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Sharing Patient Records Is Still A Digital Dilemma For Doctors

NPR Health Blog - 6 hours 49 min ago
Sharing Patient Records Is Still A Digital Dilemma For Doctors March 06, 2015 3:37 AM ET

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Eric Whitney Listen to the Story 4 min 3 sec  

U.S. taxpayers have poured $30 billion into funding electronic records systems in hospitals and doctors' offices since 2009. But most of those systems still can't talk to each other, which makes transfer of medical information tough.

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Technology entrepreneur Jonathan Bush says he was recently watching a patient move from a hospital to a nursing home. The patient's information was in an electronic medical record, or EMR. And getting the patient's records from the hospital to the nursing home, Bush says, wasn't exactly drag and drop.

"The time of letting a thousand flowers bloom and having a set of standards that are quite variable should come to an end. We should be working off the same set of standards."

"These two guys then type — I kid you not — the printout from the brand new EMR into their EMR, so that their fax server can fax it to the bloody nursing home," Bush says.

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In an era when most industries easily share big, complicated, digital files, health care still leans hard on paper printouts and fax machines. The American taxpayer has funded the installation of electronic records systems in hospitals and doctors' offices — to the tune of $30 billion since 2009. While those systems are supposed to make health care better and more efficient, most of them can't talk to each other.

Bush lays a lot of blame for that at the feet of this federal financing.

"I called it the 'Cash for Clunkers' bill," he says. "It gave $30 billion to buy the very pre-internet systems that all of the doctors and hospitals had already looked at and rejected," he says. "And the vendors of those systems were about to die. And then they got put on life support by this bill that pays you billions of dollars, and didn't get you any coordination of information!"

Bush's assessment is colored by the fact that the company he runs — athenahealth — is cloud-based, and stresses easily sharing electronic health records. The firm also got a lot of the federal cash.

Dr. Robert Wachter, with the University of California, San Francisco, says sure — in hindsight, the government could have mandated that stimulus money be spent only on software that made sharing information easy. But, he says, "I think the right call was to get the systems in. Then to toggle to, 'OK, now you have a computer, now you're using it, you're working out some of the kinks. The next thing we need to do is to be sure all these systems talk to each other.' "

Right now, the ability of the systems to converse is at about a 2 or 3 on a scale of 0 to 10, Wachter and Bush agree.

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Wachter is about to publish The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age, a book that assesses the value of information technology in health care. Up until now, he says, there has actually been a financial dis-incentive for doctors and hospitals to share information. For example, if a doctor doesn't have a patient's record immediately available, the doctor may order a test that has already been done — and can bill for that test. Keeping EMRs from talking to each other also makes it easier to keep patients from taking their medical records — and their business — to a competing doctor.

It's time for that to change, says Dr. Karen DeSalvo, the federal government's health IT coordinator. She is stepping in now, setting some standards for how to share digital information.

"The time of letting a thousand flowers bloom, and having a set of standards that are quite variable, should come to an end," she says. "We should be working off the same set of standards."

The billions of dollars a year the government pays to doctors, hospitals and other institutions for patients enrolled in Medicare is a pretty good motivator. Already, Medicare is starting to increase pay to doctors and hospitals that work together to streamline care and avoid duplicative tests, and to penalize those that don't. Winning the new payments and avoiding the penalties increasingly require proving that all of a patient's doctors, no matter where they are, are working together. That requires using good electronic records that can seamlessly move from one system to the next.

Wachter says that consumers are now demanding better health information technology, too — "because we're all used to our app stores and we know how magical it can be when core IT platforms invite in a number of apps."

"So I think," he says, "that even the vendors and healthcare delivery organizations that have been fighting interoperability recognize it's the future."

He says a lot of IT companies are now eager come up with software that meets the demands of the health care industry and consumers. About a dollar of every $6 in the U.S. economy is spent on health care. A new IT boom in that sector means there are billions of dollars to be made.

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

Copyright 2015 Montana Public Radio. To see more, visit http://www.mtpr.org.
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Colorado Debates Whether IUDs Are Contraception Or Abortion

NPR Health Blog - Thu, 03/05/2015 - 5:48pm
Colorado Debates Whether IUDs Are Contraception Or Abortion March 05, 2015 5:48 PM ET

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Megan Verlee Listen to the Story 3 min 31 sec  

An interauterine device provides long-term birth control.

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A popular contraception program in Colorado is receiving criticism from conservative lawmakers who say that the program's use of intrauterine devices, or IUDs, qualify as abortions.

More than 30,000 women in Colorado have gotten a device because of the state program, the Colorado Family Planning Initiative. An IUD normally costs between $500 and several thousand dollars. Through the program women could receive one for free.

This is because the program received a $23 million private grant in 2009 that has covered all its costs until now. To keep going, a group of bipartisan lawmakers are trying to push a bill through the Colorado Senate. But they're running into problems because of restrictions on what the state can and cannot fund.

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State health director Larry Wolk says that the program has largely been a success. "Our teen birth rate has dropped 40 percent over the last four years," says Wolk. "The decline in teen births has been accompanied by a 34 percent drop in abortions among teens." A study published in Perspectives on Sexual and Reproductive Health credited the changes to the free contraceptives.

Fewer abortions should mean success for liberals and conservatives alike, right? That's what Republican state representative Don Coram, who's sponsoring the bill, thinks. He says that the program saves state money because it decreases the number of births Medicaid covers and lowers the state's enrollment in welfare. "If you're anti-abortion and also a fiscal conservative, I think this is a win-win situation for you," Coram says.

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But not everyone agrees, because of how IUDs function. Most of the time an IUD prevents sperm from meeting an egg, and therefore prevents pregnancy. But if the egg and sperm do meet, the IUD keeps that embryo from planting itself in the uterus. In those cases, an IUD would prevent a fertilized egg from developing into a person.

"This crosses a line," says Republican Kevin Lundberg, who chairs the Senate Health Committee in Colorado. In Lundberg's view, an IUD can count as an abortion, and this makes it impossible for a program that funds IUDs to receive state funding. "The state constitution says no direct or indirect funding from the state shall go towards abortion," Lundberg says.

Private funding for the program ends in June of this year, so lawmakers have just three months to work out their differences.

Copyright 2015 Colorado Public Radio. To see more, visit http://www.cpr.org.
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State Lawmakers Keep Busy While Supreme Court Weighs Obamacare

NPR Health Blog - Thu, 03/05/2015 - 12:54pm
State Lawmakers Keep Busy While Supreme Court Weighs Obamacare March 05, 201512:54 PM ET Fred Schulte

Latoya Watson of Washington, D.C., cheers during a rally outside the Supreme Court on Wednesday, when the justices heard arguments in King v. Burwell.

Andrew Harnik/AP

As the nation awaits a Supreme Court ruling on Obamacare, lawmakers in many states are moving ahead with a range of Affordable Care Act bills, some of which seek to bolster the law and others that are bent on derailing it.

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The Supreme Court case, King v. Burwell, focuses on subsidies paid to millions of Americans who bought health insurance through exchanges set up under the Affordable Care Act. At issue: whether subsidies issued through exchanges operated by the federal government are legal. By the end of June, the justices are expected to issue a ruling, which could either uphold the law as it now operates or strike down those subsidies for good.

State lawmakers nationwide also are weighing in largely along partisan lines, as the Center for Public Integrity reported in January. Bills concerning health care exchanges are pending in at least 16 states.

The measures, all introduced this year, are split pretty evenly between ones that seek to bolster insurance exchanges and those that would impede their progress or bar them for good, according to an analysis by the National Conference of State Legislatures, or NCSL.

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Many of the proposals hinge on the outcome of the Supreme Court case. For instance a bill introduced in Indiana by Sen. Karen Tallian, a Democrat, simply requires the state insurance department to "design, implement, and administer the Indiana health exchange in accordance with federal law."

In Tennessee, a bill by State Rep. Harold M. Love, Jr., a Democrat, goes into effect only if the court decides that the Internal Revenue Service may not extend tax credit subsidies. His bill seeks to guarantee them.

State Rep. Jeremy Durham, a Tennessee Republican, sees the issue through a different prism. His bill says if the Supreme Court allows subsidies state residents "may ignore the insurance mandate" while businesses "may be excused from penalties for not offering health insurance coverage, and a business could move employees back to full-time work who had been transferred to part-time status in order to avoid health insurance costs."

The Center for Public Integrity story reported that state lawmakers have been at odds over hundreds of bills to either cripple or prop up the Affordable Care Act. More than 700 Obamacare bills have landed in state hoppers over the past two years.

The center's analysis showed that dozens of the bills took their cues from activist groups on both sides of the debate, from staunch opponents with ties to Tea Party activists to "progressive" groups seeking to expand Obamacare's reach.

