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Yes, It Is Possible To Get Your Flu Shot Too Soon

NPR Health Blog - Thu, 09/15/2016 - 5:00am

The start of flu season is still weeks or months away, but you can get a flu shot now at many pharmacies. "It's a way to get people into the store to buy other things," says Tom Charland, an analyst who tracks the walk-in clinic industry.

Darron Cummings/AP

The pitches from pharmacy chains started in August: Come in and get your flu shot.

Convenience is touted. So are incentives. CVS offers a 20 percent-off shopping pass for everyone who gets a shot, while Walgreens donates toward international vaccination efforts.

The start of flu season is still weeks, if not months, away. Yet marketing of the vaccine has become an almost year-round effort that starts when the shots become available in August and is hyped as long as the supply lasts — often into April or May.

Not that long ago, most flu-shot campaigns started as the leaves began to turn in October. But two things have stretched the flu-shot season: the decade-long increase in the number of drugstores that have a retail medical clinic inside, and state laws that allow pharmacists to give vaccinations.

Drugstores have figured out how "to deliver medical services in an on-demand way," says Tom Charland, founder and CEO of Merchant Medicine, which tracks the walk-in clinic industry. The approach appeals to customers, particularly millennials, and turns out to be good business.

"It's a way to get people into the store to buy other things," Charland says.

But some doctors warn that the marketing may be overtaking medical wisdom, since it's unclear how long the immunity imparted by the vaccine lasts, particularly in older people.

Federal health officials say it's better to get the shot whenever you can. An early flu shot is better than no flu shot at all. But the science is mixed when it comes to how long you'll get optimal protection from a flu shot promoted and given during the waning days of summer; the typical flu season peaks in midwinter or beyond. Immunologists and public health officials are divided on how patients should respond to such offers.

"If you're over 65, don't get the flu vaccine in September. Or August. It's a marketing scheme," says Laura Haynes, an immunologist at the University of Connecticut Center on Aging.

A combination of factors makes it more difficult for the immune systems of people older than 65 to respond to the vaccination, she says, and the protective effect may also wear off faster than it does in young people.

So, when is the best time to vaccinate?

The Centers for Disease Control and Prevention advises physicians that it's safe to make flu shots available to all age groups whenever the vaccine becomes available, each year. While "delaying vaccination might permit greater immunity later in the season," the CDC notes, citing evidence from a 2013 study, that "deferral could result in missed opportunities to vaccinate."

How long will the immunity last?

"The data are very mixed," says Dr. John J. Treanor, an infectious disease specialist at the University of Rochester medical school. Some studies suggest vaccines lose some protectiveness during the course of a single flu season. Flu activity generally starts in the fall, but peaks in January or February and can run into the spring.

"So some might worry that if [they] got vaccinated very early and flu didn't show up until very late, it might not work as well," he says. But other studies show "you still have protection from the shot you got last year," Treanor adds, "if it's a year when the strains didn't change."

In any given flu season, the effectiveness of immunization varies, partly dependent on how well the vaccine matches the strain of flu virus that's predominant that year. In the overall population, the CDC says studies show a vaccine can reduce the risk of flu by about 50 to 60 percent when the vaccine is well-matched.

It's especially important to vaccinate children, to help keep parents and grandparents healthy, as well as the kids themselves, doctors say. While most people who get the flu recover, it is a serious disease responsible for many deaths each year, particularly among older adults and young children.

The intensity of illness provoked by each influenza strain can vary, too; U.S. deaths associated with the flu have ranged from about 3,300 a year to 49,000 in the past 31 seasons.

To develop vaccines, manufacturers and scientists study what's circulating in the Southern Hemisphere during its winter flu season — June, July and August. Then, based on that evidence, they forecast what flu strains might be circulating in the U.S. the following November, December and January, and incorporate that information into flu vaccines that are generally ready by late July.

For the upcoming season, the vaccines will include three or four strains — including two influenza A strains, an H1N1 and an H3N2, as well as one or two B strains, according to the CDC. The federal health officials recommend that everyone older than 6 months gets vaccinated, unless they have a health condition that would prevent it.

The vaccines can't give a person the flu because the virus is killed before it's used in the shot. This year, the nasal vaccine — a squirt of liquid that includes a live attenuated virus — is not recommended for use, as studies showed it was not effective during several of the past flu seasons.

So, talk to your doctor, and weigh your options for the timing of that flu shot. "The ideal time is between Halloween and Thanksgiving," says Haynes, who specializes in the immunity of older people. "If you can't wait, and the only chance is to get it in September, then go ahead and get it. It's best to get it early rather than not at all."

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente. Follow Julie Appleby on Twitter: @Julie_appleby.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Trying To Get The Kids To Put Down Those Phones? Here's Help

NPR Health Blog - Wed, 09/14/2016 - 3:07pm
Hero Images/Getty Images

My mother swears I learned to read by watching The Electric Company on TV, so maybe that's why I was initially a bit lax when it came to my daughter and screen time.

But after realizing she would be perfectly content to spend every free minute switching between the PBS Kids app and toy unboxing videos on YouTube, my husband and I drew several lines in the sand and drastically limited her screen use by both time and content.

She's only 4, which means that we still face years of decisions surrounding smartphones, Minecraft, Snapchat and the yet-to-be developed apps, games and devices that will be competing for kids' attention in the years to come. And it's not only her I'm worried about; my own habits of constantly checking email after 6:30 p.m. and reading political Facebook posts at any hour make me anxious.

In short, like many parents, I'm confused.

Most families have accepted digital technology into their homes, but many of us are unclear on how to use it wisely. And we worry about the mental and physical effects that excess tech may be having on our kids and ourselves. Melanie Hempe, founder and executive director of the nonprofit Families Managing Media in Charlotte, N.C., says she is concerned that overuse of digital technology isolates, rather than brings together, parents and kids both emotionally and physically. It also takes them away from activities that are shown to benefit their bodies and brains, like playing outside with a friend or reading a book. Here are some guiding principles for parenting in the digital age from conversations with Hempe and other experts:

Be aware that not all tech is the same. Rather than making rules based strictly on screen time, figure out what your kids are actually doing when they're on the computer or their phone, says Devorah Heitner, who founded Raising Digital Natives and is the author of Screenwise: Helping Kids Thrive (and Survive) in Their Digital World. Ask them to show you exactly which sites they visit and how they spend their time. They might be doing homework, composing music or writing a novel. Or they might be playing a first-person shooter game or following the Kardashians' every move on Instagram. Your limits on their use are likely to vary accordingly.

Shots - Health News Boys With Autism Or ADHD More Prone To Overuse Video Games

If you're concerned about compulsive use, current research suggests that online games seem to be the technology most likely to "potentially result in problems," says Daria Kuss, a psychologist and member of the International Gaming Research Unit at Nottingham Trent University in the U.K. "They're highly interactive and can engage players to such an extent that they easily forget about the time and their environment." (Internet gaming disorder is identified in the current Diagnostic and Statistical Manual, the DSM-5, as a condition that warrants further study.) That doesn't mean your kid can't game, but it does mean you might want to be more alert to the potential for problems if that's his main online activity.

Think about the role tech plays in your family life. "You should be focused on your values and what you think is important," says Hempe. Does everyone sit around the living room watching their own shows on their own iPads? Maybe it's time to institute family game or movie night. Can your children name three things they like to do as much as or more than an online activity? If not, maybe it's time to help them broaden their horizons. Do you spend more time posting witty remarks on Twitter than saying them out loud to your spouse? Schedule a regular tech-free date night.

Model good behavior, online and off. "We've fallen into this mental sinkhole where we get a communication and feel we have to respond to it," says Larry Rosen, a psychologist and professor emeritus at California State University, Dominguez Hills. That didn't happen overnight, but by now many people feel compelled to check social media constantly and to read and respond to emails and texts within minutes.

"We act out of this creeping anxiety of not being current," says Rosen, who is co-author of The Distracted Mind: Ancient Brains in a High-Tech World. And if your kids see you drop everything to respond to an email during dinner, they're going to get the idea that it's OK to drop everything and respond to a text during their homework.

Rosen suggests weaning yourself by taking increasingly long tech breaks during the day, starting at one minute and working up to 30 minutes. And help kids with their own connectivity anxiety by telling them they're not bad friends if they aren't immediately answering a late-night text, says Heitner. "Model boundaries, and model being unplugged," she says.

Also, show your kids when and how to take your communications offline. "Show you need to be able to go to someone face to face to resolve relationship difficulties," says Heitner. "Show them how to move away from an Instagram comment to 'I'm sorry I hurt your feelings.' "

Have tech-free zones and times. One way to help everyone curb overuse is to create tech-free zones, says Rosen. Those can be geographical, like banning technology at the kitchen table or bathroom. Removing smartphones and tablets from the bedroom is also helpful — at the very least, take out the devices a few hours before bedtime, since for a variety of reasons, they seem to contribute to poor sleep.

Technology Summer Camps Struggle To Enforce Bans On Screen Time

One 2014 review of research found an association between more screen time and later bedtimes and shorter sleep lengths in kids and teens. And a study published this year found that young adults who reported greater social media use also had greater odds of a sleep disturbance.

You can also carve out time or situations where no tech is permitted. Ann Steel, a licensed mental health counselor and former practicing physician in Seattle who sees a lot of patients with technology dependence, suggests one family tech-free day a week. Or require everyone to turn devices off during family dinners or car rides.

Let them learn for themselves. Heitner is a firm believer in allowing your kids to come to their own conclusions about tech when at all possible. That may mean allowing them to face the natural consequences of staying up late chatting online the night before a test. Or it could be letting them figure out for themselves the benefits of being unplugged during tech-free periods like sleepaway camp. But on the other hand, you know your kids, and it's perfectly fine to step in and curb their technology adoption if you think they can't handle it. "If you think your kid is too immature to get a phone, don't discount that," she says.

Keep an eye out for signs of serious trouble. "There's a continuum of behavior," says Heitner. Just because you have a hard time tearing your child away from Minecraft doesn't mean he's "addicted." But in some cases kids can have serious issues with technology — whether it's gaming, social media or something else — that require professional help. If your kid is using tech to the exclusion of things like sleeping, friends and school and can't change his or her ways, Steel says, it may be time to seek out therapy.

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She's on Twitter: @katherinehobson

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Employees Are Paying A Bigger Chunk Of Health Insurance Costs

NPR Health Blog - Wed, 09/14/2016 - 11:05am
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September 14, 201611:05 AM ET Heard on All Things Considered John Labbe/Getty Images

High deductible health plans are the new normal.

Just over half of employees this year have a health insurance policy with a deductible of at least $1,000, according to a survey of employers from the Kaiser Family Foundation.

It's the continuation of a multiyear trend of companies passing more of the costs of employee health care back onto workers.

