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How To Make Sense Of Health Insurance Alphabet Soup

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

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There must be an HMO in here somewhere.

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

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

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

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

In general:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jeff Brady/NPR

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

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

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

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

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

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

Additional Information: YouTube

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

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

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

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

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

Additional Information: YouTube

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

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

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

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

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

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

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

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

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

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

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

Mental Health Cops Help Reweave Social Safety Net In San Antonio

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

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Listen to the Story 7 min 1 sec  

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

Jenny Gold/Kaiser Health News

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

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

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

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

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

Additional Information: Lessons From San Antonio

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

Listen to the story

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

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

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

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

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

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

Jenny Gold/Kaiser Health News

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

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

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

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

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

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

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

San Antonio tackled that problem, too.

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

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

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

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

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

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

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

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

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

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

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

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

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

Medicare Patients Often See Nurses Instead Of Doctors For Skin Problems

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Power Of The Peer Group In Preventing Campus Rape

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

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

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

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

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

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

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

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

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

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

A Closer Look At Sexual Assaults On Campus How Campus Sexual Assaults Came To Command New Attention

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

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

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

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

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

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

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

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

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

13.7: Cosmos And Culture To Fight Campus Rape, Culture Must Change

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

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

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

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

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

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

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

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

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

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

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

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

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

They steered her back toward their group of friends.

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

NPR Ed Enlisting Smartphones In The Campaign For Campus Safety

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

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

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

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

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

When Patients Read What Their Doctors Write

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When Patients Read What Their Doctors Write

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Has Health Law Helped Young People Get Mental Health Treatment? Maybe

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

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

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

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

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

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

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

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

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

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

Were you surprised at all by what the study found?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Wide Range Of Hospital Charges For Blood Tests Called 'Irrational'

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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What The U.S. Health Care System Can Learn From Ebola Outbreak

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2014 ProPublica. To see more, visit http://www.propublica.org/.
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