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. For more, follow the center on Twitter @Publici, or sign up for its newsletter.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Behavioral Therapy Helps More Than Drugs For Dementia Patients

NPR Health Blog - Thu, 03/05/2015 - 5:06am
Behavioral Therapy Helps More Than Drugs For Dementia Patients March 05, 2015 5:06 AM ET Listen to the Story 1 min 37 sec  

Caregivers who are trained in responding to anxiety or aggression in people with dementia can effectively reduce those symptoms, studies find.

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When we think of Alzheimer's disease or other dementias, we think of the loss of memory or the inability to recognize familiar faces, places, and things. But for caregivers, the bigger challenge often is coping with the other behaviors common in dementia: wandering, sleeplessness and anxiety or aggression.

Using antipsychotic drugs to try to ameliorate these symptoms has been common. According to a report released Monday from the Government Accountability Office, 1 in 3 dementia patients in nursing homes receives antipsychotics. Outside of nursing homes, 1 in 7 dementia patients are prescribed the drugs.

This is despite a warning from the Food and Drug Administration saying that antipsychotics increase the risk of death for people with dementia.

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And antipsychotics are much less effective than non-drug treatments in controlling the symptoms of dementia, according to a study published Wednesday in the British Medical Journal. Dr. Helen Kales, a psychiatrist who directs the University of Michigan's Program for Positive Aging, examined more than two decades of scientific studies, along with her coauthors, Laura N. Gitlin and Dr. Constantine Lyketsos, both of Johns Hopkins University. They say the treatments that showed the best results were the ones that trained caregivers how to communicate calmly and clearly, and to introduce hobbies or other activities for the patient. The treatments also followed up with caregivers.

"Why I think the caregiver interventions work is because they train caregivers to look for the triggers of the symptoms," says Kales. "And when [caregivers] see the triggers of the symptoms, they train them to manage them...It's inherently patient- and caregiver-centered."

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The study showed that antipsychotic drugs were only about half as effective as the caregiver interventions. While antipsychotics can be useful in emergency situations, Kales says their risk of deadly side effects increases over time.

"The risk is small if you look over the short term," Kales says. So over the course of 12 weeks, the risk of increased mortality would be 1 to 2 percent. But at six months, the risk of death rises to 4 to 7 percent with commonly used antipsychotics like haloperidol, risperidone and olanzapine. It continues to rise after that, she says.

Health care providers use antipsychotics, says Kales, partly because they haven't been trained to use non-drug approaches. And even if they did know how to use them, they're rarely reimbursed for doing so by Medicare or private insurance.

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For Dementia Patients, Behavioral Therapy May Outweigh Antipsychotic Drugs

NPR Health Blog - Thu, 03/05/2015 - 5:06am
For Dementia Patients, Behavioral Therapy May Outweigh Antipsychotic Drugs March 05, 2015 5:06 AM ET Listen to the Story 1 min 37 sec  

A new study in the British Medical Journal finds that non-drug approaches to treating symptoms of dementia work better than using drugs, particularly antipsychotics.

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Fertility Clinic Courts Controversy With Treatment That Recharges Eggs

NPR Health Blog - Thu, 03/05/2015 - 3:43am
Fertility Clinic Courts Controversy With Treatment That Recharges Eggs March 05, 2015 3:43 AM ET Listen to the Story 5 min 23 sec  

Along with sperm, the in vitro procedure adds fresh mitochondria extracted from less mature cells in the same woman's ovaries. The hope is to revitalize older eggs with these extra "batteries." But the FDA still wants proof that the technique works and is safe.

Chris Nickels for NPR

Melissa and her husband started trying to have a baby right after they got married. But nothing was happening. So they went to a fertility clinic and tried round after round of everything the doctors had to offer. Nothing worked.

"They basically told me, 'You know, you have no chance of getting pregnant,' " says Melissa, who asked to be identified only by her first name to protect her privacy.

But Melissa, 30, who lives in Ontario, Canada, didn't give up. She switched clinics and kept trying. She got pregnant once, but that ended in a miscarriage.

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"You just feel like your body's letting you down. And you don't know why and you don't know what you can do to fix that," she says. "It's just devastating."

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Melissa thought it was hopeless. Then her doctor called again. This time he asked if she'd be interested in trying something new. She and her husband hesitated at first.

"We eventually decided that we should give it one last shot," she says.

Her doctor is Dr. Robert Casper, the reproductive endocrinologist who runs the Toronto Center for Advanced Reproductive Technology. He has started to offer women a fertility treatment that's not available in the United States, at least not yet. The technique was named Augment by the company that developed it, and its aim is to help women who have been unable to get pregnant because their eggs aren't as fresh as they once were.

Casper likens these eggs to a flashlight that just needs new batteries.

"Like a flashlight sitting on a shelf in a closet for 38 years, there really isn't anything wrong with the flashlight," he says. "But it doesn't work when you try to turn it on because the batteries have run down. And we think that's very similar to what's happening physiologically in women as they get into their 30s."

"It may one day be shown to be of tremendous benefit. But when you amp up the energy in the egg, how much do we really know about the safety of what will follow?"

In human eggs, as in all cells, the tiny structures that work like batteries are called mitochondria. Augment is designed to replace that lost energy, using fresh mitochondria from immature egg cells that have been extracted from the same woman's ovaries.

"The idea was to get mitochondria from these cells to try to, sort of, replace the batteries in these eggs," Casper says.

Here's how it works. A woman trying to get pregnant goes through a surgical procedure to remove a small piece of her ovary, so that doctors can extract mitochondria from the immature egg cells. In a separate procedure, doctors remove some of the woman's mature eggs from her ovaries. They then inject the young mitochondria into the eggs in the lab, along with sperm from the woman's partner; except for adding mitochondria to the mix, the process is the same one that's followed with standard in vitro fertilization. The resulting embryo can then be transferred into her womb.

The extracted mitochondria "look exactly like egg mitochondria," Casper says. "And they're young. They haven't been subjected to mutations and other problems."

So they should have enough power to create a healthy embryo, he says — at least in theory. The company that developed the procedure, OvaScience Inc. of Cambridge, Mass., has reported no births from the procedure so far. The technique adds about $25,000 to the cost of a typical IVF cycle.

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OvaScience hopes to eventually bring the technique to infertile couples in the United States. But the Food and Drug Administration has blocked that effort — pending proof that the technique works and is safe. Meanwhile, the firm is already offering the technology in other countries, including the United Arab Emirates, Turkey — and in Canada, at Casper's Toronto clinic.

"We're pretty excited about it," Casper says.

Not everyone in Canada is excited about it. Endocrinologist Neal Mahutte, who heads the Canadian Fertility and Andrology Society, notes that no one knows whether the technique works. And he has many other questions.

"It's a very promising, very novel technique," he says. "It may one day be shown to be of tremendous benefit. But when you amp up the energy in the egg, how much do we really know about the safety of what will follow?"

"Is there a chance that the increased energy source could contribute later to birth defects?" Mahutte wonders. "Or to disorders such as diabetes? Or to problems like cancer? We certainly hope that it would not. But nobody knows at this point."

He and some other experts say it's unethical to offer the procedure to women before those questions have been answered.

"There are processes that are set up to ensure that products which are offered for clinical use in humans have undergone rigorous testing for safety and efficacy, based on well-established scientific and ethical testing criteria," says Ubaka Ogbogu, a bioethicist and health law expert at the University of Alberta. "To circumvent this process is to use humans as guinea pigs for a product that may have serious safety concerns or problems."

Casper defends his decision to offer his patients the treatment, saying a New Jersey fertility clinic briefly tried something similar more than 15 years ago; in that case, he says, the resulting babies seemed fine, and there have been no reports of problems since. In addition, Casper says he has done a fair amount of research on mitochondria.

"I think there's very little chance that there would be any pathological or abnormal results," he says. "So I feel pretty confident this is not going to do any harm."

Casper's first patient to try the technique — Melissa — says she's comfortable relying on the doctor's judgment.

"I think there's always risk with doing any sort of procedure," Melissa says. "IVF — I mean, there was lots of controversy and risk when that first came out. For me, and from what I've discussed with my doctor, I don't see it being a big risk to us."

And she's thrilled by the outcome so far: She's pregnant with twins.

"You know, I couldn't believe it," she says. "I still don't believe it a lot of the time. There are no words for it — it's incredible. We're very excited."

Casper says 60 women have signed up for Augment at his clinic. He has treated 20 of the women, producing eight pregnancies, he says. The first births — Melissa's twins — are due in August.