Overall, health insurance premiums for a family covered by an employer health plan rose an average 3 percent this year to $18,142. Of that, employees pay an average of $5,277.

Historically, that's not much of an increase. But it still outpaces the rate of inflation, so it takes a larger chunk of worker income and employer profits.

"There's been a gradual sea change in what insurance is for most Americans, from more comprehensive coverage to skimpier coverage," says Drew Altman, president of the Kaiser Family Foundation.

Covenant Care, a Pensacola, Fla.-based hospice and home health care nonprofit, is one organization that has made the switch. About 450 of its 600 workers now have high-deductible health plans.

"At Covenant, we pay 80 percent of the costs of the plan and even at that point, there are some business decisions that need to be made regarding what we can afford to do," says Pat Holtman, senior manager of human resources.

She says the company offsets some of that deductible by putting cash into accounts that workers can use for health care costs. And if employees participate in wellness programs, they get points to pay even more.

That includes doing a health risk assessment at the beginning of the year. "If they go online and do a wellness assessment, they can accrue points that way," Holtman says. "If they're non-tobacco users there are a certain number of points that are accrued there."

Premiums have risen 20 percent since 2011, the Kaiser survey released Wednesday shows. They rose 31 percent in the previous five years and 63 percent in the five years before that.

With the continuous increases, companies like Covenant are getting creative, Altman says.

"Your typical employer is using everything in the toolkit to control their premiums," he says. They use those wellness programs. They try to help workers manage their chronic illnesses.

"But if you want to bring down the premium increase quickly in any given year, the immediate step you can take is to increase deductibles and other forms of cost sharing," Altman says.

Employers can lop about 20 percent off insurance premiums simply by raising deductibles from $200 to $1,000, says Dave Anderson, CEO of HealthNow Inc., which runs BlueCross BlueShield of Western New York.

Shots - Health News Medical Bills Still Take A Big Toll, Even With Insurance

Anderson says companies do think hard before they bump up deductibles because employees don't like it.

"I would say no one goes there lightly," he says. "Many employers have felt like they just had to go in that direction. They had to fix premium costs in some way."

BlueCross BlueShield of Western New York offers its own employees a high deductible plan. And like Covenant in Florida, it encourages its workers to participate in wellness programs to knock down their share of the cost.

The company will pay $500 toward a $1,000 deductible if employees undergo a health risk assessment each year. Anderson says the risk assessment will help employees embrace more healthy behavior and stick with exercise and nutrition plans.

"We believe we'll have that kind of overall reduction in our health care costs," he says.

But Anderson says high deductibles raise troubling issues as well.

"And that is whether it is inherently disadvantageous to lower-income employees. And we struggle with that," he says. "A $1,000 deductible if you're making $100,000 is no big deal. If you're making $30,000 a year, a $1,000 deductible is a big deal."

In the future, Anderson says, he expects employers and insurance companies will have to address that inherent unfairness by offering health plans with deductibles indexed to workers' income.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Want A BRCA Test? Some Insurers Require Genetic Counseling First

NPR Health Blog - Wed, 09/14/2016 - 9:13am

Family medical histories are used to figure out whether it is worthwhile for a woman to be tested for BRCA genetic mutations, which increase the risk of breast and ovarian cancer.

Andrew Brookes/Cultura RF/Getty Images

Health care providers and insurers agree that it's in everyone's best interest to refer women for genetic testing if their family history of breast or ovarian cancer puts them at higher risk. What they don't agree on is what should happen before testing — whether women need to be advised by a certified genetic counselor or someone with similar training before the test is ordered.

On one hand, obstetrician-gynecologists say that counseling patients about hereditary cancers of the breast, ovaries, uterus and other reproductive organs is part of their normal routine, as is counseling pregnant patients about prenatal genetic testing. As licensed physicians, OB-GYNs are considered competent to provide this type of care.

"This is what we do," said Dr. Mark DeFrancesco, the immediate past president of the American Congress of Obstetricians and Gynecologists, noting that most physicians have been taking family histories since medical school. "There are simple-to-understand criteria for who should be considered for genetic testing, and it usually has to do with whether you or someone in your family has had cancer."

DeFrancesco recalled a patient whose mother, grandmother and maternal aunt all had breast cancer — but the insurer required she see a genetic counselor before testing would be approved.

In such cases, "it will take a few extra weeks to get tested, and she might decide not to bother," he said.

DeFrancesco said genetic counselors have an important role to play after testing has been done to help patients who test positive for a genetic mutation understand the results.

In a statement released last December, the physicians group said it opposed such restrictions by insurers and warned that the requirement limits some patients' access to care.

Shots - Health News More People Seek Genetic Testing, But There Aren't Enough Counselors

But insurers sometimes take a different view, although their rules vary. Two national insurers, UnitedHealthcare and Cigna, for example, require women to receive counseling by a certified genetic counselor or other professional trained in cancer genetics before they will approve coverage for tests that look for harmful irregularities in BRCA1 and BRCA2, the two genes most commonly linked to an increased risk for cancers of the breast, ovaries and some other organs.

UnitedHealthcare began requiring genetic counseling for BRCA tests in January. The insurer allows physicians to do the counseling themselves if they attest to being qualified to do so, said Dr. Lee Newcomer, senior vice president for oncology and genetics.

In 2013, Cigna made independent counseling by counselors unaffiliated with the testing lab a requirement for any patient getting a genetic test for BRCA mutations or for inherited mutations linked to colorectal cancers or a heart condition called Long-QT. Last July, the company expanded the list to include all hereditary cancers.

Cigna generally requires physicians to get additional training in cancer genetics to meet its counseling requirement, said Dr. Jeffrey Hankoff, Cigna's medical officer for clinical performance and quality.

BRCA mutations increase a woman's risk of developing breast cancer by age 70 by between 45 and 65 percent, the evidence suggests. Mutations in these two genes are thought to account for about 5 to 10 percent of all breast cancers and raise a woman's risk of develping ovarian and other cancers, as well.

There are other particular genetic mutations known to increase the risk for breast and ovarian cancers, but they are less commonly tested for.

The U.S. Preventive Services Task Force, an independent panel of medical experts, recommends that women with a family history of breast, ovarian, fallopian tube or peritoneal cancer be screened to determine whether they are at increased risk for BRCA mutations and be referred for genetic counseling and testing, if that's indicated.

Under the Affordable Care Act, women with insurance aren't responsible for paying anything out of pocket for the testing and counseling recommended by the task force if it is performed by in-network providers.

The health law coverage requirement didn't drive Cigna's BRCA genetic counseling decision, said Hankoff.

"We had concerns that people were having testing ordered that didn't appear to need it and probably didn't understand it," Hankoff said. In addition, "Too often the wrong tests were being ordered."

For example, a woman whose sister has been diagnosed with breast cancer and tested positive for a specific mutation doesn't need a genetic test that looks for all hereditary breast cancer mutations, Hankoff said. She only needs to be tested for the specific mutation that her sister has.

Genetic counselors, meanwhile, try to walk a middle line in the debate. To become certified, people complete a master's degree program that encompasses both classroom study and clinical training in, among other things, genetics, ethics and the psychosocial aspects of helping families through diagnosis and the decision-making process. Certification by the American Board of Genetic Counseling is typically required to practice.

"There are a lot of complexities with genetic testing," said Mary Freivogel, president-elect of the National Society of Genetic Counselors, who practices in the Denver area. "A lot of [OB-GYNs] don't have the time or interest to do this well."

With the number of genetic tests growing by leaps and bounds, meeting the demand for counseling can be a challenge, many in the cancer field agree.

And physicians don't necessarily get it right. For one thing, said Robert Smith, a cancer epidemiologist who is vice president for cancer screening at the American Cancer Society, they often aren't great at taking family histories, neglecting to gather information about male relatives, for example. Or they don't factor in close relatives who died at a young age.

"Not everybody has a set of family members that allow for the elevated risk to be obvious," Smith said. "There's a lot to be said for having a specialist do it."

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter: @mandrews110

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

Doctors Test Drones To Speed Up Delivery Of Lab Tests

NPR Health Blog - Tue, 09/13/2016 - 2:20pm

Timothy Amukele, an assistant professor of pathology at Johns Hopkins Medical School in Baltimore, and systems engineer Jeff Street are trying to figure out how to use drones to deliver blood samples.

Johns Hopkins School of Medicine

Three years ago, Geoff Baird bought a drone. The Seattle dad and hobby plane enthusiast used the 2.5-pound quadcopter to photograph the Hawaiian coastline and film his son's soccer and baseball games.

But his big hope is that drones will soon fly tubes of blood and other specimens to Harborview Medical Center, where he works as a clinical pathologist running the hospital's chemistry and toxicology labs. In the near future, Baird and others say, drones could transform health care — not only in rural areas by bringing critical supplies into hard-to-reach places, but also in crowded cities where hospitals pay hefty fees to get medical samples across town during rush hour. By providing a faster, cheaper way to move test specimens, drones could speed diagnoses and save lives. "It's super exciting to me," Baird says.

The technology seems to be there. Drones are delivering pizza in New Zealand and taking condoms to parts of Ghana that lack reliable roads or access to birth control. Tech giants and big retailers, including Amazon and Wal-Mart, are testing drones for deliveries and pickups.

However, "blood specimens are not like a book or a shoe," Timothy Amukele, an assistant professor of pathology at Johns Hopkins School of Medicine, said in a TED talk earlier this year. No one knew whether bumpy flights would hurt cells or otherwise make biological samples unsuitable for lab tests.

Additional Information: Drones In Flight

Amukele and his colleagues transport donated blood samples by drone in this video. The drones climbed to over 328 feet above ground and circled the field for six to 38 minutes.

So Amukele and co-workers conducted several experiments to find out. In their first study, published in PLOS ONE last July, the team collected several hundred blood samples from healthy volunteers. They drove the samples to a flight field an hour northwest of Baltimore, packed half of them into foam containers and flew them around in a drone for up to 40 minutes. The other samples sat. All specimens went back to the lab for 33 routine tests. The results were the same for each group, suggesting samples stay intact during drone flights.

In follow-up analyses, drone transport also seemed safe for samples containing microbes and for donated blood. The microbial study was published in August in the Journal of Clinical Microbiology; a manuscript on the blood products study is under review. (Videos of each experiment can be found here.)

"The results don't surprise me," says Bill Remillard, chief technical officer at TriCore Reference Laboratories in Albuquerque, N.M. "But until you do the science, you just don't know."

TriCore handles nearly three-quarters of New Mexico's clinical lab testing. And in a sparsely populated state, moving samples over large distances is expensive. TriCore spends $3.5 million per year. So after Remillard heard the results of Amukele's first drone experiment at a meeting last summer, the two started discussing a possible pilot study using drones to transport lab samples in New Mexico.

