in an adult, for instance. We have natural cannabinoids, they're called, in the brain. We have kind of a natural substance that actually locks onto receptors on brain cells. It has, for the most part, a more dampening sedative effect. So when you actually ingest or smoke or get cannabis into your bloodstream, it does get into the brain and it goes to these same targets.

It turns out that these targets actually block the process of learning and memory so that you have an impairment of being able to lay down new memories. What's interesting is not only does the teen brain have more space for the cannabis to actually land, if you will, it actually stays there longer. It locks on longer than in the adult brain. ... For instance, if they were to get high over a weekend, the effects may be still there on Thursday and Friday later that week. An adult wouldn't have that same long-term effect.

On marijuana's effect on IQ

People who are chronic marijuana users between 13 and 17, people who [use daily or frequently] for a period of time, like a year plus, have shown to have decreased verbal IQ, and their functional MRIs look different when they're imaged during a task. There's been a permanent change in their brains as a result of this that they may not ever be able to recover.

It is a fascinating fact that I uncovered going through the literature around adolescence is our IQs are still malleable into the teen years. I know that I remember thinking and being brought up with, "Well, you have that IQ test that was done in grade school with some standardized process, and that's your number, you've got it for life — whatever that number is, that's who you are."

It turns out that's not true at all. During the teen years, approximately a third of the people stayed the same, a third actually increased their IQ, and a third decreased their IQ. We don't know a lot about exactly what makes your IQ go up and down — the study is still ongoing — but we do know some things that make your IQ go down, and that is chronic pot-smoking.

On teenagers' access to constant stimuli

We, as humans, are very novelty-seeking. We are built to seek novelty and want to acquire new stimuli. So, when you think about it, our social media is just a wealth of new stimuli that you can access at all times. The problem with the adolescent is that they may not have the insider judgment, because their frontal lobes aren't completely online yet, to know when to stop. To know when to say, "This is not a safe piece of information for me to look at. If I go and look at this atrocious violent video, it may stick with me for the rest of my life — this image — and this may not be a good thing to be carrying with me." They are unaware of when to gate themselves.

On not allowing teenagers to have their cellphones at night

It may or may not be enforceable. I think the point is that when they're trying to go to sleep — to have this incredibly alluring opportunity to network socially or be stimulated by a computer or a cellphone really disrupts sleep patterns. Again, it's also not great to have multiple channels of stimulation while you're trying to memorize for a test the next day, for instance.

So I think I would restate that and say, especially when they're trying to go to sleep, to really try to suggest that they don't go under the sheets and have their cellphone on and be tweeting people.

First of all, the artificial light can affect your brain; it decreases some chemicals in your brain that help promote sleep, such as melatonin, so we know that artificial light is not good for the brain. That's why I think there have been studies that show that reading books with a regular warm light doesn't disrupt sleep to the extent that using a Kindle does.

Read an excerpt of The Teenage Brain

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

Is It OK To Pay Pregnant Women To Stop Smoking?

NPR Health Blog - Wed, 01/28/2015 - 12:02pm
Is It OK To Pay Pregnant Women To Stop Smoking? January 28, 201512:02 PM ET

Smoking during pregnancy increases the risk of premature birth, stillbirth and infant death.

iStockphoto

Women who smoke while they're pregnant are more likely to have health problems, and their babies are at risk, too. But attempts to get women to stop smoking while pregnant usually fail.

When pregnant women in Scotland got paid to quit, 23 percent of them managed to stop smoking, compared with 9 percent who quit after they got counseling, support calls and free nicotine replacement therapy, according to a study published Tuesday in The BMJ.

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Researchers at Glasgow University gave pregnant women gift cards totaling 400 pounds, or about $607, if they stopped smoking and kept off cigarettes. Here's how the payment plan worked:

  • Women got a 50-pound gift card, the equivalent of about $76, if they attended a counseling session and set a quit date.
  • If they stayed off cigarettes for two weeks, they got another 50 pounds.
  • Extend that to 12 weeks, and they got another 100 pounds, about $152.
  • And if they were still not smoking in the last weeks of pregnancy, they got a final 200 pounds, or $303.

This sounds like a total win, because keeping a preemie in the hospital for weeks costs a lot more than $607. Smoking during pregnancy increases the risk of miscarriage, preterm delivery, low birth weight and sudden infant death syndrome, according to the Centers for Disease Control and Prevention.