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Justices Roberts And Kennedy Hold Key Votes In Health Law Case

NPR Health Blog - Wed, 03/04/2015 - 7:40pm
Justices Roberts And Kennedy Hold Key Votes In Health Law Case March 04, 2015 7:40 PM ET Listen to the Story 5 min 40 sec  

Fans and foes of Obamacare jockeyed for position outside the Supreme Court Wednesday. Inside, the justices weighed arguments in the case of King v. Burwell, which challenges a key part of the federal health law.

Pete Marovich/UPI/Landov

With yet another do-or-die test of Obamacare before the U.S. Supreme Court on Wednesday, the justices were sharply divided.

By the end of the argument, it was clear that the outcome will be determined by Chief Justice John Roberts and Justice Anthony Kennedy. The chief justice said almost nothing during the argument, and Kennedy sent mixed signals, seeming to give a slight edge to the administration's interpretation of the law.

Judging by the comments from the remaining justices, the challengers would need the votes of both Roberts and Kennedy to win.

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The challengers hinge their argument on six words in the 1,000-plus-page law. Those words stipulate that for people who cannot afford health insurance, subsidies are available through "an exchange established by the state." Only 16 states run their own exchanges. The federal government runs the exchanges for the remaining 34 states that opted out of running their own.

Representing the challengers was lawyer Michael Carvin, whose florid-faced passion prompted Justice Sonia Sotomayor to tell him gently at one point, "Take a breath!"

Carvin took incoming shots from all of the court's more liberal members.

Justice Stephen Breyer noted that the statute says that if a state does not itself set up an exchange, then the federal "Secretary [of Health and Human Services] shall establish and operate such exchange."

"Context matters," added Justice Elena Kagan. And "if you look at the entire text, it's pretty clear that you oughtn't to treat those five words in the way you are."

Justice Sotomayor, looking at the law through a different lens, asked how the challengers' reading of the law would affect the federal-state relationship.

"The choice the state had was, establish your own exchange or let the federal government establish it for you," she said. "If we read it the way you're saying, then ... the states are going to be coerced into establishing their own exchanges."

With all eyes on Justice Kennedy, he seemed to agree with Sotomayor's point.

It does seem "that if your argument is accepted," he told Carvin, "the states are being told, 'Either create your own exchange, or we'll send your insurance market into a death spiral.' " By "death spiral," Kennedy was referring to the consequence of having no subsidies in 34 states, leading to a collapse of the individual insurance market.

That, Kennedy suggested, is a form of coercion. So "it seems to me ... there's a serious constitutional problem if we adopt your argument."

Justice Antonin Scalia, a leader of the court's conservative wing, jumped in to help Carvin.

"Do we have any case which says that when there is a clear provision, if it is unconstitutional, we can rewrite it?" Scalia asked.

Justice Ruth Bader Ginsburg, however, pointed to what she called the familiar patterns of federal aid, in which the federal government says to the states: Here's a grant; take it or leave it. Or, a pattern like the one at issue here, which says to a state, "you can have your program if you want it, and if you don't," the fallback is a federal program.

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But, said Ginsburg, "I have never seen anything" such as you are suggesting, where a state's failure to set up a program results in "these disastrous consequences."

If Carvin got a hostile reception from the court's liberals, Solicitor General Donald Verrilli Jr. got equal treatment from some of the court's conservatives.

"Is it not the case," asked Scalia, "that if the only reasonable interpretation of a particular provision produces disastrous consequences in the rest of the statute, it nonetheless means what it says? Is that true or not?"

Verrilli replied that it isn't just a question of onerous consequences, but that the states had no notice of disastrous consequences when they chose to let the federal government run the state exchanges.

"It's not too late for a state to establish an exchange if we adopt" the challengers' interpretation of the law, interjected Justice Samuel Alito. "So going forward, there would be no harm."

Verrilli replied that the tax credits would "be cut off immediately," and millions of people in many states would be unable to afford their insurance. Even if the court were to somehow delay the effect of its ruling for six months, it would be "completely unrealistic" to set up the exchanges by May of this year, as required by law, so that they could begin operating in 2016.

"You really think Congress is just going to sit there while all of these disastrous consequences ensue?" asked Scalia. How often have we come out with a problematic decision and "Congress adjusts, enacts a statute that takes care of the problem. It happens all the time. Why is that not going to happen here?"

Verrilli paused, eyebrows raised. "This Congress, your honor?" he asked, as laughter filled the courtroom.

Justice Kennedy once again raised the question of the federal government impinging on state sovereignty.

That's why our reading is far preferable, replied Verrilli. If a state doesn't want to participate, it can "decide not to participate without having any adverse consequences visited upon the citizens of the state."

Chief Justice Roberts, who remained quiet through most of the argument, finally had this question: If we decide the language of the law is ambiguous and we thus defer to the administration's interpretation, he asked, could the next administration "change that interpretation?"

Some court observers thought that comment set a way out for the chief. But by the end of the argument, nobody was making any predictions.

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College Help For Students Cuts Drinking, But Not For Long

NPR Health Blog - Wed, 03/04/2015 - 2:42pm
College Help For Students Cuts Drinking, But Not For Long March 04, 2015 2:42 PM ET

Women and younger students were more likely to drink less after alcohol-education programs.

iStockphoto

Most colleges require students to go through some sort of alcohol education program. When I was a freshman in college, I was required to play a video game that involved helping Franklin the frog navigate through various college parties without succumbing to alcohol poisoning. (Easy, Frank, remember to hydrate).

Other universities require students to watch educational videos or take online quizzes about appropriate alcohol use.

These one-time interventions do work, but their effect tends to wear off as the school year progresses, according to a study published Tuesday in the Journal of Consulting and Clinical Psychology.

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The study combines data collected from three previous alcohol intervention studies and analyzed the drinking behaviors of over 1,000 college students who had been through some sort of alcohol education program. Some of the students took an online course either at home or in a lab, while others received in-person education.

A month later, 82 percent of the students reported drinking less, regardless of the type of alcohol education they had. But 12 months later, 84 percent had increased their drinking — often to dangerous levels.

The alcohol education programs were more effective for some students than others. The courses worked especially well for women, and for younger, inexperienced drinkers. But for about 10 percent of the students — mostly men involved in Greek life — the courses had no effect.

"You do still need that education," says James Henson, an associate professor of psychology at Old Dominion University who led the study.

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But the study highlights the need to find more ways to keep reminding students that if they do drink, they should be aware of their limits, pace themselves and stay hydrated, Henson tells Shots. "You need to remind students that people can still have fun and consume alcohol without hurting themselves."

Some colleges have started sending students email reminders, Henson says.

He's also working on developing a system to send students text reminders while they're out at parties. Ideally, he says, it's best to reach out right before they're about to have one too many drinks.

"I think this study also shows that our interventions do work, but maybe they don't work equally well for all students," says Lori Scott-Sheldon, an assistant professor of psychiatry and human behavior at Brown University who wasn't involved in the research.

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It may be that the 10 percent who didn't change their behavior after going through alcohol education need extra attention or counseling, Scott-Sheldon notes. "We need to be taking a more targeted, individualized approach."

While public health researchers have developed lots of alcohol intervention programs that work to some extent, they're still trying to figure out which ones work best for which students, she says. (NPR's Jennifer Ludden reported on two schools' experiments in reducing binge drinking.)

To help sort things out, the National Institute on Alcohol Abuse and Alcoholism is working on developing a system to codify all the existing research on alcohol interventions, says NIAAA director George Koob.

"When you're young, your brain isn't fully developed," Koob says, which means that college freshmen are especially prone to making bad decisions when it comes to alcohol.

"Plus on campuses there's this perception that it's OK to drink and it's OK to drink as fast and as much as possible," he says. "So this is obviously a very complicated problem."

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Few Clues On Health Law's Future Emerge In Supreme Court Arguments

NPR Health Blog - Wed, 03/04/2015 - 2:40pm
Few Clues On Health Law's Future Emerge In Supreme Court Arguments March 04, 2015 2:40 PM ET

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Julie Rovner

Opponents of the Affordable Care Act protest outside the Supreme Court Wednesday before oral arguments in the second major challenge to be heard by the justices.

Jim Lo Scalzo/EPA/Landov

For the second time in three years, the Affordable Care Act went before the Supreme Court Wednesday. And before a packed courtroom, a divided group of justices mostly picked up right where they left off the last time.

Once again, people inside the courtroom and out were left to wonder where Chief Justice John Roberts and Justice Anthony Kennedy, considered swing votes in the case, stand. A decision is expected by the end of June.

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Unlike in 2012, the current case, King v. Burwell, doesn't challenge the constitutionality of the law's centerpiece that requires most Americans to have health insurance or pay a penalty. In a 5-4 ruling, the court decided then that the law could continue, albeit with a twist: States could elect not to expand Medicaid.