Goats and Soda Condoms By Drone: A New Way To Get Birth Control To Remote Areas

While Amukele's experiments show it's feasible to move lab specimens with drones, pilot studies in real clinical settings are still needed to work out logistics. Questions include how to request a drone, where it would land, who would pick up the samples and how often a drone would need new batteries.

Safety is another concern. Some drones drop cargo with parachutes or other release mechanisms, making it harder for people to tamper with the vehicles. But as far as how safe drones are, "those data don't yet exist," Amukele says. Though millions of drones have been sold worldwide, "we don't know how many crashes happen and how many are due to operator error," he says. The Federal Aviation Administration is starting to collect this data.

It's a promising development for an industry where legislation has lagged behind the fast-advancing technology. For years, the FAA had imposed a near-ban on commercial drones, only allowing them to fly if businesses applied for an exemption. But in June the agency announced a set of rules for companies to operate drones in the United States, and on Aug. 29 those regulations took effect. The FAA expects the number of registered commercial drones to jump 30-fold, from 20,000 to 600,000, within months.

"The rules had not been well defined. This is an attempt to define them," says Lawrence Williams, who heads business development at Zipline, a Silicon Valley startup making drones for medical applications. Zipline is focusing much of its effort in Rwanda, where less crowded skies, relative to the U.S., make it easier to negotiate drone delivery of blood samples.

Another drone startup, Vayu, whose CEO is a co-author on the PLOS ONE drone study, is also dipping into the international arena. In July, the Michigan-based company did a demo flight in Madagascar, carrying specimens from a remote village to a lab for testing. Vayu makes a quadricopter plane capable of vertical takeoff — an appealing feature for hospitals with limited landing space.

All Tech Considered Drones That Launch Flaming Balls Are Being Tested To Help Fight Wildfires

While it's easy to see how drones could improve health care in poor countries, Amukele thinks medical drone delivery could make a bigger splash in the U.S. Compared to Africa and developing countries, the U.S. does much more testing per person, he says, and many of the country's 200,000 medical labs are collection-only sites that rely on central labs for testing. So "there are likely to be more [medical drone users] in the U.S. than anywhere else," Amukele says.

As Zipline prepares to launch blood delivery drones in Rwanda, the company is also seeking regulatory approval for three projects using drones to bring medical supplies to underserved communities in the U.S.

One project would integrate drone delivery of medications with telemedicine appointments at a small clinic in rural Maryland. Another would use Zipline drones to link a large health care distribution center to hospitals and tribal clinics around Reno, Nev. And for the third project, the company would partner with a regional blood bank in Washington state, creating a plan to distribute blood to various hospitals and clinics in the event of earthquakes and other natural disasters.

Johns Hopkins was initially skeptical of Amukele's experiments — the review board thought his first proposal was a joke — but now the university is giving the pathologist space and funds to hire a drone engineer and continue researching medical delivery drones.

In Seattle, Baird is working with Amukele and aeronautical engineers at the University of Washington on their own drone proposal. Ideally their test flights would take samples from Seattle Children's to Harborview, a bustling facility that runs thousands of tests each day. However, that flight path would violate the FAA rule requiring drones to stay within the pilot's line of sight. So the initial plan is to run 2-mile line-of-sight flights between the children's hospital and UW Medical Center, Baird says.

Drones could be a huge help in poison emergencies, Baird says. In a typical scenario, a child gets rushed to the emergency room after accidentally swallowing some pills. Though routine tests can rule out some things, clinics often send samples to a centralized toxicology lab for confirmation and further testing. This can take hours. A drone could zip samples downtown in five to 10 minutes, Baird says, helping a child get diagnosed and receive medications more quickly.

He also envisions drones collecting samples from patients' homes and taking them to the hospital. You could prick your finger and rub the blood onto a card that a drone could fly back to the lab for testing, Baird says.

In the meantime, though, Zipline's U.S. projects remain on hold, awaiting the regulatory go-ahead, and the Seattle team continues studying maps and sketching flight routes for the small drone test it hopes to launch. The team has presented the plan to grant agencies and gotten positive responses — but no funding yet.

Like other technological advances, Baird suspects drones for medicine will "wait, wait, wait and then go very quickly."

Esther Landhuis is a freelance science journalist in the San Francisco Bay Area. Follow her at @elandhuis.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

Would You Like Some Insurance With Your Insurance?

NPR Health Blog - Tue, 09/13/2016 - 12:08pm
Would You Like Some Insurance With Your Insurance? Audio for this story is unavailable. September 13, 201612:08 PM ET

From

A screenshot from a video touting a gap plan called "Premium Saver."

Screenshot by NPR/Crema Design Studio

For the first time in her life, 26-year-old freelance designer Susannah Lohr had to shop for health insurance this year.

She called up a major insurer in the St. Louis area where she lives, and it offered her a plan with a hefty $6,000 deductible — that's the amount she would have to cover herself before the insurance kicks in.

When she balked, the salesman on the phone suggested that she could buy a "gap plan," a separate policy for $50 a month to cover her deductible.

"After I got off the phone with him, I realized: That's actually just insurance for my insurance," she said, laughing.

Gap plans, used to cover out-of-pocket expenses like high deductibles, are becoming increasingly popular among consumers and businesses.

The rising price of insurance is driving the trend, explains insurance broker Ryan Hillenbrand, president of the Missouri Association of Health Underwriters.

"People see the prices of individual insurance and they say, 'Boy, a $6,000 deductible seems really high. I don't want something that gives me that much risk,' " Hillenbrand says. "That's why [the gap insurance] market is heating up a little bit more."

Gap insurance is in a category of insurance known as "limited benefit." No matter how bad a person's situation, the plan will pay out only a certain amount of money. "Mini-med" policies, now illegal under the Affordable Care Act, are another example of a limited benefit plan

Now, there's renewed interest in gap plans. With monthly premiums on health insurance going up, more people are choosing cheaper, high-deductible options. In 2016, more than 90 percent of people buying insurance under the ACA chose plans with an average deductible of $3,000 or higher.

Next year, the cost of one of the most popular plans available under the Affordable Care Act could increase by 10 percent on average across the country. That comes on top of a 5 percent jump the year before.

When consumers see those prices, Hillenbrand says, "they get sticker shock."

"If you don't qualify for a subsidy, you're bearing the brunt of all that cost," Hillenbrand says. "And here come the gap plans."

About 8 in 10 people qualify for some form of subsidy on the Obamacare exchanges, helping to make insurance more affordable for consumers.

Businesses, on the other hand, are facing those costs on their own. And for some businesses, especially smaller firms, gap plans can make a lot of sense, says Alex Forrest, an insurance broker in South Carolina.

"The cost of health insurance is going up and businesses have been forced to deal with that by raising their deductibles or increasing out-of-pocket costs for their employees," he says. "That stinks."

With a gap plan, he says, companies can offer a package of health benefits that keeps out-of-pocket-expenses for employees down. And they still spend less than they would with higher-priced plans with lower deductibles.

Forrest says he has seen more gap insurance products for businesses come to market in the past few years. They're being marketed as a way to keep out-of-pocket expenses low for employees. This video explaining a plan called the "Premium Saver" boasts: "The only thing that's really different for you is, now, you have two [insurance] cards instead of one."

St. Louis footwear company Diba Imports, for example, purchases both a high-deductible health plan and a type of gap plan called "hospital indemnity insurance" for its roughly 30 employees.

"It basically reimburses most of your deductible if you have an illness or injury that puts you in the hospital," says Diane Butrus, the company's COO.

Butrus says that Diba used to pay the deductibles directly for its employees, but as those deductibles started rising, eventually up to $3,000, "we couldn't afford to do that anymore."

The unpredictability was especially hard for a small company like Diba. The cost of covering employee deductibles swung widely year to year, hitting $25,000 one year when several employees needed serious care.

The hospital indemnity plan only costs the company just under $50 a month per employee — not exactly cheap at about $18,000 per year — but at least Diba knows exactly how much it will spend on insurance every year.

"It's been very good," says Butrus.

Not everyone is bullish about gap plans, however, especially for individual buyers.

Health economist Deborah Chollet of Mathematica Policy Research, an independent research firm, says the insurance reforms in the ACA were designed "basically to drive these kinds of creative insurance arrangements out of the market."

Because gap plans aren't major medical insurance, Chollet explains, they're not regulated by the health care law and can avoid complying with consumer protections built into the law. So the companies providing gap insurance, she says, "can ask you about your health status, they can deny you coverage, they can do all of the kinds of things that the Affordable Care Act prohibits."

Chollet says individuals might be better off getting an Obamacare plan through their state exchange, or at least checking to see if they qualify for subsidies, as 80 percent of consumers on the exchanges do.

That's what Lohr ended up doing. It took her three full days on HealthCare.gov to find the best plan, but after her tax credit, her monthly premium is about $200 and her deductible is just $600.

It's "a much better plan," she says.

For people who are intimidated, overwhelmed or find the whole process of choosing a plan unmanageable, there are dozens of free health insurance navigators in each state — people you can talk to who will help you choose your coverage. It's something Lohr wishes she had known about when she started searching for a plan.

Editor's note at 5:20 p.m. ET: It should have been noted when this story was broadcast and published that until early this summer, Susannah Lohr was an employee of St. Louis Public Radio, which like KBIA is licensed by the University of Missouri. She and reporter Bram Sable-Smith have not worked together.

This story is part of a reporting partnership with NPR, Side Effects Public Media and Kaiser Health News.

Copyright 2016 KBIA-FM. To see more, visit KBIA-FM.
Categories: NPR Blogs

As More States Consider Legalizing, Questions About Pot And The Brain

NPR Health Blog - Tue, 09/13/2016 - 5:12am
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September 13, 20165:12 AM ET Heard on Morning Edition

From

Aaron Tilley/Getty Images

Five states are voting this fall on whether marijuana should be legal, like alcohol, for recreational use. That has sparked questions about what we know — and don't know — about marijuana's effect on the brain.

Research is scarce. The U.S. Drug Enforcement Agency classifies marijuana as a Schedule I drug. That classification puts up barriers to conducting research on it, including a cumbersome DEA approval application and a requirement that scientists procure very specific marijuana plants.

One long-term study in New Zealand compared the IQs of people at age 13 and then through adolescence and adulthood to age 38. Those who used pot heavily from adolescence onward showed an average 8 percent drop in IQ. People who never smoked, by contrast, showed slightly increased IQ.

Critics pounced on the study, which was published in 2012, because it didn't adjust for many other things that affect IQ such as home life or family income. And there's no proof the IQ differences are due to pot.

One of those critics, Nicholas Jackson, now a senior statistician at the University of California, Los Angeles, wondered what would happen if he could rule out some of those elements by comparing twins.

"Individuals that share the same genes, grew up in the same household, where the difference between them was that one of the twins was using marijuana and one was not," Jackson says.