The Scottish researchers estimate that smoking during pregnancy costs the United Kingdom $8 million to $97 million a year in extra health care costs for women, and $18 million to $35 million in the first year of the baby's life.

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A total of 609 women participated in the study. After 12 months, 15 percent of the women who were offered financial incentives were not smoking, compared with 4 percent of the control group.

So why isn't paying people to quit smoking, or lose weight or take their medicine, used all the time in public health?

"You're sort of saying, 'Why are pregnant women smokers being rewarded for what's deemed as being reckless?' " says Dr. David Tappin, a pediatrician and professor of clinical trials at Glasgow University, who led the study.

"Every mother knows that to be pregnant is a challenge as well as a joy," Tappin tells Shots. "For a lot of these women, it's just a challenge. A lot of them have poor housing, difficult relationships, poor self-esteem. The prospect of a new baby can be overwhelming."

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The vouchers, which could be used at stores that sold groceries, furniture and baby gear, lift a bit of the pressure, Tappin says. "That very small amount of incentive allows them to pull themselves out of their addiction."

Other public health researchers have tried paying people to stop smoking, and some employee wellness programs pay people to lose weight (or penalize them for smoking). But the pay-for-performance idea is far from mainstream, and earlier attempts in the U.K. got a lot of blowback.

Tappin spent six years trying get women to stop smoking by giving them high-quality counseling through midwives. It didn't work. So he's ready to embrace paying people, even if we think they're wrong for engaging in bad behavior. "It's thinking about a health problem without thinking about the morality of it."

He's awaiting funding to expand the voucher project to a number of sites around the U.K., where smoking rates during pregnancy range from 20 percent of women to 5 percent.

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

VA Steps Up Programs As More Veterans Enter Hospice Care

NPR Health Blog - Wed, 01/28/2015 - 3:26am
VA Steps Up Programs As More Veterans Enter Hospice Care January 28, 2015 3:26 AM ET Listen to the Story 3 min 57 sec  

A hospital bed is draped with a flag after a veteran died in the hospice ward at St. Albans VA in Queens, N.Y.

Quil Lawrence/NPR

Ask Americans if someone in their family served in the military, and the answer is probably no. After all, fewer than 1 percent of Americans serve these days.

But ask if one of their grandfathers served, and you'll likely get a different answer. Between World War II and the wars in Korea and Vietnam, millions of men were drafted into service — and both men and women volunteered.

Now, that generation of veterans is getting older. And as many of them near the end of their lives, aging into their 80s and 90s, the demand for hospice care has been growing with them. That means that the Department of Veterans Affairs is spending a lot more on what's known as end-of-life care.

"I think they call it end-of-life care," notes Thomas O'Neill, a 68-year-old resident at the St. Albans VA hospital in Queens, N.Y. "But whatever it is ... they treat you like gold. If you're going to be sick, this is the place to be."

O'Neill served a year in Vietnam, from 1966 to 1967, at a time when the war was killing more Americans in a year than the total U.S. casualties from Iraq and Afghanistan combined.

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"The only good thing was the nighttime, because you knew another day closer to coming home," he says. "To be honest with you, I was scared. I was very scared the whole year — and I don't think I was the only one."

When he came home, he didn't talk to anyone about the war. O'Neill says he nearly drank himself into the grave. In 2011, he finally went to the VA to treat the post-traumatic stress disorder he'd been enduring for 40 years. Last year, he learned he has terminal cancer.

"They can tell you you got three months. They don't really know," he says. "I came to terms with this. I'm not happy with the diagnosis, but I came to terms with it."

Coming to terms with the end of life can be a bit different for veterans, says Dr. Alice Beal, who directs VA palliative care for most of New York City.

"If a veteran's been in combat, a veteran's likely to have killed," Beal says. "I think no matter what your culture is, when you meet your maker — even if it's been to save your buddy, to save your life, to save your country — it's just a burden the rest of us haven't even thought of."

Sometimes that means vets want to tell their stories at the end of life, Beal says. Sometimes the stories come unbidden.

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"If you've had blood on your hands, it comes up," she says. "People who have PTSD, maybe have not had it unmasked their whole life, but as they're dying, all of a suddenly they get flashbacks."

Beal says the goal in hospice is to make life as good as it can be for as long as possible; that usually means focusing on relieving pain for the last weeks or months of life.