But the latest case does challenge another piece that's pivotal to making the law work: whether tax credits to help moderate-income Americans afford coverage can be provided in the three dozen states where the marketplace is being run by the federal government.

The court's most conservative justices seemed to side with the challengers, who say that a sentence in the law stipulating that tax credits are available only on health insurance exchanges "established by the state" means just that. In other words, credits wouldn't be available in the three dozen states that are using HealthCare.gov, the federal exchange.

"If Congress did not mean 'established by the state' to mean what it normally means, why did they use that language?" asked Justice Samuel Alito.

Liberal justices, however, seemed much more comfortable with the Obama administration's argument that the phrase encompasses both federal and state-run exchanges — and that reading the text to allow tax help only on state exchanges runs counter to the rest of the law.

If they were to read the law the way the challengers argue, said Justice Elena Kagan, "there will be no customers and no products" on the federal exchange, because no one would be eligible. "When you're interpreting a statute generally, you try to make it make sense as a whole," she said.

But almost nothing could be gleaned from the questioning and comments of Roberts and Kennedy.

Kennedy had hard questions for both sides. He suggested at one point that withholding tax credits from states that failed to set up their own insurance exchanges could pose "a serious constitutional problem," because it could disrupt insurance markets in states that don't set up their own exchanges. Giving states such an unpalatable choice would be unfair coercion by the federal government, Kennedy said.

But Kennedy also questioned whether, in the absence of more specific language, Congress intended to let the Internal Revenue Service decide how to distribute billions of federal tax dollars. "That's a lot of responsibility," he said.

The question specifically before the court is whether the IRS overstepped its authority in interpreting the law to allow tax credits in both state-run and the federal exchanges. (Find a transcript of the oral arguments here.)

Roberts, meanwhile, was uncharacteristically quiet during the nearly hour and a half argument. In 2012, it was the chief justice who surprised many observers by joining the liberals to find the law constitutional because Congress was using its taxing power.

Outside the court, standing in a light rain, those on both sides predicted victory.

"It looks good for the plaintiffs," said Michael Cannon of the libertarian Cato Institute. Cannon helped push the court case — and traveled the country working to persuade states not to set up their own exchanges. He said he was pleased by questions about the IRS's interpretation. "It's absurd to give the IRS that kind of authority," he said.

But Elizabeth Wydra of the Constitutional Accountability Center, which supported the administration's position, said she thought the arguments leaned her side's way. "If the court follows the plain text of the law and prior precedents, then it's clear tax credits are available to all Americans no matter what entity runs the exchange," she said.

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

People With Eczema Are Itching For Better Health Care

NPR Health Blog - Wed, 03/04/2015 - 1:01pm
People With Eczema Are Itching For Better Health Care March 04, 2015 1:01 PM ET Poncie Rutsch

The itchy rash of eczema, also sometimes called atopic dermatitis, can be painful and unsightly.

Meredith Rizzo/NPR

It might seem silly to miss work for a rash. But people who have eczema often have to put a lot of time and money into managing the itchy, inflamed rashes they get over and over. Lindsay Jones, who lives in Chicago, was diagnosed with eczema when she was 2 weeks old.

"I try to take proactive measures to keep my skin calm, but the flare-ups are inevitable," Jones, age 34, tells Shots. Last year, her eczema got so bad that she missed work to go to the doctor and took a sick day just to treat her skin. Other days she would sneak in and out of her office so that only her immediate team would see her. "Because my flare-ups were so bad and they were on my face, it's not like I could put makeup over it," she explains. "I looked a little scary."

Shots - Health News How The Skin Disease Psoriasis Costs Us Billions

Jones isn't alone in her struggle to manage eczema; almost 10 percent of people in the United States have this skin disorder, which causes red, swollen, itchy skin, and is often related to allergies.

But most studies don't look at how eczema affects the lives of people who have it. Dr. Jonathan Silverberg, a dermatologist at the Northwestern University Feinberg School of Medicine, noticed that many of his patients were frustrated with their options, and wanted to figure out why. He used data from the National Center for Health Statistics for a study published Wednesday in JAMA Dermatology.

"Part of my job is trying to understand why eczema isn't just skin deep," Silverberg tells Shots. He found that in 2010, people with eczema spent an average of $371 on out-of-pocket health care. "That's above and beyond what the average person pays," says Silverberg. In 2012, that number had jumped to $489.

Shots - Health News Kids, Allergies And A Possible Downside To Squeaky Clean Dishes

That increase worries Silverberg. "When you look at the brand-new Affordable Care Act there's a lot more patient burden of cost," he says. "So this problem will only get worse."

People with eczema missed 68 million work days in 2012, Silverberg found. Almost one-tenth of those were due to doctor appointments and other management of the disorder. Most of the days were lost to health problems commonly associated with eczema, including allergies, asthma, heart disease or osteoporosis. Having eczema, explains Silverberg, means that you're about 60 percent more likely to miss six or more days of work each year.

Part of the problem is that eczema is a chronic disorder, and one that's notoriously hard to treat. People with eczema often take preventive measures such as choosing soft clothing or using gentle moisturizers. Treatments include steroid, antihistamines, bleach baths and wet wrap therapy. Sometimes it takes dozens of doctors before a patient sees any progress. "There's not a one- size-fits-all answer," says Silverberg. "Patients are suffering for maybe weeks or months before they get in to receive appropriate care."

Shots - Health News A Pill For Grass Allergies May Replace Shots For Some

Jones estimates that she spent between $1,200 and $1,300 treating her eczema last year and visited several doctors before finding one she truly liked. "I'm lucky enough that my employer will let me make up the time that I miss for doctor's appointments," she says. She even took a day off to attend the National Eczema Association conference in Boston, where she says she made friends and found support.

This year she plans to do the Itching for a Cure Walk in Chicago. She's hoping that the walk will draw attention to eczema and put pressure on the medical and pharmaceutical industry to find better products for people like her.

"You have to do what you have to do to live your life, so we're pretty tough," says Jones. "We are very mentally strong."

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

What's A Patient To Do When Hospital Ratings Disagree?

NPR Health Blog - Wed, 03/04/2015 - 10:25am
What's A Patient To Do When Hospital Ratings Disagree? March 04, 201510:25 AM ET

When you face a choice about hotels, restaurants or cars, the chances are you head to the Web for help.

Online ratings have become essential tools for modern consumers. Health care is no exception to the ratings game, especially when it comes to hospitals.

Many people check up on hospitals before they check in as patients. But there's a catch. A hospital that gets lauded by one group can be panned by another.

Some of the biggest names in health quality research got together to look at the variation in ratings among four of the top arbiters: Consumer Reports, U.S. News & World Report, the Leapfrog Group and HealthGrades.

What did the researchers find?

All told, 844 hospitals came out as a high performer on at least one of the ratings scales. But the researchers found that no hospital — not one — came out as a high performer in all four ratings systems. In fact, only 10 percent of hospitals rated as a high performer by one group were rated as a high performer by another.

How could that be? Well, the ratings systems slice health care quite differently.

Leapfrog Group, which was founded by employers, uses five letter grades to rate hospitals primarily on safety.

U.S. News and Consumer Reports make ratings on a 0-100 scale. Consumer Reports takes a safety bent. U.S. News bears down on key medical specialties, such as cancer care and orthopedics, in its ratings, which focus on the needs of patients with complex conditions. Only 17 hospitals made the latest U.S. News honor roll, reserved for those institutions that get superlative scores in at least six specialties.

Then there's HealthGrades, which looks at how outcomes, or how patients fare, to come up with quality rankings. The researchers focused on HealthGrades' top 100 hospital list.

If you consult several rating services to gauge a hospital, you can expect to get different results. The key to getting helpful answers is figuring out what matters most to you and consulting the ratings outfit that's the best match.

"Consumers should insure that when they see a rating for a hospital that they dig into it a little bit," says Matt Austin, an engineer by training who now specializes in measuring health care performance at Johns Hopkins Medicine. "What is that rating for? What does that rating represent?"

Austin is the lead author of the ratings analysis that appears in the March issue of the journal Health Affairs.

He says ratings groups should help consumers interpret the hospital grades by explaining the criteria used. "When ratings use words like 'top' and 'best,' it isn't always clear what 'top' and 'best' are referring to," Austin tells Shots.

What does the future hold for hospital ratings? "As we move into a world where the value of health care services is more important, I believe we're going to need to look for ratings systems that balance quality of care and cost of care," Austin says. "And I feel like the travel industry, specifically hotels, is one where online sites do a pretty good job."