Jackson and Joshua Isen, now an assistant professor of psychology at the University of South Alabama, conducted a study comparing IQ tests of twins age 9 to 12, before either had smoked marijuana, and then seven to 10 years later, after one had started.

"If marijuana was causing IQ decline, what we would expect to see is that the twin who goes on and uses marijuana should have IQ deficits," Jackson says. "We don't find that."

IQ scores for both twins varied slightly over time. And for twins who smoked marijuana, there was no significant difference in effect between daily and occasional use. So was the New Zealand finding wrong? The authors did not comment for this story, but have said that the twins study of teenagers does not address the effects of decades of heavy marijuana use.

Marijuana seems to affect a particular kind of intelligence, like short term retention of vocabulary words and other information that you might learn in school, says Mitch Earleywine, a professor of psychology at the University of Albany.

"They haven't learned a whole lot of vocabulary words or they never learned the capital of Maine because they were high at school that day," he says. "But when it comes to things that are more liquid intelligence, more fluid intelligence, they're usually pretty good at those because it requires just intelligence in the moment, so to speak."

It's not clear how marijuana use may keep Augusta from being filed next to "capital of Maine" in the brain. Some studies that compare brain scans of teenagers who use marijuana to those who don't show thinner, less dense connections between lobes. Nora Volkow, director of the National Institute on Drug Abuse, says brains with less connectivity don't work as well as they should.

"You could expect that that will decrease your capacity to memorize things and to learn them which is necessary to you to actually further develop your cognitive abilities," she says.

Volkow says there's little proof that marijuana causes poor brain connections. Studies so far have not compared brains before and after pot. Maybe kids who are already having trouble in school are more likely to try marijuana. Still, she is convinced that marijuana is bad for the brains of adults who began smoking in their youth.

People who regularly smoked marijuana as teens, "are achieving much less both in their education as well as their profession as well as their economic earnings," Volkow says. "They also tend to be much more dissatisfied with life. Many studies have shown that."

NIDA is one of several agencies behind a major study that will map the effects of marijuana and other substances on brain development. The Adolescent Brain and Cognitive Development Study (ABCD) will follow 10,000 9- to 10- year-olds through early adulthood, using neuroimaging to map changes in the brain.

But as of now, the research suggests if you don't start young and don't use marijuana often, there's not much evidence of permanent harm to the brain. That's led some experts in marijuana brain science to say it might be OK to make pot legal, with strong oversight. That includes Kevin Hill, an assistant professor of psychiatry at Harvard Medical School.

"I'm not sure how I would vote [on the Massachusetts ballot question] at this point. I want to see sensible marijuana policy that works, that gives people what they want while limiting risk," says Hill, who wrote Marijuana: The Unbiased Truth about the World's Most Popular Weed.

Massachusetts is one of five states, including Arizona, California, Maine and Nevada, that will vote in November on legalizing recreational marijuana.

Hill would like to see stronger regulation of marijuana if it becomes legal, with limits on advertising and of edible products that attract children, as well as a higher rate of taxation than the proposed 12 percent. If Massachusetts approves marijuana for recreational use, it would not be legal for anyone under age 21, when most, but not all, brain development occurs.

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

Copyright 2016 WBUR. To see more, visit WBUR.
Categories: NPR Blogs

Kratom Advocates Speak Out Against Proposed Government Ban

NPR Health Blog - Mon, 09/12/2016 - 4:07pm
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September 12, 20164:07 PM ET Heard on All Things Considered

From

The federal government is moving to crack down on kratom, which some people use for chronic pain and to lessen cravings for opioids and alcohol.

Joe Raedle/Getty Images

Kratom is made from the leaves of a tree native to Southeast Asia that is a relative of the coffee plant. According to David Kroll, a pharmacologist and medical writer, farmers and indigenous people have used it for hundreds of years as both a stimulant to increase work output and also at the end of the day as a way to relax.

The leaves are often brewed like a tea, or crushed and mixed with water. In the U.S., kratom has become popular among people coping with chronic pain and others trying to wean themselves off opioids or alcohol.

Karisa Rowland is one of them.

Since 2014, she has woken up every morning, removed a bag of kratom powder from her fridge, put about a teaspoon in a mug and drunk it.

In the past, Rowland, who lives a half-hour south of Fort Worth, Texas, struggled with a serious prescription opioid dependence. After several back surgeries, she was using pills — hydrocodone, fentanyl and oxycodone — to deal with her chronic pain.

One night, in jail after being picked up for a DUI, she hit a low. "I'm looking around and I'm watching raw [sewage] flow through a vent in the floor and I'm thinking, 'Wow. This has to stop. I'm going to end up dead,' " she says.

Today, though, she has no kratom.

In late August, the Drug Enforcement Administration announced its intent to classify kratom in the same category as heroin and LSD by the end of September. Since then, the place Rowland orders from online has been sold out. Rowland says she's in pain and she is angry. She has plenty of company.

In a YouTube video, a veteran shakes a bottle he says contains prescription opioids he has been given for pain. "This," he says, "is not Schedule I."

"Do I seem angry?" he continues, "Yes. Because you're taking away a right that I fought for. When I did my tour in Iraq, I fought for my right to be in America and be able to help myself, to cure myself. I'm not talking about snorting cocaine, shooting up heroin, I'm not even talking about puffing a joint. I'm talking about brewing some tea leaves, having a sip and feeling better."

In another video, comedian Trae Crowder says, "This would be like us banning pole vaulting because of concussions." (Please note, the video contains prolific and inspired cursing.)

People have uploaded hundreds of videos talking about why they drink or swallow kratom pills — veterans coping with PTSD, recovering alcoholics, people with fibromyalgia. A petition on WhiteHouse.gov to keep it legal has more than 118,000 signatures.

Even the Drug Enforcement Administration has been hammered with calls, says special agent Melvin Patterson. "The response has been unexpected," he says. "People calling us in opposition of our plan to temporarily schedule kratom as a Schedule I, due to it not having a medicinal use."

Patterson says the move to schedule kratom come out of a concern for public safety. Between January 2010 and December 2015, U.S. poison control centers received 660 calls related to kratom, he says.

In Texas, there have only been 17 kratom calls so far this year, but Kristina Domanski, with the North Texas Poison Center, says the numbers are creeping up.

"Most people obtain this online," Domanski says. "Because this is not necessarily legal or regulated, you don't know what you're buying, there's no quality control, it's not a supplement [that's] regulated. You don't know what you're buying, so there's a risk that it's not kratom; it could be mixed with something else."

The DEA attributed 15 deaths to kratom between 2014 and 2016. Critics call it a legal heroin, ripe for abuse and addiction.

The science behind kratom is still evolving.

Pharmacologist Kroll says it is going overboard to classify this plant as a dangerous drug. "Kratom being lumped in with other opioids is both unfair and unscientific," he says. "It glosses over the subtleties of how the main chemical in kratom actually works."

The main chemical is mitragynine. It binds to some of the same receptors as opioids, providing some pain relief and feelings of euphoria, but, Kroll says, not the same high. And the chemical doesn't cause the same, sometimes deadly, side effects as opioids, such as respiratory depression.

"It turns out mitragynine has a very low risk of respiratory depression," Kroll says. "It also appears that it's very difficult to at least get animals, get mice addicted to 'mitra' — either with the herb or with the pure chemical."

So what about the people who died? Fourteen of the 15 people also had other drugs or illegal substances in their systems. Advocates for keeping kratom legal also point out that opioid abuse kills tens of thousands of people every year.

Kroll worries an outright kratom ban could push people back to opioids or alcohol. And, he says, it would delay scientists' researching the alleged risks of kratom and anecdotal benefits of the herb.

Kratom user Rowland is trying to get her friends and kratom users to speak out along with her. She has already sent a letter to Texas Sens. John Cornyn and Ted Cruz seeking support.

"I'm the one in pain. The people making these laws, they're not the ones going through this pain; they're not the ones whose families have broken up," she says. "I found life and I have no intention of letting it go."

Rowland says if drinking kratom means becoming a criminal, so be it.

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

Copyright 2016 KERA. To see more, visit KERA.
Categories: NPR Blogs

Insurance Data Show A Surge In Spending On Opioid Treatment And Testing

NPR Health Blog - Mon, 09/12/2016 - 12:59pm

Drug users in recovery listen to a counselor at a treatment center in Westborough, Mass., in March.

John Moore/Getty Images

The nation's opioid problem comes with staggering physical and emotional costs to patients and families. But the financial burden on the health system has been harder to peg.

A report set to be released Tuesday shows a more than thirteenfold increase in spending by health insurers in a four-year period on patients with a diagnosis of opioid dependence or abuse.

From 2011 to 2015, insurers' payments to hospitals, laboratories, treatment centers and other medical providers for these patients grew from $32 million to $446 million.

While the latest figure represents a small portion of the overall spending on medical care in the United States, the rapid rise is cause for concern, says Robin Gelburd, president of Fair Health, a nonprofit databank that provides cost information to the health industry and consumers.

"That really shows the stress on the health system and the impact on the individuals," said Gelburd.

The Fair Health study found a sharp difference in how much insurers spend on individual patients with such a diagnosis.

On average, insurers spend $3,435 a year on an individual patient, but for those with an opioid dependence or abuse diagnosis, that amount jumps to $19,333. Those numbers reflect what insurers actually paid. The report also includes data on what providers charged, amounts that are lowered by their contracts with insurers.

The study, out Monday, builds on a study Fair Health released in early August that found a thirtyfold increase in the volume of insurance claims related to opioid dependence diagnoses between 2007 and 2014.

Shots - Health News Many More People Seek Medical Help For Opioid Abuse

The latest study by Fair Health — part of a series — looked at amounts associated with claims billed by providers and paid by insurers for the types of medical services used.

Both studies use de-identified claims data from insurers representing more than 150 million insured Americans who either have insurance through work or buy coverage on their own.

There have been other efforts by several researchers to quantify the cost of the opioid problem on the overall economy, estimated in the tens of billions of dollars.

The new report adds to the available data "that it's not just the human cost associated with the opioid crisis that is enormous, but also that the economic costs are staggering," said Dr. Andrew Kolodny, senior scientist at Brandeis University. He didn't work on the study.

The surge in spending on patients with opioid diagnoses is likely a combination of factors, the report notes. As media attention focuses on drug dependency, more people may be seeking treatment. At the same time, prescription and illegal use of narcotics may also be increasing.

The study found that emergency room visits and laboratory tests accounted for much of the spending.

Based on claims volume, the fastest-growing set of services in terms of utilization were for alcohol or drug therapy. Lab tests, including checks for barbiturate or opioid use, weren't far behind.

Researchers didn't use 2015 data for lab test costs, noting that a change in billing codes was made that increased the number of categories — and, in some cases, appear to generate higher charges by insurers. It is too early to estimate the long-term effects of the change, Gelburd said.