The hospice ward is a contradiction: It's brightly decorated, and at the entrance there's a fish tank and an electric fireplace. But there's also usually a room recently vacated, with an American flag draped on the bed and a lantern on the nightstand honoring a veteran who passed on.

"It's a real tossup between respect and release. Around here we tend to be full of life," Beal says. "But you don't want to be too joyful in the presence of a family who is grieving."

All VA facilities now have a palliative care team, but only a fraction of veterans enter VA hospice, according to Dr. Scott Shreve, who directs VA hospice care nationwide. Shreve says the vast majority prefer to stay in their communities and near family instead.

National Security First Rule Of This Fight Club: You Must Be A Veteran

The VA and the National Hospice and Palliative Care Organization are collaborating on a project called We Honor Veterans, to help civilian hospice workers ask the right questions.

Volunteers with We Honor Veterans sometimes show up to find elderly veterans who haven't mentioned much about serving in the military to their family or community, like 92-year-old Florence Keliher, in Hallowell, Maine.

"I served during World War II in the Army Nurse Corps. I was on Tinian, the little island in the South Pacific," Keliher says. "We had a ward full of patients — airplane crashes and things like that. They flew from Tinian to Japan to bomb. Some had trouble taking off sometimes."

Keliher's son, Pat, who lives up the road, says he never heard much about his mother's time at war until a grandchild asked to type up some of Keliher's stories:

"The patients we nursed in the wards on afternoon duty broke our hearts. It sounds like a cliche, but they were so young. Malaria, horrible burns. ... I was only 23 years old, but I felt much older than the patients I tended, some of whom called for their mothers in their distress."

Besides Keliher's kids and grandchildren, a volunteer with Beacon Hospice also visits her regularly as part of the We Honor Veterans campaign. They play cribbage and swap stories.

Shreve says only half the community hospices nationwide are taking advantage of the We Honor Veterans program, which is free. He'd like to see more of them get on board. That's because half a million veterans will be needing end-of-life care each year for the next five years.

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

To Protect His Son, A Father Asks School To Bar Unvaccinated Children

NPR Health Blog - Tue, 01/27/2015 - 5:05pm
To Protect His Son, A Father Asks School To Bar Unvaccinated Children January 27, 2015 5:05 PM ET

fromKQED

Lisa Aliferis

Rhett Krawitt, 6, outside his school in Tiburon, Calif. Seven percent of the children in his school are not vaccinated.

Courtesy of Carl Krawitt

Carl Krawitt has watched his son, Rhett, now 6, fight leukemia for the past 4 1/2 years. For more than three of those years, Rhett has undergone round after round of chemotherapy. Last year he finished chemotherapy, and doctors say he is in remission.

Now, there's a new threat, one that the family should not have to worry about: measles.

Rhett cannot be vaccinated, because his immune system is still rebuilding. It may be months more before his body is healthy enough to get all his immunizations. Until then, he depends on everyone around him for protection — what's known as herd immunity.

But Rhett lives in Marin County, Calif., a county with the dubious honor of having the highest rate of "personal belief exemptions" in the Bay Area and among the highest in the state. This school year, 6.45 percent of children in Marin have a personal belief exemption, which allows parents to lawfully send their children to school unvaccinated against communicable diseases like measles, polio, whooping cough and more.

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Carl Krawitt has had just about enough. "It's very emotional for me," he said. "If you choose not to immunize your own child and your own child dies because they get measles, OK, that's your responsibility, that's your choice. But if your child gets sick and gets my child sick and my child dies, then ... your action has harmed my child."

Krawitt is taking action of his own. His son attends Reed Elementary in Tiburon, a school with a 7 percent personal belief exemption rate. (The statewide average is 2.5 percent). Krawitt had previously worked with the school nurse to make sure that all the children in his son's class were fully vaccinated. He said the school was very helpful and accommodating.

Now Krawitt and his wife, Jodi, have emailed the district's superintendent, requesting that the district "require immunization as a condition of attendance, with the only exception being those who cannot medically be vaccinated."

Carl Krawitt provided me with Superintendent Steven Herzog's response. Herzog didn't directly address their query, instead saying: "We are monitoring the situation closely and will take whatever actions necessary to ensure the safety of our students."

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Typically, a response to health emergencies rests with county health officers. During the current measles outbreak, we've already seen that unvaccinated students at Huntington Beach High School in Orange County were ordered to stay out of school for three weeks after a student there contracted measles. It's one way to contain an outbreak.