Part of the challenge is the inherent tension in rating hospitals stems from the fact that a summary rating applies to the whole institution yet quality and safety can vary by department or specialty. "Consumers' lives would be a lot easier if every hospital was either outstanding or lackluster hospitalwide," says Ben Harder, chief of health analysis at U.S. News & World Report. "But health care quality in American is maddeningly inconsistent."

Harder has his own take on the Health Affairs analysis: "The real question isn't whether the ratings systems put the same hospitals at the top, it's whether each rating system succeeds at measuring the aspects of quality it set out to measure."

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

FDA Mandates Tougher Warnings On Testosterone

NPR Health Blog - Tue, 03/03/2015 - 5:03pm
FDA Mandates Tougher Warnings On Testosterone March 03, 2015 5:03 PM ET

AndroGel, a testosterone replacement made by AbbVie, is seen at a pharmacy in Princeton, Ill.

Bloomberg via Getty Images

The Food and Drug Administration said Tuesday that it is requiring drugmakers to warn patients that testosterone products may increase the risk for heart attacks and strokes.

Testosterone replacements are approved to treat men with low testosterone related to medical problems, such as genetic deficiencies, chemotherapy or damaged testicles.

But the level of the hormone can fall as men grow older. And testosterone is increasingly being prescribed to men to stave off aging, something the agency never approved. Doctors and specialized clinics have jumped on the bandwagon, offering testosterone replacements to treat what some refer to as "Low T."

Shots - Health News Testosterone, The Biggest Men's Health Craze Since Viagra, May Be Risky

But in a drug safety warning, the FDA said there's no good evidence that testosterone can help counteract the effects of aging. "The benefit and safety of these medications have not been established for the treatment of low testosterone levels due to aging," the FDA's statement says. So the agency is requiring drugmakers to make that crystal clear on the instructions for their testosterone products.

Shots - Health News Big Questions About Testosterone Treatment For Men

The FDA is also requiring that drug companies conduct a study to get a clearer idea about just how risky testosterone replacements are.

Last September, an advisory panel to the FDA voted 20-1 in favor of changing the labels for testosterone replacement therapy to reflect the risks and clarify the narrow indication for their use. The panel also voted 20-1 in favor of FDA requiring a study of the risks.

AbbVie, one of the leading marketers of testosterone replacements, said in an email that it had received the FDA's safety communication and the request for a labeling change for all testosterone replacement therapies. "TRT is an important men's health topic," the statement said. "AbbVie is committed to our patients and we continue to work with the FDA."

Public Citizen's Health Research Group, a consumer group, criticized the FDA for not issuing a stronger warning sooner. The group had petitioned the agency last year to issued the strongest warning possible — a request the agency had rejected.

The group noted that the Canadian government had issued warnings earlier.

"In the seven and a half months since the Canadian action, approximately 4 million prescriptions have been filled in the U.S.," said Dr. Sidney Wolfe, the group's founder and senior adviser, in a statement. "Had the FDA made this announcement last summer when the Canadian government acted, it would have reduced the number of U.S. prescriptions for and damage from testosterone, a medication of questionable effectiveness for a large proportion of users and one that increases the risk of heart attacks and strokes."

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

10 Questions Some Doctors Are Afraid To Ask

NPR Health Blog - Tue, 03/03/2015 - 4:04pm
10 Questions Some Doctors Are Afraid To Ask March 03, 2015 4:04 PM ET Laura Starecheski Listen to the Story 8 min 8 sec   Vidhya Nagarajan for NPR Shots - Health News Can Family Secrets Make You Sick?

Imagine that the next time you go in for a physical, you're told there's a new tool that can estimate your risk for many of the major health problems that affect Americans: heart disease, diabetes, depression, addiction, just to name a few.

It's not a crystal ball, but might hint at your vulnerability to disease and mental illness — long before you start smoking or drinking, gain a lot of weight, develop high blood pressure or actually get sick.

And all you have to do is answer 10 yes-or-no questions about your childhood:

Additional Information: NPR

First developed in the 1990s, these 10 questions of the Adverse Childhood Experiences test are designed to take a rough measure of a difficult childhood.

Answering those questions would give you an "adverse childhood experiences" score (or ACE score, for short). The test's proponents say that it provides a rough measure of a tough childhood, and some of the experiences — death of a parent, childhood abuse or neglect — that can have long-term effects on your health.

Dr. Vincent Felitti of the University of California, San Diego, who did much of the research that gave rise to the ACE score, thinks the tool is so useful it should be part of a routine physical exam. But it's not, for a variety of reasons.

For one thing, doctors aren't taught about ACE scores in medical school. Some physicians wonder what the point would be, as the past can't be undone. There also is no way to bill for the test, and no standard protocol for what a doctor should do with the results.

The ACE score is still really the best predictor we've found for health spending, health utilization; for smoking, alcoholism, substance abuse. It's a pretty remarkable set of activities that health care talks about all the time.

But Felitti thinks there's an even bigger reason why the screening tool largely has been ignored by American medicine: "personal discomfort on the part of physicians."

Some doctors think the ACE questions are too invasive, Felitti says. They worry that asking such questions will lead to tears and relived trauma ... emotions and experiences that are hard to deal with in a typically time-crunched office visit.

I wondered if those concerns were warranted, so with the permission of the patient and the doctor, I sat in on an appointment.

Bonnie Ratliff, a mother of two in her 30s, met with Felitti at Kaiser Permanente in San Diego, where he did his research more than 15 years ago with the Centers for Disease Control and Prevention.

Shots - Health News Childhood Maltreatment Can Leave Scars In The Brain Author Interviews 'Children Succeed' With Character, Not Test Scores

As Felitti talked with Ratliff, he went over the extensive, customized medical history form she'd filled out before the appointment — a form that included the ACE questions. Felitti asked Ratliff about her mother's nervous breakdown, and the drinking and hoarding that followed it.

"It was hard, you know? It was especially hard because she made us keep it a secret," Ratliff said.

Ratliff also explained that she was molested once, as a kid, although she didn't think that had affected her in a lasting way.

It took about a half hour to go over everything — which included some issues with irregular heartbeat, weight gain, allergies and an eye problem, in addition to the questions about Ratliff's childhood. It took a bit longer than a typical doctor's appointment, but otherwise wasn't so different. Despite the intimate content of the conversation, Ratliff never got upset.

"You don't feel like you have to bare your emotions, you know?" Ratliff said afterward. "If it's just, like, just a checklist, and you can just check off these things that have happened to you — 'yep, yep, yep' — it doesn't feel so scary."

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Felitti hadn't even mentioned the term "ACE score," or told Ratliff what her score was — 4 out of 10 — but he methodically had asked her how she thought each adverse childhood experience had affected her. After the appointment, Ratliff said that as she spoke with Felitti, something clicked into place.

"I've done a lot of thinking about how my childhood experiences have turned me into the person I am, how I still carry them with me," she said. "I haven't necessarily connected it, for the most part, to physical issues before this."

That's the point, Felitti believes: Asking patients about ACEs helps patients understand their health more deeply, and helps doctors understand how to help.

There are no randomized controlled trials that show that applying these screening tools to a large population changes any outcomes that a patient cares about. Someone's got to show me that it's going to actually make a difference in my patients' lives.

According to Dr. Jeff Brenner, a family doctor and MacArthur Fellows award-winner in Camden, N.J., getting these rough measures of adversity from patients potentially could help the whole health care system understand patients better.

The ACE score, Brenner says, is "still really the best predictor we've found for health spending, health utilization; for smoking, alcoholism, substance abuse. It's a pretty remarkable set of activities that health care talks about all the time."

Brenner won his MacArthur fellowship in 2013 for his work on how to treat the most complicated, expensive patients in his city — people who often have high ACE scores, he found.

"I can't imagine, 10, 15 years from now, a health care system that doesn't routinely use the ACE scores," he says. "I just can't imagine that."

Brenner only learned about ACE scores a few years ago, and says he regrets not integrating the tool into his practice sooner. But like most doctors, he says, he was taught in medical school to not "pull the lid off something you don't have the training, time or ability to handle."

In theory, Brenner says, talking to patients about adverse childhood experiences shouldn't be any different than asking them about domestic violence or their drinking — awkward topics that doctors routinely broach now.

But spreading the word about ACE scores has been a challenge, he says.

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Even doctors who want to screen their patients in this way say that figuring out exactly how to do so is complicated. Who would review the answers with patients? A doctor? A nurse? A social worker? And what should doctors do with a patient's ACE score, once they have it?

"You can't go back 40 years and make the bad childhood go away," says Dr. Richard Young, a family physician who also trains residents in family medicine in Fort Worth, Texas.

Young says he sees patients all the time with lots of health problems who had rough childhoods — and he's not afraid to talk to them about what they've been through. But he's skeptical of the usefulness of asking every single patient about adverse childhood experiences.