The report gives some examples of the changes, however. For example, one billing code for a test on opiate use commonly brought in a $31 payment from insurers prior to the change. The two billing codes that replaced it now are commonly paid at $78 and $156.

The new billing codes may reflect new technology in testing, said Gelburd. She said some observers speculate that the rapid increase in lab spending might reflect that, with more patients in therapy, the tests are being used to ensure they are taking their proper medications and not abusing narcotics.

But the spending might also reflect a growing use of very expensive urine and blood tests when less expensive ones would be sufficient, said Kolodny.

"I worry about profiteering," said Kolodny. "We do need tests, but not the expensive ones. A lot of clinics are making extra money off these lab tests."

The overall increase in spending across all types of medical services "is a societal issue," said Gelburd, who says policymakers need to ensure that changes are made to address the problem.

"Are medical school curricula adjusting to recognize the growing need for these services? Are insurers increasing the number of providers in their networks to ensure sufficient access? Are consumers being educated? It's an issue that has to be dealt with in all quadrants."

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Julie Appleby is on Twitter: @Julie_appleby.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
Categories: NPR Blogs

A Good Dentist Is Hard To Find In Rural America

NPR Health Blog - Mon, 09/12/2016 - 6:50am
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September 12, 20166:50 AM ET Heard on Morning Edition Michelle Kondrich for NPR

Jessica Stefonik is grinning. She's got a bounce in her step. Her cheeks are a little puffy and her speech is a bit thick.

"It feels weird right now, but I'll get used to it," she says.

What she's trying to get used to is the feeling of having teeth.

On the day we met, Stefonik, a mom of three from Mosinee, Wis., got a set of dentures to replace all of her upper teeth, which she lost over many years to disease and decay.

Stefonik is just 31 years old.

She's one of millions of people who are poor and live in rural America and have little to no access to dental care.

A study by the Federal Reserve found that a quarter of Americans went without dental care they needed in 2014 because they couldn't afford it.

For those in rural areas, the problem is far worse. A 2015 report by the Pew Charitable Trusts found that people in rural areas are poorer and less likely to have dental insurance than their urban counterparts. They're also less likely to have fluoridated water, and more likely to live in an area where dentists are in short supply. Those dentists that are there probably don't take Medicaid, government health insurance for the poor.

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"You've got a double whammy if you're on Medicaid and you're living in a rural area," says Jane Koppelman, research director for the Pew Charitable Trusts' dental campaign.

For years, Stefonik lived in pain from her cracked and decaying teeth. If she got to a dentist at all, they'd usually just pull one tooth and tell her to take better care of the rest.

She was on Medicaid, and in Wisconsin that included dental insurance. Wisconsin's comprehensive dental benefit is considered one of the best in the nation. According to the National Academy for State Health Policy, four states don't offer any dental insurance to Medicaid beneficiaries, and another 15 offer only emergency care.

Still, most dentists in Wisconsin, and across the country, don't accept patients on Medicaid because they say the reimbursement rates are too low. The Wisconsin Dental Association says Medicaid pays only about 35 percent of the dentists' costs.

"My teeth were pretty much rotting out to where I couldn't brush them," Stefonik says.

She tried to just gut it out, hiding her pain from her children so they wouldn't worry about her and living with the gaping holes in her mouth. She ate only soft foods because anything else hurt too much.

"I'm hiding my smile, I'm hiding my pain and I'm trying to be happy, but I just found myself depressed," she says.

Earlier this year she heard about the dental center run by the Marshfield Clinic. It's about 40 miles from her home, takes all comers, and gives them comprehensive dental care for whatever they, or their insurance, can pay.

They pulled all the remaining top teeth in Stefonik's mouth and fitted her for dentures. She paid nothing. The care was paid for by Medicaid.

Jessica Stefonik's story isn't unusual.

John O'Brien, a dentist and the clinic's director of dental operations, says he sees about four or five new patients every day, and at least one of them needs more than half their teeth pulled.

When he told a 40-year-old hunter and fisherman at the clinic in Rhinelander Wis., that his periodontal disease was so bad that he needed all his teeth pulled, "He just broke down in tears," says O'Brien.

"He couldn't find someone in 20 years to care for his teeth," O'Brien says. "There are just not enough dentists, so they can pick and choose who they want to treat."

But that's changing. Over the past 12 years, the Marshfield Clinic has opened 10 state-of-the-art dental centers to serve the rural poor.

The clinics are the brainchild of Greg Nycz, executive director of Family Health Center of Marshfield, a string of medical clinics for the poor run by the Marshfield Clinic, a major medical center in central Wisconsin. Through that work, Nycz says, he saw people in pain with broken and missing teeth all the time. And he got calls from desperate people looking for help. One from a young mother haunts him to this day.

"Her child was screaming in pain, alternately screaming and sobbing in the background," he recalls on a recent afternoon.

Nycz talked at length with the mom and learned this had been going on for weeks. She couldn't find a dentist to help.

"As we talked it became very clear that she was viewing herself as a failure as a mother because she couldn't take that pain away from that child, and other mothers could," Nycz says, choking back a sob at the memory. "And I said, 'No more. We're going to fix this.' "

That was in 2002. A year later, the Marshfield Clinic opened its first dental center in Ladysmith, Wis.

Nycz underplays the difficulty in getting this job done. He tells me that state lawmakers were on board because they too got calls like the one he described. So were members of his board, who knew that access to dental care was a crisis in the region.

He has lobbied successfully for changes in laws, for federal grants, and even for low-interest loans from the Department of Agriculture's rural development program. "We've been very lucky to have a supportive Congress," he says.

One key to the clinics' survival is a law that allows community health centers like those the Marshfield Clinic runs to be reimbursed their full costs for caring for Medicaid patients, on the condition that they also care for people who have no insurance.

But Nycz's relentless drive is also a key. "There are a lot of hoops we have to jump through to do this work," he says.

The Marshfield Clinic centers aren't unique. Federal law requires community health centers that get certain types of government support to offer dental care. But the scale of Marshfield's operation is unusual. Its 10 clinics employ 45 dentists, three oral surgeons and 41 hygienists. They have a budget of nearly $44 million and can serve 60,000 patients a year.

Mary Kate Scott, a management consultant who has done extensive research on dental centers that cater to the poor, says Marshfield is ahead of the curve. But she says more states are seeing high-quality dental centers that serve the poor open up, in part because of the expansion of Medicaid under the Affordable Care Act.

Nycz grew up outside Milwaukee. His family didn't have much money. "McDonald's back in the day — 15-cent hamburgers — that was a big treat for us," he says.

He's not your typical hospital executive. His hair is a bit too long. He's big, with a quiet demeanor that barely tames what is a missionary-like zeal to ensure that the poor get quality health care — and dental care is included in that calculation.

His office is piled high with papers. Stacks 1 to 2 feet high cover his desk and extend to the floor. He has a dog-eared copy of a 16-year-old surgeon general's report on the sorry state of oral health in America. Its pages are highlighted and marked with Post-its. He actually had it signed by the author, and grins when he shows me the inscription.

That first dental clinic in Ladysmith was supposed to be a modest affair. They'd work with a dentist who was already in town and put up money so he could care for those who couldn't pay. Maybe they'd add a chair and bring in one more dentist.

The plan was to announce the endeavor just after Labor Day 2002. "On Monday a tornado hit Ladysmith. Rendered his dental facility nonfunctional," Nycz recalls.

It could have been a disaster, but Nycz saw an opportunity. First he and his staff set up a makeshift clinic in a church. Operations manager Terri Kleutsch, who runs all 10 dental clinics, called it a MASH unit.

Then Nycz went to the Family Health Center's board and asked for more money. A lot more. "If we put a big chunk of our reserves into this effort, we could build a state-of-the-art facility that the community can be proud of," he told them.

The board agreed and committed a large chunk of its reserves to the effort, and the state gave them a grant as well.

A year later, a clinic with 17 treatment rooms, big enough to accommodate five dentists and five hygienists, opened on Miner Street in Ladysmith.

In that first year, people came from across Wisconsin, from 42 different counties. Some drove four hours to get there. Some arrived by the busload.

And that's still happening. Anyone who walks in the door of any of the 10 clinics is welcome and gets high-quality care.

"We don't leave vets behind, we don't leave people with HIV/AIDS behind, the disabled, exceptionally heavy people. We want everybody to have access," Nycz says.

"Greg is a visionary," says Jane Koppelman of Pew. "He's taking what we know about science and he's applying it to practice."

What we know is that oral health is closely tied to overall health. Research shows bad teeth are linked to a host of problems, including heart disease and premature birth. They can aggravate diabetes and spread infection to the heart.

"When you treat the gum disease, there are fewer complications and lower costs in treating people like diabetics and people with heart disease," Koppelman says.

At the Marshfield Clinic centers, dental care is treated as another part of general health care. Dental and medical records are combined. Patients who come to the dentist get their blood pressure and blood sugar checked. Patients who are there for a filling may end up being sent to the hospital for a stress test or diabetes followup.

And doctors at the health centers routinely look into patients' mouths. If there's a problem, they refer them to the dentist.

Nycz and his colleagues think that providing dental care not only makes people healthier, it can also make them more financially secure. That's because, very simply, bad teeth can make it hard to get a job.

"You've got a mouthful of broken, cracked and decaying teeth, your ability to contribute to society is impaired, and your options are impaired," Nycz says.

In rural Wisconsin, many manufacturing jobs have disappeared and been replaced with service jobs that often aren't open to people with rotten or missing teeth. The Marshfield Clinic dental centers work with job placement programs to ensure that if someone has an interview and needs dental work to be ready, they will fit the person in and get the work done in time.

For Jessica Stefonik, just the ability to smile again and enjoy normal social events may be enough.

"I haven't smiled in probably eight years. I mean a good smile," she says. "And I'm very excited to be able to go out to eat with my family and not have soup," she adds with a laugh.

Armed with her new teeth and a paper bag carrying denture adhesive and a new toothbrush, she walks to the lobby to see her daughter, Kylie.

"Hey, Kylie. Did you see my teeth? Do you like 'em?" Stefonik asks the blond girl sitting quietly in a corner chair.

The little girl whispers back. "They're awesome."

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

California Aims To Limit Surprise Medical Bills

NPR Health Blog - Sun, 09/11/2016 - 5:11am
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September 11, 20165:11 AM ET Heard on Weekend Edition Sunday

From

Cassie Ray (seen with her husband, Gerry) got a surprise bill from an out-of-network anesthesiologist after an operation.

Courtesy of Cassie Ray Shots - Health News Surprise Medical Bills: ER Is In Network, But Doctor Isn't

When it comes to navigating the intricacies of health insurance, Cassie Ray considers herself a pro. She actually reads her policy, including the fine print.