But those steps were taken in the face of a confirmed case at the school.

When I called Marin County health officer Matt Willis to see what he thought of keeping unvaccinated kids out of school even if there were no confirmed cases, he sounded intrigued. "This is partly a legal question," he said.

But he was open to the idea and said he was going to check with the state to see what precedent there was to take such an action.

Right now, there are no cases of measles anywhere in Marin and no suspected cases either. Still, "if the outbreak progresses and we start seeing more and more cases," Willis said, "then this is a step we might want to consider" — requiring unvaccinated children to stay home, even without confirmed cases at a specific school.

Rhett has been treated at the University of California, San Francisco, and his oncologist there, Dr. Robert Goldsby, said that he is likely at higher risk of complications if he were to get measles.

Rhett, just weeks after starting chemotherapy in 2010.

Courtesy of Carl Krawitt

"When your immune system isn't working as well, it allows many different infections to be worse," Goldsby said. "It's not just Rhett. There are hundreds of other kids in the Bay Area that are going through cancer therapy, and it's not fair to them. They can't get immunized; they have to rely on their friends and colleagues and community to help protect them."

Goldsby pointed to the number of people who, when facing a friend or family member who receives a challenging diagnosis, will immediately ask how they can help. "Many families will say, 'What can I do to help? What can I do to help?' " he said, repeating it for emphasis. "One of the main things they can do is make sure their [own] kids are vaccinated to protect others."

Krawitt has been speaking up about vaccination for a long time now. He told me about going to a parent meeting at his daughter's school just before the start of the school year, where a staff member reminded parents not to send peanut products to school, since a child or children had an allergy. "It's really important your kids don't bring peanuts, because kids can die," Krawitt recalls the group being told.

The irony was not lost on him. He told me he immediately responded, "In the interest of the health and safety of our children, can we have the assurance that all the kids at our school are immunized?"

He found out later from a friend that other parents who were present were "mad that you asked the question, because they don't immunize their kids."

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

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

Am I Responsible If The Insurance Exchange Flubs My Subsidy?

NPR Health Blog - Tue, 01/27/2015 - 9:28am
Am I Responsible If The Insurance Exchange Flubs My Subsidy? January 27, 2015 9:28 AM ET

Partner content from

Michelle Andrews

Insurance and the subsidies available to buy it can be confusing. Here are some answers to recent questions from people who are running into difficulties with premiums and tax credits on their marketplace plans.

My 63-year-old husband has Alzheimer's disease. Our annual income is $41,000, from a combination of his Social Security disability insurance (SSDI) and a disability policy he had from a previous job. Last year I bought a single policy on the health insurance exchange. My husband gets coverage through the Department of Veterans Affairs. The monthly premium was reduced by a $278 tax credit based on our estimated annual income. Now I'm reviewing IRS form 8962 that's used to reconcile what we received in premium tax credits against what we should have received based on our actual income. It looks like we'll have to repay $2,500! We can't afford that. If the marketplace made a mistake in figuring our tax credit, do we still have to pay the money back?

If you received too much in premium tax credits, you'll generally have to pay some or all of it back. Health policy experts say they know of no provision in the health law or rules that would excuse someone from repayment if an error that resulted in a tax credit overpayment was made by the online marketplace. An administration official didn't respond to a request to clarify whether those situations would be handled differently than if someone underestimates their own income and receives too much.

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The amount you'll have to repay is capped based on your income. A couple with an income between 200 and 300 percent of the federal poverty level ($31,460 to $47,190 for a family of two in 2014) would have to repay up to $1,500. (People with incomes above 400 percent of poverty — $62,920 for a couple — would have to repay the entire amount.)

It's hard to know if or where an error occurred. It's possible that you or the marketplace calculated your income incorrectly. SSDI counts as income when figuring your eligibility for premium tax credits, but disability insurance payments received from an employer policy may or may not count as income depending on who paid the premium.

Perhaps you or the marketplace entered information incorrectly, transposed figures or made some other manual or computer entry error.

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By early February you should receive Form 1095-A from the marketplace detailing how much you received in tax credits for reconciliation purposes. It will be important to use that to make sure your calculations on Form 8962 are correct.

If you discover there was an error in your premium tax credit last year, you'll still have time to sit down with a navigator to go over your 2015 coverage choices before open enrollment ends Feb. 15.