For those who already have reckoned with demons from their past, the questions could bring up issues they'd rather not relive, Young says. And many of the biggest factors that can foster disease and shorten life — depression, alcoholism, drug abuse, and complicated, chronic conditions like diabetes and obesity — are problems he says he would find out about anyway, without having to ask patients about their childhoods.

"There are no randomized controlled trials that show that applying these screening tools to a large population changes any outcomes that a patient cares about," says Young. "Someone's got to show me that it's going to actually make a difference in my patients' lives — and to my knowledge no one has done that."

Felitti agrees that there is no research tracking how asking for ACE scores affects patients in the long term, but says that from his experience with many thousands of patients, the benefits of getting an ACE score come down to something more spiritual than medical: alleviating shame.

Felitti says that many of his patients never had told anyone that they'd been abused as a kid — ever — until he asked them. Disclosing their secrets, they told him afterward, brought them tremendous relief.

He likens that unburdening to a lay version of a Catholic church confession.

"They leave with the understanding that they're still an acceptable human being, they're still part of the group," Felitti says.

Instead of treating a specific medical problem, talking about an ACE score with a patient is a process of listening and accepting, Felitti says. But for busy doctors eager to diagnose and cure, that's harder than it sounds.

This story is part of the NPR series, What Shapes Health? The series explores social and environmental factors that affect health throughout life. It is inspired, in part, by findings in a poll released Monday by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

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

GOP Faults Shift Of Funds To HealthCare.Gov From NIH And CDC

NPR Health Blog - Tue, 03/03/2015 - 9:47am
GOP Faults Shift Of Funds To HealthCare.Gov From NIH And CDC March 03, 2015 9:47 AM ET

Partner content from

Phil Galewitz

How much flexibility does the Department of Health and Human Services have to move funding around within its budget?

Saul Loeb/AFP/Getty Images

House Republicans are questioning why the Obama administration transferred money last year from the National Institutes of Health and the Centers for Disease Control and Prevention to pay for the operation of the federal health insurance marketplace.

"Now it appears that we are robbing Peter to pay Paul in order to finance the disaster that is HealthCare.Gov," said Rep. Jody Hice, a Republican congressman from suburban Atlanta.

Hice complained at a hearing Thursday that the Department of Health and Human Services shifted millions of dollars last year from those agencies to help pay the $1.4 billion cost of running the insurance marketplaces in 37 states, according to an HHS spending document.

But HHS officials say they have authority to move money between agencies that are under their jurisdiction. And they note that only about 0.25 percent of each department's funding — about 50 in all, including global health and AIDS and substance abuse treatment programs — was used to finance the exchange.

Congressional Democrats did not appropriate sufficient funding to support the startup and operation of the federally run exchange, partly because they expected most states to run their own marketplaces. More than three dozen states decided to rely on the federal government, leaving HHS scrambling to find money to do the job. In 2013, HHS took $454 million from the $15 billion Prevention and Public Health Fund, created by the health law, and $158 million from the health law's Health Insurance Reform Implementation Fund, according to the Congressional Research Service.

In 2014, the single largest dollar amount that was transferred within HHS — $34.2 million — came from the Low Income Home Energy Assistance program, which helps poor people heat their homes in winter. Another $12 million came from the National Cancer Institute and nearly $11 million came from the National Institute of Allergy and Infectious Diseases. In contrast, the state-run exchanges received an "indefinite appropriation" from Congress to support their operations until this year when they were supposed to become self-sufficient. However, the federal exchange could not tap that money. Both the state and federal exchanges are also supported by premium taxes paid by those buying health plans in the marketplaces.

HHS officials say they have used their authority to transfer funds from one budget category to another when faced with pressing needs before, including paying for cybersecurity protection, caring for unaccompanied children caught crossing the U.S.-Mexico border and helping states provide medicines to individuals living with AIDS.

Sabrina Corlette, senior research fellow at Georgetown University, said the Obama administration is doing the best it can with funding limitations from the law and a resistant Republican controlled Congress. "A successful launch of the exchanges and health reform in general is a huge priority for the administration and in their first year of operation the user fees (from the exchange) are not completely covering their costs," she said.

"They are having to run exchanges in more states than anyone anticipated ...and they did the best they could with the cards they were dealt," Corlette said.

Joe Antos, a health economist at the conservative American Enterprise Institute, agrees that officials can shift money between departments within their jurisdiction.

"There is no issue on whether they have the authority to do this," he said, "but the question is whether this is the best way to fund the federal exchange."

Antos questioned whether the federal exchange is costing the federal government more money not just because more states are using it than originally envisioned, but because of the technological problems that caused sign-up delays during the first open enrollment period in the fall of 2013.

President Obama's 2015 fiscal year budget proposed about $1.8 billion to operate the federal exchange, of which nearly $1.2 billion would come from the premium tax and $629 million would come from Centers for Medicare & Medicaid Services, according to a Congressional Research Service report last October.

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

Alleged Patient Safety Kickbacks Lead To $1 Million Settlement

NPR Health Blog - Tue, 03/03/2015 - 8:27am
Alleged Patient Safety Kickbacks Lead To $1 Million Settlement March 03, 2015 8:27 AM ET

Partner content from ProPublica

Marshall Allen

Dr. Chuck Denham, once a leading voice for patient safety, will pay $1 million to settle civil allegations that he took kickbacks to promote a drug company's product in national health quality guidelines, the Justice Department announced Monday.

Denham, a patient safety consultant from Laguna Beach, Calif., had allegedly solicited and accepted monthly payments from CareFusion Corp., maker of the antiseptic ChloraPrep, while serving as co-chairman of a National Quality Forum committee in 2009 and 2010.

The nonprofit quality forum in Washington, D.C., reviews evidence and makes recommendations on best practices that are considered the gold-standard by health care providers nationwide.

ProPublica previously reported that Denham hadn't disclosed the payments to the panel of experts he was leading for the forum, and that other members of the Safe Practices Committee hadn't intended to endorse ChloraPrep. But Denham had advocated for the drug during the group's meetings.

Shots - Health News Patient Safety Journal Finds Violations, Tightens Standards After Scandal

The committee's final report recommended the product's formulation to prevent infections, ProPublica found.

"Kickback schemes undermine the integrity of medical decisions, subvert the health marketplace and waste taxpayer dollars," said Benjamin C. Mizer, acting assistant attorney for the Justice Department's civil division, in a news release announcing the settlement.

According to the Justice Department, the kickbacks to Denham caused the submission of false or fraudulent claims for ChloraPrep to the government's health care programs. As part of the settlement, Denham will be excluded from participating in Medicare and Medicaid programs.

"Quality and patient safety must drive all medical recommendations," said Inspector General Daniel R. Levinson of the U.S. Department of Health and Human Services' Office of Inspector General. "Doctors that put profits ahead of this core value must be held accountable."

Neither CareFusion nor Denham, who runs the consulting company Health Care Concepts and the research organization Texas Medical Institute of Technology, returned calls for comment.

Denham didn't admit to wrongdoing as part of the settlement. He previously denied any wrongdoing, saying his company had legitimate contracts for $11.6 million starting in 2008 with Cardinal Health, the parent company of CareFusion.

Denham had enjoyed star status in the patient safety world until January 2014, when the Justice Department first alleged an improper relationship involving his work with CareFusion. He was beloved by patient advocates, a regular on the conference speaking circuit and produced a documentary with actor Dennis Quaid, whose newborn twins had suffered a medication error.

After the kickback allegations, he was removed as editor of the Journal of Patient Safety, where an expert review found conflicts of interest. Denham's downfall has been called the patient safety movement's first scandal.

ProPublica is a nonprofit investigative reporting newsroom based in New York. Like this story? Sign up for ProPublica's daily newsletter to get more of their best work.

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

What Shapes Health? Webcast Explores Social And Economic Factors

NPR Health Blog - Tue, 03/03/2015 - 4:03am
What Shapes Health? Webcast Explores Social And Economic Factors March 03, 2015 4:03 AM ET NPR Staff

Communities are working to change social and environmental issues that affect health.

Health is more than the sum of its parts. Sometimes in surprising ways, factors such as childhood experiences, housing conditions, poor diets and health care access drive who ends up sick — and who does not.

As part of our series "What Shapes Health," created in partnership with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, Harvard sponsored a webcast on the question.

Shots - Health News Poll Finds Factors Large And Small Shape People's Health

The speakers investigated public perceptions of what impacts health, based on the new poll, as well as what actions can be taken to improve health, both for individuals and communities.