So when the 57-year-old from Fairfield, Calif., needed routine follow-up surgery after a mastectomy, she did her homework. "I looked up on my insurer's network and made sure the outpatient facility that I was being referred to was in my network," Ray says.

A month later, she received an unwelcome surprise: a $580 bill for an out-of-network anesthesiologist.

"I called the facility back, and at first, I felt like, this has to be a mistake. They'll fix it," Ray says.

Instead, the clinic said her only option was to negotiate the bill directly with the doctor. Ray's experience illustrates the surprise of balance billing.

The unexpected charged come when patients are treated by an out-of-network provider at an in-network facility.

After several failed attempts in recent years, the California legislature last week passed AB-72, which aims to protect patients' pocketbooks when they're hit by these surprise bills. Gov. Jerry Brown has until the end of September to sign or veto the legislation. He is expected to sign it into law.

A 2015 Consumers Union survey suggests the surprise bill phenomenon is fairly common. It found nearly 1 in 4 Californians who'd had hospital visits or surgery in the prior two years reported receiving an unexpected bill from an out-of-network provider.

"They can range in price from a hundred dollars to many thousands," says Betsy Imholz, special projects director for Consumers Union. "So it's a big financial burden on consumers."

In Ray's case, she says she tried to speak with a manager at the outpatient clinic, but no one returned her repeated calls. Then the bills stopped coming, so she figured all was resolved. Soon after, however, her bill was sent to collections.

"I was so frustrated," she recalls. "I was just in tears as I was dealing with it."

Ray says it took about seven months of wrangling before her insurance company finally paid the bill and she was able to clean up her credit rating.

"My immediate response was, there does need to be a law to fix this," says Ray. "This is so wrong."

The legislation, by Assemblyman Rob Bonta (D-Oakland) and six colleagues, would limit a patient's financial obligation to no more than what he would have owed if the provider had been in-network.

While agreeing that "patients should never have surprise bills," Dr. Karen Sibert, president-elect of the California Society of Anesthesiologists, says her organization and a number of other specialty medical groups oppose AB-72.

At issue, Sibert says, is the bill's formula for paying doctors who fill the gap left when insurance companies don't have enough providers in their networks. The legislation would set the payment rate at either the amount the insurer normally pays a doctor on contract for such services or 125 percent of the Medicare rate, whichever is greater.

That's insufficient, argues Sibert. "It's a problem because it removes any incentive for insurance companies to reach fair contracts with physicians."

Without such an incentive, she says, insurance companies will continue to stick consumers with inadequate provider networks.

The powerful California Medical Association agrees with Sibert about the bill's payment formula, but it has shifted its position on AB-72 from opposed to neutral, says Janus Norman, the Association's vice president of governmental affairs.

There are a few reasons for the change of heart, he says. First, the bill would create stricter oversight of how in-patient services are delivered, and it would allow for tougher regulations on insurers if the state finds their provider networks to be inadequate.

The provision regarding tougher regulations, "is one improvement that AB-72 included that prior legislation did not," he says.

In addition, the measure would give out-of-network doctors the chance to appeal payment disputes with insurers through an independent third party, and the decision would be binding, another important change from previous versions of the bill, Norman says.

The California Association of Health Plans and the Association of California Life and Health Insurance Companies don't have a formal position on AB-72, according to an analysis by the Assembly Health Committee. Instead, they have expressed "concerns" about the measure, the committee said.

"While they laud the authors' efforts to protect consumers from balance billing," the analysis says, the insurer groups worry that the legislation might lead to higher premiums and cost-sharing, and that the bill's dispute resolution process might spark more lawsuits between providers and health insurance firms.

Anthony Wright, executive director of Health Access California, a consumer health care advocacy coalition, says Gov. Brown took an interest in the legislation.

"The governor's office did provide input during the negotiation process and we are hopeful that he will sign it," he says.

Consumers Union's Imholz says the California Medical Association's neutral position on the legislation was key in getting AB-72 across the finish line.

She predicts that if Brown signs the measure, a number of other states now considering similar protections against surprise bills will likely follow suit next year.

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

Copyright 2016 Southern California Public Radio. To see more, visit Southern California Public Radio.
Categories: NPR Blogs

Seeing A Mother's Alzheimer's As A Time Of Healing And Magic

NPR Health Blog - Sat, 09/10/2016 - 5:00am
Courtesy of Dana Walrath

In 2008, Dana Walrath asked her mother Alice to move in with her. Alice's Alzheimer's disease had gotten worse, and even though she still had all her humor and graces, she could no longer take care of herself.

During the next two and-a-half years, Walrath and her mother connected through stories and memories, even though Alice didn't always recognize her daughter. Walrath, a medical anthropologist at the Vermont College of Medicine, in Burlington, Vt., looks back fondly on that time.

"As an anthropologist you're always encouraged to document everything you do, but it just felt right to live the experience," Walrath says.

In 2010, she began sketching Alice as a way to process her feelings about transferring her mother to an Alzheimer's care residence. She cut up a paperback copy of Alice in Wonderland, a book her mother loved, and used the fragmented words to craft collages of Alice.

Through curiously-sketched comic illustrations and vignettes, Walrath documents her experience with her mother's dementia in Aliceheimer's: Alzheimer's Through The Looking Glass, published in March by Penn State University Press.

Dana Walrath with her mother, Alice, in 2013.

Courtesy of Dana Walrath

Sometimes funny, sometimes heart-breaking, each comic weaves in a different facet of their shared experience: hallucinations, repetition, memory, loss, magic, and sometimes even time travel. In one vignette, Alice is transported to 1954, where she believes her grandsons are Johnny Depp-like pirates and Dana's husband is a fellow captive.

Walrath spoke with Shots about making the book and her experiences taking care of her mother. The conversation has been edited for length and clarity.

You say your experience was a time of "healing and magic," which doesn't follow the typical narrative around Alzheimer's disease. Can you explain that?

We've got a medical system that is so focused on curing things that when a cure hasn't been discovered yet, it's really scary. Most people are pining for the cure and focusing on the loss. If we say, "This is reality, this is what it is," and we stop fighting it, then surprising things can happen. People with dementia keep their sophistication and their intentions — they've just lost their short-term memories. They're working hard to figure out how to communicate and stay connected. And for those of us who have our memories, if we can read those signs, we can have those amazing connections. It just came naturally to me as an anthropologist — being used to this notion that everyone is walking around with a framework in their head that comes from their culture that may be very different from mine.

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If she was hallucinating, she'd wake up from a nap and say her mother was right there, and say, "Can't you see her?" I'd say, "That's so cool you can see her, you have special powers." It was a way of making her reality safe and then being able to explore from there.

I like thinking about it the way improv comedians do. They use a "yes and" principal. So whatever she was experiencing I would endorse and then build upon it so that there would be collective magic.

How would she respond?

She felt great that what she was experiencing was a special power. And then she had pride in that, she felt met, and then we could go on and process the next thing. The hallucinations about her parents made me think she needed to go and visit her parents' graves. Once we did that, she stopped having those hallucinations.

You say that it wasn't until you started cutting up the book Alice In Wonderland that this book started to come together. How did that happen?

Once I found the collage element, my subconscious was completely engaged and then all these other things started to come out.

Like those halos around Alice's head. I think, oh my gosh, that's a subconscious reference to her first language, her reversion to childhood, and the altered magical state that dementia is and was for me.

Has the process of making this book changed the way you think about Alzheimer's?

Courtesy of Dana Walrath

I believe that if we can look at people with dementia and cognitive differences as just another way of being human, it's better. We can learn so much from people in altered states. When my mother was living with us, I got in the habit of buying cut flowers because she would just marvel at them. At dinner she'd say nearly 20, 30 times, "Those flowers are gorgeous!" and it's something a lot of us forget to do. It's probably good for all of us to stop and notice what's there and good and what we can be grateful for. I look at it as a different window into being human.

Copyright 2016 NPR. To see more, visit NPR.
Categories: NPR Blogs

College High: Students Are Using More Marijuana, Fewer Opioids

NPR Health Blog - Fri, 09/09/2016 - 3:12pm

Legalization of recreational marijuana may be a factor influencing increased use college-age young adults.

Diverse Images/UIG/Getty Images

High school students and young adults are much less likely to use illicit drugs than their parents, according to data released Thursday. And compared to baby boomers, young adults today look like outright angels. Except for their acceptance of marijuana, that is.

This report comes from a running, four-decade-long study of drug, tobacco and alcohol use from the University of Michigan. This most recent iteration shows that people in their 40s and 50s used far more drugs in their youth than do people in their teens and 20s today.

"The proportion of Americans in their 40s and 50s who have experience with illicit drugs is quite shocking," says Lloyd Johnston, a research scientist at the University of Michigan and the lead investigator on the study. "It's a great majority."

Not counting marijuana, over 70 percent of people in their 50s have used illegal drugs in their lifetimes. Including marijuana, the proportion soars to about 85 percent of people in their 50s. Back when these people were in college, nearly half of them were using illegal drugs compared to around 40 percent of college-aged adults today.

In fact, young people have been increasingly shunning psychoactive substances for a while now. Cigarette use is at an all-time low, with 20.5 percent of college students saying they smoked in 2015 compared to 44.5 percent in 1999.

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"Maybe the most important of all is the decline in narcotic drugs like Vicodin and OxyContin and so forth," Johnston says. Use of prescription opioids by college students has dropped from 8.7 percent in 2003 to 3.3 percent in 2015. "That's despite the fact that we know from the news that the use and misuse of narcotic drugs is a growing problem in the country," Johnston says.

The reason is not completely clear, Johnston says, but it probably has to do with young people learning to be wary. "When someone sees a substance is dangerous, they tend to avoid it," he says. "And one of the things we've seen is an increased in perceived risk for a number of drugs."

But when it comes to marijuana, the trend reverses. "For the most part, among both college and high school students their perception of how dangerous [cannabis] is has dropped like a rock," Johnston says. That tracks closely with how use of cannabis, which has been steadily rising for the past couple of decades.

The policy debate around the legalization of recreational and medical marijuana is probably making the drug seem a lot less dangerous, Johnston thinks. "It's hard to see what else would account for such a dramatic change in perceived risk," he says. Other studies have shown that negative messages about cannabis are rare on social media.

And negative opinions or information about other drugs floating on the Internet could make them seem more dangerous.

Shortly after synthetic marijuana, also called spice, became popular, videos on YouTube and Twitter showed terrifying effects the drug had on users. This report shows an abrupt drop in spice use, from 8.5 percent of college students to 1.5 percent in 2015.

"The use of the Internet has certainly increased information exchange from objective sources and other people the same age," Johnston says. "Perhaps young people today are more informed about things."