I had coverage through a health insurance marketplace plan last year, and this year I'm told my costs will increase significantly. The actual premium the insurance company will charge won't change and my income hasn't changed. But the amount of premium tax credit I receive will go down. What can I do?

Before you renew your coverage with the same plan you had last year, go back to the marketplace and check out what else is available. It sounds as if the benchmark plan in your area may have changed, and that could mean a higher bill for you unless you switch plans.

Here's how it works: Premium tax credits are based on the second-lowest-cost silver plan in your area, called the benchmark plan. If the cost of the benchmark plan this year is lower than it was last year, your tax credit may be lower as well. That's not a problem if you switch to the new, cheaper benchmark plan. But if you renew your old plan, you'll have to pay the difference in cost between its higher premium and that of the new benchmark plan.

"Even though your premium didn't change and your income didn't change, you could see a significant difference in what your contribution is because the premium for the second-lowest-cost silver plan is different," says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

I am being told that I must furnish automatic debit card information before an insurance company will provide me with coverage through the exchange. Can they do that?

Health insurers that sell coverage on the marketplaces are required to accept various forms of payment, says Sandy Ahn, a research fellow at Georgetown University's Center on Health Insurance Reforms. That includes paper and cashier's checks, money orders, electronic funds transfers and prepaid debit cards.

An insurance industry representative said this sounded like a misunderstanding. "Plans accept various forms of payment and wouldn't limit a consumer only to a debit card," says a spokeswoman for America's Health Insurance Plans, an insurance industry trade group. "Health plans regularly work with their members to establish the payment plan that works best for them."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

Child Abuse And Neglect Laws Aren't Being Enforced, Report Finds

NPR Health Blog - Tue, 01/27/2015 - 3:47am
Child Abuse And Neglect Laws Aren't Being Enforced, Report Finds January 27, 2015 3:47 AM ET Listen to the Story 3 min 41 sec   Will Crocker/Getty Images

Laws intended to protect children from abuse and neglect are not being properly enforced, and the federal government is to blame. That's according to a study by the Children's Advocacy Institute at the University of San Diego School of Law, which says children are suffering as a result.

The numbers are grim. Almost 680,000 children in the United States were the victims of abuse and neglect in 2013. More than 1,500 of them died.

Federal officials say they're encouraged that the numbers are lower than they were in 2012. But children's advocates say abuse is so often not reported that it's impossible to know if there's really been a decline.

"This is just something that's chronically underreported," says Elisa Weichel, a staff attorney with the Children's Advocacy Institute, which published the report Tuesday.

She says abuse and neglect cases — especially those resulting in death — are often not disclosed as required by law. That lack of information has led to other problems in the system.

"It all boils down to having the right amount of data about what's working and what's not," Weichel says. "And when your data is flawed, every other part of your system is going to be flawed."

"This is just something that's chronically underreported."

Her group has found plenty of flaws. The institute conducted a three-year study and found that not one state has met all of the minimum child welfare standards set by the federal government. Those standards include such things as timely investigation of reports of child abuse. The institute blames Congress and the courts for failing to get involved.

The Department of Health and Human Services, which reviews state programs, declined to comment on the report.

But there's broad agreement among those involved in child welfare that the system is in desperate need of repair, agencies are underfunded, and caseworkers are often overwhelmed.

"Whether or not individual states can meet a reporting standard to us is not where the emphasis ought to be," says Ron Smith, director of legislative affairs for the American Public Human Services Association, which represents child welfare administrators.

"It needs to be on making sure that the kids who need assistance are getting assistance, and the families that need assistance are getting the assistance," he says.

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Smith says state and local officials complain that they spend too much time filling out federal forms and trying to meet requirements that aren't necessarily best for kids.

Instead, he says, they want flexibility on how to spend federal funds so they can focus more on keeping families together, rather than on helping kids after they've been abused and removed from their homes.

Ron Zychowski of Eckerd, a nonprofit company that runs child welfare services in three of Florida's largest counties, agrees that change is needed. Eckerd has developed a new system to identify which of the 5,000 children under its care are at the highest risk of serious injury or death, so they can fix problems quickly.

"And I'm very pleased to report that in two years we have not had a child death from abuse or neglect in any of our cases," Zychowski says.

That program is getting lots of national attention, including from a new commission set up by Congress to help eliminate abuse and neglect deaths.

But Zychowski warns, in this field, there's no silver bullet.