NPR's Joe Neel, deputy senior supervising editor, moderated the discussion with:

  • Robert Blendon, professor of health policy and political analysis, Harvard T.H. Chan School of Public Health and Harvard Kennedy School
  • Lisa Berkman, professor of public policy and of epidemiology, Harvard T.H. Chan School of Public Health
  • Dwayne Proctor, director and senior adviser, Robert Wood Johnson Foundation
  • Rebecca Onie, co-founder and CEO of Health Leads
Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Abortion Restrictions Complicate Access For Ohio Women

NPR Health Blog - Tue, 03/03/2015 - 3:37am
Abortion Restrictions Complicate Access For Ohio Women March 03, 2015 3:37 AM ET Listen to the Story 5 min 51 sec  

Abortion-rights opponent Brian Normile of Beavercreek, Ohio, holds up a poster during a prayer vigil outside Planned Parenthood in Washington, D.C., in January.

Alex Wong/Getty Images

Ohio may not have gotten the national attention of say, Texas, but a steady stream of abortion restrictions over the past four years has helped close nearly half the state's clinics that perform the procedure.

"We are more fully booked, and I think we have a harder time squeezing patients in if they're earlier in the pregnancy," says Chrisse France, executive director of Preterm. It's one of just two clinics still operating in Cleveland, and its caseload is up 10 percent.

Additional Information: Shots - Health News States Continue Push To Ban Abortions After 20 Weeks Law U.S. Court Weighs Texas Law's Burden On Women Seeking Abortions

France says women are also coming from farther away, from places that used to have clinics but no longer do. Because Ohio mandates an in-person meeting with a doctor followed by a 24-hour waiting period, women must come twice or stay overnight.

"That's tough for women who are working, who may not have paid time off," France says. "They're very likely to have children. Children and transportation are often big issues."

Some are even going to neighboring states. Ohio restricts the use of drugs that induce abortion early on, the method chosen by about a quarter of all women who end a pregnancy.

Then there's the state's confusing requirement for a fetal viability test after 20 weeks of pregnancy. Fetuses are generally not considered viable until several weeks later. But Dr. Lisa Perriera, an OB-GYN at Preterm, says there is no such test.

"The laws say that we have to do some kind of testing," she says. "They don't tell us what kind of tests to do, nor do those tests even really mean anything. It's just another hoop to jump through."

Preterm came up with its own test based on a fetus's age and weight. But Kellie Copeland of NARAL Pro Choice Ohio says the law has prompted other clinics to simply stop doing abortions after 20 weeks. "We know that women who have pregnancy complications have to go to Pittsburgh often," Copeland says. "Someone who may be later in pregnancy [and] found out that there was a severe fetal anomaly."

Then there's this new twist on an old law: All outpatient surgery centers in Ohio need a transfer agreement with a hospital in case of emergency. But now, only clinics that perform abortions are barred from having one with a public hospital.

"So clinics are in this Catch-22 that really doesn't have anything to do with patient care," Copeland says.

Abortion opponents say this keeps tax dollars from funding the procedure. But private hospitals, many of them Catholic-affiliated, are reluctant to enter such agreements. The public hospital ban has shut down at least one clinic that provides abortion and left others in legal limbo.

In all, eight of Ohio's clinics that perform abortion have closed since 2011, leaving eight still open. A judge is expected to rule soon on whether the last clinic in the city of Toledo can keep operating.

Not all the closings are tied to new laws; one shut after safety violations, another for business reasons. But NARAL's Copeland says the relentless barrage of restrictions has left providers feeling besieged. Still, she says even the toughest laws won't keep women from ending their pregnancies.

A poster put up by an abortion opponent outside Preterm clinic in Cleveland. Preterm is seeing more women, and from farther away, since new restrictions shuttered a number of the state's other clinics that perform abortion.

Jennifer Ludden/NPR

"At no time in history, nowhere around the globe did outlawing abortion mean women stopped having them," she says. "What it meant is they became dangerous."

Abortion opponents say they aim to change the culture around the procedure.

"Our goal ultimately is to live in a society where abortion is no longer even considered," says Mike Gonidakis, president of Ohio Right to Life, whose offices overlook the statehouse in Columbus. He's the key architect of a strategy even opponents call brilliant. Gonidakis calls his approach incremental and says it's driven by concern for civil rights.

"Every pregnant woman, regardless of her socioeconomic status, should be able to get the prenatal care she deserves, be able to have a real doctor and then have her child," says Gonidakis.

Bucking many peers, Gonidakis even supports expanding Medicaid coverage on the theory that it will keep some lower-income women from going to Planned Parenthood. He believes he's been so successful because he doesn't push too far.

"What happens in federal court is when you overreach, you lose," he says. "And when you lose, you lose bad."

Among groups opposing abortion here, Ohio Right to Life is considered the moderate middle. It took heat for opposing a "heartbeat bill" that would have banned abortion as early as six weeks. The measure has failed twice so far.

This session the group has rolled out a long list of new measures with a solid group of backers.

"I think we as a society need to be looking at this issue," says state Rep. Kristina Roegner, who keeps a framed copy of the Ten Commandments on her office wall.

When she first ran in 2010, Roegner says, she was struck that constituents asked her about abortion more than anything else. She's now sponsoring a bill to ban the procedure at 20 weeks, based on the medically disputed assertion that fetuses feel pain then.

"Those are precious, beautiful little lives that left alone will develop into human beings," she says. "And they have rights, too."

Another proposal would ban abortion based on a diagnosis of Down syndrome. And there's a "trigger law" that would ban virtually all abortions in Ohio, to take effect if the Supreme Court overturns Roe v. Wade.

"This is part of a bigger effort to rig the system against abortion providers," says Al Gerhardstein, a civil rights attorney in Cincinnati. "We have in Ohio laws that criminalize medical procedures that are unique to abortion. No other area of medicine has doctors fearing for criminal prosecution because they do the right thing for women, and that's wrong."

Gerhardstein's colleague Jennifer Branch is dismayed there hasn't been more of an outcry as Ohio loses one abortion provider after another. Major cities are down to one clinic each. If more close, "my biggest concern is that there's going to be a young woman who dies from trying to self-abort," says Branch. "And that's what it's going to take to galvanize people."

She and others continue to challenge Ohio's abortion laws. But so far, courts have let stand some of the toughest restrictions.

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

Improving Housing Can Pay Dividends In Better Health

NPR Health Blog - Tue, 03/03/2015 - 3:37am
Improving Housing Can Pay Dividends In Better Health March 03, 2015 3:37 AM ET Listen to the Story 7 min 4 sec  

Faiza Ayesh says her family's new home in the Terraza Palmera apartments in Oakland, Calif., has gotten them away from lead paint and asthma triggers.

Courtesy of Keith Baker

Faiza Ayesh giggles with delight as she describes her brand-new two-bedroom apartment in Oakland, Calif. She shares her home with her husband and three little girls, ages 3, 2 and 5 months. Ayesh, 30, says she just loves being a stay-at-home mom. "It's the best job in the world."

Shots - Health News People With Low Incomes Say They Pay A Price In Poor Health

But Ayesh wasn't always this happy. A little over a year ago she was living in a cramped one-bedroom apartment with her family. It was in just terrible shape, she says, "paint chipping all over apartment, no heat, roaches, the windows were terrible, some held up by rope on a wheel, really bad conditions."

Shots - Health News Poll Finds Factors Large And Small Shape People's Health

Dust from outside seeped in and her oldest daughter's asthma got worse fast, she says. "She's had a mild case of asthma since she was a baby, but when we lived there it went full blown. We didn't know why. She had to take albuterol every day to control her asthma, every day."

But the biggest scare came the day county officials called to say a routine doctor visit showed that both her girls had lead poisoning. A county health official came to test the apartment for lead. "She couldn't believe it; the windows and wood framing with paint chipping everywhere," Ayesh says. "And when she tested it, it all showed it had lead in it; it was so serious she wanted me to take care of it right away."

Uzuri Pease-Greene, right, leads a walk through the public housing complex in the Potrero Hill neighborhood of San Francisco where her family lives. She is working to have the old buildings replaced.

Talia Herman for NPR

The health official told Ayesh that her toddlers were probably eating the paint chips. She told Ayesh to use duct tape to cover the peeling paint. Ayesh did that. Then she started looking for a new place to live.

In NPR's latest poll with the Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health, 40 percent of lower-income Americans like Ayesh, with household incomes under $25,000 a year, told us they believe that poor neighborhoods and housing conditions lead to poor health.

Pease-Greene works for the nonprofit redevelopment group Bridge Housing.

Talia Herman for NPR

Across the bay in San Francisco, another mother, Uzuri Pease-Greene, shares a two-bedroom apartment in a public housing complex with her husband, two daughters and granddaughter. What worries Pease-Greene, 49, the most about their situation is the health of her 4-year-old granddaughter, who has asthma. Marijuana and crack laced cigarette smoke seep into the apartment, including the bedroom where her granddaughter sleeps.