There's also a lot of federal funding available for drug prevention programs that target young people, particularly high school-aged students, says Jennifer Whitehill, a public health researcher at the University of Massachusetts, Amherst. And a lot of drug awareness campaigns didn't get started until after the 1980s. That could also contribute to the declining use of drugs among young people.

Whatever the reason, the declines in illicit drug use don't mean our society is going to become drug-free. The last period of declining drug use was in the late '80s, and Johnston says that efforts to reduce drug use started dropping off after that. "Congress spent less time and money on the drug issue and, most importantly, the media dropped the drug issue." That gave a bump to drug use in the '90s.

The decline right now could just be setting the stage for another resurgence of illegal drug use, Johnston says. "As we're seeing a period of decline in illicit drugs, there's less attention to the issue, and young people grow up knowing less about why they shouldn't use them."

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Categories: NPR Blogs

A Map To Help Cancer Doctors Find Their Way

NPR Health Blog - Fri, 09/09/2016 - 9:32am

A computer model could map the paths a cancer is likely to take.

Jennifer C. Waters/Science Source

What if doctors could call up a computerized map that would show them how a case of cancer is likely to progress?

Tumor cells can mutate in unexpected ways. And cancers can suddenly grow. For doctors, anticipating cancer's next moves can help guide timely, effective patient treatment.

A mapping program, called PiCnIc for short, aims to help physicians in staying a step ahead of cancer and preparing long-term treatment plans with fewer elements of surprise.

How does it work?

PiCnIc "takes in patient data, guesses potential scenarios and tells you the most likely scenario," says Bud Mishra, a professor at New York University's Courant Institute of Mathematical Sciences who led a multinational team in developing the program.

PiCnIc produces maps of cancer progression in much the same way historical explorers drew maps of the Earth without satellite imaging. The program, like the explorers, draws tiny regional maps and then pieces them together like a puzzle.

The program extracts the simplest pieces of information from medical data, which Mishra calls "little blocks of causality." They describe one stage of cancer, along with a potential outcome.

Once the blocks of causality are constructed, PiCnIc examines them to retain only the likeliest paths. This process is akin to discarding poorly drawn regional maps before attempting to put together a global map.

The end result is a graphical representation of the possible scenarios a cancer patient might encounter. From it, physicians can hypothesize how cancer will progress and plan accordingly.

Just like a good cartographer, PiCnIc is capable of drawing all kinds of maps, as long as appropriate medical data are available. "[PiCnIc] is quite flexible. It can incorporate pretty much any cancer type," says Nicholas Navin, a professor at the University of Texas MD Anderson Cancer Center who wasn't involved in the creation of PiCnIc. Navin says that PiCnIc, at its current stage of development, "already gives [us] enough information to be clinically useful."

The program can also update the maps to factor in advances in cancer research as well, says Giulio Caravagna, a computational biologist at the University of Edinburgh who participated in the research project. As new medical data become available, researchers can rerun PiCnIc with ease to generate updated maps of cancer. "And there is already a pretty good amount of data, like the Cancer Genome Atlas," says Caravagna.

The research work was published on the Proceedings of the National Academy of Sciences in late June. Mishra says that he plans to look into "commercial opportunities" for PiCnIc and collaborations with "large research labs" to improve it.

For now, though, the PiCnIc maps "shouldn't be interpreted too much in making decisions for individual patient," says Navin.

"We are a little bit underpowered to comprehensively build these [maps of cancer]... there are still little ways to go," says Ben Raphael, a computational biologist at Brown University.

A cartographer is only as good as the measurements the explorers bring in, after all.

Copyright 2016 NPR. To see more, visit NPR.
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Pot And Pregnancy: No Harm Seen At Birth, But Many Questions Remain

NPR Health Blog - Thu, 09/08/2016 - 5:09pm

Since marijuana doesn't benefit mother or baby it should be avoided, researchers say. But there is stronger evidence for the harms of alcohol and tobacco.

Roy Morsch/Getty Images

Between 2 percent and 5 percent of women say they use marijuana while pregnant, according to the American College of Obstetrics and Gynecology. And while harm to the fetus is certainly plausible since the drug crosses the placenta, the evidence has been spotty. Now a review and analysis of 31 previously published studies has found no independent connection between a mother's pot use and adverse birth events. But the doctors say that doesn't mean it's OK to partake.

Based on unadjusted data, the review found a link between marijuana use and both low birth weight and preterm delivery. But when the researchers adjusted the data to account for confounding factors including tobacco — which is often used alongside marijuana — there was no association, says Shayna Conner, an assistant professor in the division of maternal fetal medicine and ultrasound at Washington University in St. Louis School of Medicine and an author of the study.

In other words, from the available evidence it seems that the risk surrounding birth is from tobacco use and other factors, not from the marijuana itself.

Shots - Health News Pediatricians Say Absolutely No Drinking While Pregnant

Conner emphasizes that message is still clear: Don't use pot when you're pregnant. "Any foreign substance that doesn't directly benefit maternal or fetal health should be avoided," she says. But the analysis suggests that public health dollars budgeted for preventing bad birth outcomes should be spent to discourage the things with more evidence of harm, such as tobacco or alcohol, she says.

There are still plenty of reasons for women to be cautious about marijuana use. For one, the body of evidence on this topic is inconsistent. Different studies looked at different neonatal outcomes. And most of the studies relied at least in part on women to report their marijuana use. "That may mean that patients who do smoke but don't tell their provider may be misclassified," says Conner.

Moreover, this review, which was published Thursday in Obstetrics & Gynecology, focused only on adverse neonatal outcomes such as low birth weight, preterm delivery and stillbirth. It didn't cover the long-term risk of neurodevelopmental problems such as cognitive difficulties or ADHD. A separate review of evidence published in December found that while the studies in humans on that topic are flawed, "there is a concerning pattern of altered neurodevelopment with early, heavy maternal use of marijuana."

"Any time there's a substance that we're not sure of the effects on the fetus or the mother during pregnancy, unless we know of a strong benefit to using the substance we'd advise not to use it," says Torri Metz, an assistant professor of maternal-fetal medicine at the University of Colorado Denver, and an author of that December paper. It also found no solid evidence for the benefits of medical marijuana in pregnancy to prevent nausea. She and her co-author called for high-quality prospective studies to better understand the impact of marijuana use on pregnancy and breastfeeding.

And how should women who are trying to conceive or who aren't using birth control think about pot? The Centers for Disease Control and Prevention got a lot of flak earlier this year for recommending that women in those circumstances abstain from drinking alcohol altogether.

Very few studies have looked at the time of marijuana exposure and connected that to outcomes. But Conner said many of the studies covered by the new review included women in the earliest part of their pregnancies, which might give some reassurance to women who are worried about pot use before they discovered they were pregnant.

In Colorado, where both medical and recreational use of marijuana are legal, the Department of Public Health & Environment advises women not to use the drug during pregnancy. In fact, if the baby is tested at birth and is positive for THC, the law requires child protective services be notified.

The question of how prenatal exposure to pot affects a baby will almost certainly become more pressing, with five states including California voting in November on whether to legalize recreational use.

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She's on Twitter: @katherinehobson

Copyright 2016 NPR. To see more, visit NPR.
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Widespread Use Of Prescription Drugs Provides Ample Supply For Abuse

NPR Health Blog - Thu, 09/08/2016 - 4:25pm

Nearly half of Americans 12 and older take sedatives, stimulants, painkillers or tranquilizers.

Izabela Habur/Getty Images

Almost half of all Americans take prescription painkillers, tranquilizers, stimulants or sedatives, according to results of a federal survey released Thursday. The prevalent use of these drugs could help explain why millions of Americans end up misusing or abusing them.

Last year, for the first time, the government's National Survey on Drug Use decided to ask the people it interviewed about all uses of prescription medicines, not just inappropriate use. The survey found that 119 million Americans age 12 and over took prescription psychotherapeutic drugs. That's 45 percent of the population.

Of those, about 19 million Americans didn't follow a prescription. Most misuse involved people who acquired the drugs from friends or family. More than a third had a prescription but took those drugs excessively. And about 5 percent bought drugs from a dealer or stranger.

All told, 16 percent of all prescription drug use was actually misuse, according to the report.

There's no question that these drugs help alleviate pain and suffering for millions of Americans. But it's also clear that the system encourages overuse.

"Any of us go to the doctor and feel like we don't get our money's worth if we don't come out with a prescription, right?" Kim Johnson told Shots. She is director of the Center for Substance Abuse Treatment at the federal Substance Abuse and Mental Health Services Administration.

"Just like any drug, the more it's out there, the more it's available, the more likely it is to be abused," she said. And many of these drugs pose an additional risk because of their physical effects, including in some cases their addictive properties.

The Centers for Disease Control and Prevention is trying to reform prescribing practices, particularly for opioid drugs, to reduce the overuse of these pain medications. The new survey also documents the dire need for affordable and accessible treatment options.

"One in 12 people aged 12 or over needed treatment for substance use disorder, yet nearly 90 percent of those people didn't get specialty treatment that could have helped them toward recovery," said Kana Enomoto, SAMHSA's principal deputy administrator, at a news conference.

That need for treatment pertains not just to prescription drug abuse but to street drugs such as heroin.

"We need to expand access to treatment and we need to do it now," said Michael Botticelli, director of the White House Office of National Drug Control Policy. "Because, like every other disease, people who want treatment should be able to get it. And it should not be dependent on where they live or how much money they have."

President Obama's budget for fiscal year 2017 called for more than $1 billion to expand access to drug treatment, but Congress has not acted on it.

You can email correspondent Richard Harris.

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WATCH: Bacteria Invade Antibiotics And Transform Into Superbugs

NPR Health Blog - Thu, 09/08/2016 - 2:02pm

If you've ever wanted to watch a superbug evolve before your very eyes, you're in luck. Researchers filmed an experiment that created bacteria a thousand times more drug-resistant than their ancestors. In the time-lapse video, a white bacterial colony creeps across an enormous black petri dish plated with vertical bands of successively higher doses of antibiotic.

The colony pauses when it hits the first band of antibiotic, creating a stark border between the white colony and the black petri dish. Then the bacteria start to edge their way into the toxic soup. More dots appear and they start growing, racing to the next, stronger band of antibiotic. The bacteria are evolving. After almost two weeks of real time have passed, they've become resistant to the strongest antibiotic and completely taken over the kitchen-table-sized petri dish.

We know dangerous bacteria are getting stronger all the time and that it's our fault because of our excessive and indiscriminate use of antibiotics. Each year, 23,000 people in the U.S. die as a result of superbug infections. But we typically don't get to see superbugs created.

For most people, evolution is just conceptual, says Tami Lieberman, an evolutionary microbiologist at MIT. She and her Ph.D. adviser, Roy Kishony at Harvard Medical School and Technion — Israel Institute of Technology, wanted something that would make the evolution of superbugs seem more concrete. "The goal was to see evolution, not to abstract it," she says.