"Bad people will do bad things to children," he says. "We're not going to catch them all, and we're not going to stop them all."

There was a horrific reminder of that earlier this month. A Florida man was accused of killing his 5-year-old daughter by throwing her off a bridge. Zychowski says the family was not in the child welfare system.

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

Medicare Looks To Speed Up Pay For Quality Instead Of Volume

NPR Health Blog - Mon, 01/26/2015 - 5:14pm
Medicare Looks To Speed Up Pay For Quality Instead Of Volume January 26, 2015 5:14 PM ET

Partner content from

Jordan Rau

The Obama administration said Monday that it wants to speed up changes to Medicare so that within four years half of its traditional spending will go to doctors, hospitals and other providers that coordinate patient care.

The shift is being made to stress quality and frugality over payment by the procedure, test and visit.

The announcement by Health and Human Services Secretary Sylvia Burwell is intended to spur efforts to supplant Medicare's traditional fee-for-service medicine, in which doctors, hospitals and other medical providers are paid for each case or service without regard to how the patient fares. Since the passage of the federal health law in 2010, the administration has been designing new programs and underwriting experiments to come up with alternative payment approaches.

Last year, 20 percent of traditional Medicare spending, about $72 billion, went to models such as accountable care organizations, or ACOs, where doctors and others band together to care for patients with the promise of getting a piece of any savings they bring to Medicare, administration officials said.

There are now 424 ACOs, and 105 hospitals and other health care groups that accept bundled payments. Medicare's bundles give them a fixed sum for each patient, which is supposed to cover not only their initial treatment for a specific ailment but also all the follow-up care. Other Medicare-funded pilot projects give doctors extra money to coordinate patient care among specialists and seek to get Medicare to work more in harmony with Medicaid, the state-federal health insurer for low-income people.

Burwell's targets are for 30 percent, or about $113 billion, of Medicare's traditional spending to go to these kind of endeavors by the end of President Obama's term in 2016, and 50 percent — about $215 billion — to be spent by the end of 2018.

The administration also wants Medicare spending with any quality component, such as bonuses and penalties on top of traditional fee-for-service payments, to increase, so that by the end of 2018, 90 percent of Medicare spending has some sort of link to quality. These figures do not include the money that now goes to private insurers in the Medicare Advantage program, which enrolls about a third of all Medicare beneficiaries.

Monday's announcement didn't include any new policies or funding to encourage providers, but Burwell said setting a concrete goal alone would prompt changes not only in Medicare but also in private insurance, where some of these alternative models are also being tried.

"For the first time we're actually going to set clear goals and establish a clear timeline for moving from volume to value in the Medicare system," Burwell said at the department's headquarters, where she was joined by leaders from the insurance, hospital and physician leaders. "So today what we want to do is measure our progress and we want to hold ourselves in the federal government accountable."

Some providers have eagerly embraced the new payment models, some with success. Roughly a quarter of ACOs saved Medicare enough money to win bonuses last year. Others are wary, particularly since they could lose money if they fall short on either saving Medicare money or achieving the dozens of quality benchmarks the government has established.

"ACOs are quite expensive to set up," said Andrea Ducas, a program officer at the Robert Wood Johnson Foundation, a New Jersey philanthropy that is funding research into ACO performance. "There's a significant upfront investment and if you're not sure you're going to make it back, there's a pause."

In the largest ACO experiment, the Medicare Shared Savings Program, 53 ACOs saved enough money in 2013 to get bonuses from the government, but 41 spent more than the government estimated they should have. Those ACOs did not have to repay any money, but in the future Medicare intends to require reimbursements from those who fall short. Providers have been pushing Medicare to increase the cut they get from these programs and lessen the financial risks in ACOs and the other programs.

"Government needs to do more to make sure there's more shared savings going back to the providers," said Blair Childs, an executive with Premier, a company that helps hospitals and providers in establishing ACOs and other models.

It is still too early to know whether these alternative payment models actually improve health of patients and whether the savings that have been achieved so far — often by focusing on the most expensive patients — will plateau. Studies on the success of these programs have shown mixed results.