The girl's asthma has gotten so severe she had to be hospitalized three times. But that might soon change. The nonprofit group Bridge Housing, which builds subsidized housing for low income individuals and families, plans to tear down the buildings and develop a whole new neighborhood. Pease-Greene, who works for Bridge Housing as a junior community builder, is hopeful that it won't just deliver clean, working apartments but also a neighborhood where it's more difficult for drug dealers to openly sell drugs.

In fact, a number of studies cite clear benefits when people move into decent housing. Lisa Sturtevant, vice president for research at the National Housing Conference, says most of the research has to do with the health of children. Asthma improves. There are fewer visits to the emergency room for routine health problems. And for adults there are often physical health benefits, including reduced obesity and heart disease, along with improved mental health.

The community garden in the public housing complex in Potrero Hill overlooks the bay.

Talia Herman for NPR

And this is pretty much what happened for Faiza Ayesh and her family. Ayesh applied and qualified for subsidized housing built by Bridge Housing. Her family was the first to move into the gleaming new building. She pays an affordable $580 a month for the apartment. It's just a few blocks from the old apartment but feels like another world, she says, with palm trees, lots of grass and safe play areas for the children.

And the family's health? A huge difference, Ayesh says. "We're not sick all the time, our apartment is clean, I don't have to worry about bugs, and when it's cold I can turn on the heat."

Getting out of the old apartment removed the risk of lead exposure. Routine tests show that the girls no longer have lead poisoning.

And her daughter's asthma? Well, you would hardly know she has it, says Ayesh. She hasn't had an attack since moving.

For more about the What Shapes Health poll and the issues influencing individual health, tune in to a live webcast from the Harvard T.H. Chan School of Public Health Tuesday from 12:30 to 1:30 ET.

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

Walk A Little Faster To Get The Most Out of Your Exercise Time

NPR Health Blog - Mon, 03/02/2015 - 5:04pm
Walk A Little Faster To Get The Most Out of Your Exercise Time March 02, 2015 5:04 PM ET Katherine Hobson

Government guidelines say exercising 2.5 hours a week will keep you healthy, but a study says you can get the job done in less time if you rev it up.

iStockphoto

Some people — who are they? — have no problem fitting regular aerobic exercise into their lives. The rest of us want to know how much we have to exercise to see health benefits. Now we have some answers: You may want to go just a tad longer and harder than you'd thought.

Current government guidelines advise adults to get the equivalent of at least 2 1/2 hours of moderate-intensity aerobic exercise or 75 minutes of higher-intensity exercise every week, plus some strength training. In effect, those guidelines say there's no particular benefit from working out harder, other than saving time.

To find out if that's true, researchers at Queen's University in Ontario studied different combinations of exercise intensity and duration in a group of 300 sedentary adults with abdominal obesity. (That's generally defined as a waist circumference of more than 35 inches for women who aren't pregnant and more than 40 inches for men.) People with abdominal obesity are at higher risk of heart disease and early death than people with slimmer waistlines.

All the exercisers were told to work out under supervision five times per week for 24 weeks. One group worked out at low intensity, about 50 percent of maximum oxygen uptake (VO2 max, a measure of cardiovascular fitness), for about 31 minutes per session — enough to burn 180 calories for women and 300 for men. That exercise prescription was about the same as in the government guidelines. The intensity was about equivalent to walking slowly, said study author Robert Ross, a kinesiologist at Queen's University.

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Another group exercised at the same low intensity but almost twice as long — about 58 minutes on average, or five hours a week, until the women had burned 360 calories and the men 600.

And a third group exercised at a higher but still moderate intensity, 75 percent of VO2 max, until they'd burned the same number of calories as the second group. That took about 40 minutes a day, or 3.3 hours a week. That intensity was equivalent to brisk walking for the previously sedentary participants, Ross told Shots. (Note that we're not talking about the all-out sprints of high-intensity interval training.)

A fourth group was told to do no exercise.

All the participants were told to keep a food diary and to eat a healthful diet but to keep their calorie intake constant. They also wore accelerometers to track their physical activity during the rest of the day, to make sure the more intense exercisers weren't compensating with more time on the sofa.

Shots - Health News Interval Training While Walking Helps Control Blood Sugar

At the end of the study, members of all three exercise groups lost an average of about 2 inches from their waist circumference. There weren't differences between the three groups. The average exerciser also lost 5 to 6 percent of body weight.

"The take-home message here is that if you're consuming a healthful diet and engaging with exercise consistent with the guidelines, you're going to see a benefit in your waistline and on the bathroom scale," said Ross. The results were published Monday in Annals of Internal Medicine.

But there was also a benefit from going just a bit faster: Only participants in the higher-intensity group saw an improvement in glucose tolerance, a risk factor for heart disease. (It's unclear whether the 9 percent improvement seen will be enough to cut their risk of heart disease, though.)

Shots - Health News To Make Interval Training Less Painful, Add Tunes

The result makes sense, since there's some previous evidence suggesting that higher-intensity exercise is tied to improving how the body processes sugar, said Neal Pire, an exercise physiologist who puts together medically based training programs at HNH Fitness in Oradell, N.J., a program of Holy Name Medical Center. Strength training can also improve glucose tolerance, which is why it's part of the government guidelines, he told Shots.

Cardiovascular fitness also improved in all three groups, but the lower-intensity exercisers who went longer did better than those who went shorter, and the higher-intensity group did better still.

Bottom line: All the exercisers improved, but the folks who did the best walked briskly for about 40 minutes five times a week. (Ross suggests you walk as if you're late for a bus.) "It doesn't take a lot," said Ross. "That's why our participants were so surprised. They didn't have to climb Mount Everest."

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Categories: NPR Blogs

GAO Report Urges Fewer Antipsychotic Drugs For Dementia Patients

NPR Health Blog - Mon, 03/02/2015 - 4:15pm
GAO Report Urges Fewer Antipsychotic Drugs For Dementia Patients March 02, 2015 4:15 PM ET Listen to the Story 1 min 52 sec  

About 1 in 3 patients with dementia who live in nursing homes are being sedated with antipsychotic drugs, the GAO says. Outside nursing homes, about 1 in 7 dementia patients are getting the risky drugs.

Wladimir Bulgar/iStockphoto

Older adults with Alzheimer's Disease or other forms of dementia are at risk of being prescribed dangerous antipsychotic medication whether they live in nursing homes or not. That's according to a study from the Government Accountability Office published Monday.

"They blunt behaviors. They can cause sedation. It increases a patient's risk for falls. And, if you just want to get to the very basic bottom line, why should someone pay for something that's not needed?"

The chance of a person with dementia receiving antipsychotic drugs in a nursing home is about 1 in 3, according to the report. For dementia patients who aren't in nursing homes — those living with family, for example, or in assisted living — the chance of being prescribed an antipsychotic is about 1 in 7.

These drugs are used to control the challenging behaviors that sometimes go along with Alzheimer's, but they are not approved by the Food and Drug Administration for that use. In fact the FDA has slapped these drugs with a strong warning, saying they can increase the chance of death for older adults with dementia.

"They blunt behaviors. They can cause sedation. It increases [a patient's] risk for falls," says Bradley Williams, a geriatric pharmacist who teaches pharmacy and gerontology at the University of Southern California. He says antipsychotics should be given to dementia patients for as brief a time as possible, and only if they have certain extreme symptoms, that have not responded to other therapies. That's not the majority of patients.

"And, if you just want to get to the very basic bottom line," he says, "why should someone pay for something that's not needed?"

Shots - Health News Old And Overmedicated: The Real Drug Problem In Nursing Homes Shots - Health News Feds Hope Hitting Nursing Homes In The Wallet Will Cut Overmedication

It's Medicare that's usually paying for the drugs – such as Risperdal, Seroquel or Zyprexa. The medicines are approved by the Food and Drug Administration to treat symptoms of schizophrenia and bipolar disorder, but not symptoms of dementia.

Senator Susan Collins (R-ME) called the report troubling. She's the chair of the Senate's Special Committee on Aging, and one of the senators who asked the GAO to look into the matter.

"The report," Collins says, "raises many red flags concerning the potential misuse and excessive use of antipsychotic drugs for patients with Alzheimer's and other dementias who are living in nursing homes." In a written statement she noted that the report found that "factors unrelated to the patient — such as low staffing levels — contributed to the overprescribing of antipsychotic medications."

In 2012, the federal Centers for Medicare and Medicaid Services launched a campaign to reduce the use of these drugs in nursing homes. In fact, usage in those institutions is declining. The GAO report says the government needs to put the same effort into curbing the use of antipsychotics among patients with dementia who reside in assisted living centers or with their families.

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