"We still have very little evidence about which payment methods are going to be successful in getting the results we want, which are better quality care and more affordable care," said Suzanne Delbanco, executive director of Catalyst For Payment Reform, a California-based nonprofit that has been tracking the spread of alternative payment models in the private sector. "We're just wanting to avoid a situation where a few years from now, where we've completely gotten rid of fee-for-service, we don't want to wake up and say, 'Oh my gosh, we did it and we're no better off.' "

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Pediatricians Say Don't Lock Up Teenagers For Using Marijuana

NPR Health Blog - Mon, 01/26/2015 - 11:46am
Pediatricians Say Don't Lock Up Teenagers For Using Marijuana January 26, 201511:46 AM ET

A marijuana bud displayed in Denver. Don't legalize pot, the pediatricians say, but don't lock teenagers up for using it, either.

Seth McConnell/The Denver Post/Getty Images

Across the country, efforts to make marijuana more accessible have quickly gained traction. Medical marijuana is now legal in 23 states, and recreational use is also legal in four states and the District of Columbia.

Science, however, hasn't quite caught up. Largely due to its illegal status, there's been very little research done on marijuana's health effects. And researchers don't fully understand how pot affects the developing teenage brain.

This may explain the why the nation's pediatricians have changed their recommendations on marijuana and children.

On Monday, the American Academy of Pediatrics revised its policy on medical marijuana, saying pediatricians should avoid prescribing it to children until more research is done, except in cases where patients are suffering from chronic, debilitating conditions. The pediatrics group is also recommending the decriminalization of weed, but it's advising against legalization.

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Well, that's confusing. So we called up Dr. Seth Ammerman, a pediatrician at Stanford University who wrote the policy paper. Arresting teens who use pot won't do them any good, Ammerman says. Hundreds of thousands of adolescents and teens have been incarcerated for marijuana possession, "and the vast majority of marijuana-related arrests are minority youths."

The pediatricians' stance is that marijuana use among young people is a public health issue rather than a criminal justice issue, and it should be treated as such.

Its views on legalizing pot for recreational use, however, are more conservative.

"There's no evidence that legalizing will benefit youth," Ammerman tells Shots. "And the concern is that legalization will increase youth access to marijuana and maybe increase use."

Marijuana hasn't been legal anywhere in the U.S. for very long, so no one knows how these changing laws will affect teen usage rates. But if marijuana companies start marketing their products like alcohol and tobacco companies have done, kids and teens could be affected, Ammerman says.

"We would certainly be willing to revisit the issue as new data comes up," he adds. "But for now, let's not get into the position where we're looking back a decade from now and saying, 'Oh God, we've now addicted a bunch more kids.' "

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Convincing kids that they should stay away from weed can get tricky, the pediatricians acknowledge, especially as support for legalization grows. Part of the issue is that campaigns to legalize marijuana often portray it as a benign substance, says Dr. Leslie Walker, chief of the adolescent medicine division at Seattle Children's Hospital.

"People make arguments that say, 'Oh, this is safer than alcohol, it's safer than tobacco, it's safer than heroin,' " Walker says. And all that may be true, she says. "But marijuana on its own is harmful for adolescents."

Preliminary research suggests that marijuana isn't good for teens' developing brains. And studies show that adolescents who use pot are more likely than adults to become addicted.

Of course, there is still a lot we don't know about marijuana, whether it's used recreationally or medicinally. The AAP policy paper recommends that the Drug Enforcement Agency remove marijuana from the Schedule 1 listing for controlled substances, so that it's easier for researchers to get hold of the substance and study it.

"In the meantime, there's definitely a risk of having a kind of mixed message for teens," says Brendan Saloner, an assistant professor at the Johns Hopkins Bloomberg School of Public Health. "The frank answer is we don't know the best ways to communicate with teens about marijuana."

Refer-madness style scare tactics probably won't work, Saloner says. But both Walker and Ammerman recommend that parents be firm with kids. They should feel empowered to tell kids that using pot when you're under 21 isn't OK, even if they themselves use it. The AAP also recommends that parents set a good example by not smoking around kids.

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In Colorado, where adult use is legal, Children's Hospital Colorado suggests that parents "present the facts to your child objectively and use them to explain why marijuana use is still illegal for people under age 21."

In states where marijuana is legal, there are ways to mitigate teen usage, Saloner says.

States can and should control the extent to which companies can advertise marijuana products, he says. "The biggest concern here is edibles — candies and cookies can look really appealing to kids and adolescents," he notes.

Research also shows that the price of alcohol and tobacco can deter adolescents from using it.

"I don't think my position is to say whether or not it's right or wrong to legalize it," Saloner says. "Still, there are better and worse ways in which to legalize marijuana."

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