Their video and report were published Thursday in the journal Science.

By having the E. coli bacteria grow across bands of increasingly stronger doses of antibiotic, the scientists could make it look like evolution was marching across the dish. But the setup had another effect that the researchers didn't expect. The faster growing colonies of resistant bacteria were cutting off the growth of slower but more drug-resistant colonies and becoming more successful.

When bacteria evolve drug resistance, it usually comes at some kind of cost to the bug. In the presence of an antibiotic, faster growing colonies don't grow as robustly as the slower ones — but that often doesn't matter. If the strain wants to live on, it just needs to be the first to get to the next human or food source. "[This] phenomenon has been very, very tough to study classically," says Michael Baym, the postdoc who built the 4- by 2-foot petri dish in Kishony's lab. In his contraption, it's impossible to miss.

And if scientists can see it, maybe they can start to study it. Using something as simple as a giant petri dish like this could help scientists open up that spatial dimension that has been missing from the lab, says Pamela Yeh, a microbiologist at UCLA who was not involved in the experiment. "Hopefully this will put back in people's minds how important the spatial element can be."

It's possible that there's a lot of research that can be done by getting away from small, classic petri dishes, Yeh says. But for now, Kishony's 2-by-4 is mostly just a demonstration. Hopefully, a useful one, Lieberman says. "Getting more people to understand how quickly bacteria evolve antibiotic resistance might help people understand why they shouldn't be prescribed antibiotics. The drug resistance is not some abstract threat. It's real."

Copyright 2016 NPR. To see more, visit NPR.
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How A Dog In An MRI Scanner Is Like Your Grandma At A Disco

NPR Health Blog - Thu, 09/08/2016 - 4:58am
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September 8, 20164:58 AM ET Heard on Morning Edition

A relaxed, undrugged dog patiently waits its turn in the MRI scanner. The scientists' trick: Make it seem fun.

Enikő Kubinyi/Science

Dogs can be trained to do a multitude of tasks. Most can learn to sit, lie and stay; others can guide the blind, rescue the injured and maybe even detect cancer. But the hardest thing of all might be to train them to do nothing. Stop scratching. Don't wag your tail. Don't drool. Don't even lick your chops.

My dog can heed the command "stay" for a total of about four seconds. And that's on a good day. So when I read the terms of the recent study in the journal Science — dogs had to lie still for eight minutes straight in a clanging MRI machine, while wearing earphones and a radiofrequency coil — I had to talk to the researchers.

Shots - Health News Their Masters' Voices: Dogs Understand Tone And Meaning Of Words

Marta Gacsi, a behaviorial scientist at Eotvos Lorand University in Budapest, was responsible for training the dogs and is a co-author of the study by the Family Dog Project that's exploring how dogs understand and process human language.

"The dogs were not restrained in any way," Gacsi said. "We didn't apply any restraints to keep the dogs in the desired position or in the scanner. They could leave the tube and the scanner at any time they wanted to — and sometimes they did."

The dogs also had to be fully awake inside the scanner, she explained, as their owners talked to them. They could not be drugged. That would have thrown off the results. Oh, and they also had to learn to wear headphones and a radiofrequency coil — and lie still with their head between their paws.

My dog would never do that. Actually, Gacsi insisted, the easy part was teaching them to wear headphones. It's no different than training a puppy to wear a collar, she said.

Still, some of the best-trained dogs — those you might think would be ideal for this study — could not stay still for more than a minute or two and had to be kicked out of the experiment.

"They couldn't stand this," Gacsi said. The dogs were so attuned to the trainers' wishes, they couldn't relax. "OK, I've been lying for two minutes," these smart, good dogs seemed to say. "Now tell me what to do!"

Because those dogs got so frustrated, Gacsi said, "we couldn't use them. They couldn't understand the task was doing nothing."

So what was the trick to getting them to lie still inside an fMRI scanner for an entire eight minutes, with the machine horrifically banging away?

The secret, Gacsi said, was to convince the dogs that the whole thing was fun — that the MRI machine is the place where all the cool dogs party. Before the experiment actually began, all the dogs were invited in — they were praised, got lots of treats. Everyone was having a great time in the scanner.

To get a better sense of the scientists' strategy, Gacsi said, think about how you'd persuade your grandmother to enjoy going to a disco.

"It's noisy," Gacsi pointed out. "So many people! It smells. It doesn't seem fun for a grandma." But throw in some good food, or Grandma's favorite cocktail, and some fun, happy companions, and she might be persuaded.

"We tricked our dogs that we are happy to be there," she said. "So they wanted to be part of the party."

Not every dog, in the end, was persuaded to stay at this particular "disco." For the canines that were left, another difficult moment arose when the researchers had to take away the food reward. A disco without cocktails and salty snacks. Oh, and no dancing.

"They had to be absolutely motionless," Gacsi said. "They couldn't move their mouths; they couldn't swallow. ... They couldn't even expect food because of the drooling problem. They couldn't even think of cheese!"

Now, instead of using cheese bribes, the researchers solely rewarded the dogs with praise.

Each pup learned to stay longer and longer on the table, earning ever more praise. In the end, the scientists ended up with 13 dogs that could understand that they would get a treat at the end of the experiment — but only if they stayed still. Very, very still.

Try that at home.

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How Much Do Drugs For Rare Diseases Add To Health Care Spending?

NPR Health Blog - Wed, 09/07/2016 - 4:19pm

How big a deal is the spending on drugs for rare diseases?

Mark Airs/Ikon Images/Getty Images

Rising concerns about spending on prescription drugs that treat rare diseases are overblown, according to an analysis published Wednesday in the journal Health Affairs.

"We wanted to focus on the true impact of orphan drugs," said Victoria Divino, a senior consultant at IMS Health and an author of the study. Researchers at IMS Health, a health care analytics firm, and drugmaker Celgene Corp. looked at U.S. pharmaceutical spending from 2007 to 2013 on more than 300 drugs that had orphan approval under the 1983 Orphan Drug Act.

The Orphan Drug Act has long been considered a success for encouraging the production of hundreds of drugs for rare diseases. But the law's very success has raised economic concerns as the number of high-priced drugs for rare diseases has grown.

The review found that orphan drug spending in the United States totaled $15 billion in 2007 and $30 billion in 2013, an increase from 4.8 percent of total pharmaceutical spending to 8.9 percent. The current study projects orphan drug spending will remain fairly stable as a proportion of total drug spending. That stands in contrast to other published reports that estimate orphan drugs will account for 20 percent of worldwide spending on drugs (other than generics) by 2020.

The rise in orphan drug spending since 2007, Divino said, was caused by an increase in the number of orphan drugs approved by the Food and Drug Administration. The number of orphan drug approvals increased from 16 in 2007 to 33 in 2013, the analysis' time period.

The Health Affairs article is the latest in a growing debate about the causes of high prescription drug prices and how orphan drugs may play a role. Drugs that win orphan approval have been cited for commanding premium prices, costing up to $300,000 per year or more, according to market research reports.

The Orphan Drug Act provides a seven-year exclusivity period that blocks competition and other financial incentives to companies that develop drugs for diseases that affect fewer than 200,000 people.

The pharmaceutical industry's interest in orphan drugs has escalated in recent years and, increasingly, doctors and researchers have raised questions about unintended consequences of the act.

Celgene has been one of the top beneficiaries of the orphan drug law. The company's flagship drug Revlimid, which has orphan status for multiple myeloma and many other cancers, had sales of $5.8 billion in 2015. Evaluate Ltd., a London-based research firm, forecasts that Celgene will become the No. 1 orphan drug company in world, as measured by sales, in 2020.

"When those financial incentives become sort of an investment opportunity to take advantage of the Orphan Drug Act. That's a huge, huge concern," said Clare Krusing, a spokeswoman for America's Health Insurance Plans, a national association for health insurance companies. AHIP released a paper in August that questioned prices on orphan drugs when they were being used outside of their approved orphan indication.

For the Health Affairs paper, Divino and her team narrowed their analysis to orphan drug spending on drugs when they were used only on the rare diseases they were approved to treat under the act. The researchers used a database estimated to represent 98 percent of overall U.S. sales.

"The number of orphan drugs is increasing but when we look at this line of the actual spending and the forecast as well ... yes, there is growth but it's a consistent linear trend," Divino said.

Still, the authors' write, "in a broader context, drug expenditures are minimal when considered as part of total health care expenditures." Total orphan drug spending represented approximately 1 percent of total U.S. health care spending, according to the authors.

Divino said the study's focus was on aggregate spending and they didn't look at the effect of orphan drug prices on individual patients.

In an email statement, the pharmaceutical industry trade group PhRMA, said the study "reinforces that the overall impact of orphan medicines on payer budgets is relatively small and contrary to rhetoric, the percentage of medicines with both orphan and non-orphan indications is small."

But AHIP and others say that not including the cost of orphans when they aren't used to treat rare diseases skews the pricing issue for patients.

"It's not really the true orphans we worry about. It's about the other types of gaming and abusing the orphan drug act which drives up expenditures," AHIP's Krusing said.

Researchers at Johns Hopkins Medicine called on lawmakers last year to close loopholes in the act, saying the law's financial incentives encouraged high prices and motivated companies to apply for orphan designation even when a drug is known to treat more common conditions.

The paper, published in the American Journal of Clinical Oncology, noted that seven of the top-10 selling drugs worldwide in 2014 had received orphan status. Those listed included popular drug such as Crestor, a cholesterol fighter, and Humira, for rheumatoid arthritis and Crohn's disease.

"There are a lot of factors I think that have come up in pricing in general, but what people are getting a glimpse of is the sheer greed," said Dr. Martin Makary, an author of the 2015 paper and professor of health policy at Johns Hopkins School of Public Health.

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation. Follow Sarah Jane Tribble on Twitter: @sjtribble.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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EpiPen's Dominance Driven By Competitors' Stumbles And Tragic Deaths

NPR Health Blog - Wed, 09/07/2016 - 12:52pm

Mylan lobbied state legislatures for laws that require schools to stock EpiPens.

Rich Pedroncelli/AP

Thirteen year-old Natalie Giorgi probably didn't know the name of the company that makes EpiPen. But the Sacramento, Calif., girl's death from a peanut-induced allergy attack in 2013 inspired passage of the California law that made the Mylan product a staple at every school in the state.

It was Giorgi's story, not industry lobbying, that state Senate Minority Leader Bob Huff says inspired him to usher through the requirement that public schools stock the injectors. He says he was also influenced by one of his staffers, who has a child with life-threatening allergies.

"It was just sort of organic," Huff says about carrying the bill. "It seemed like we ought to do better to protect these kids."

Mylan, the company that raked in $1 billion last year for the EpiPen, takes credit for passing legislation in 48 states to ensure schools have them. But its political maneuvering is only one reason the company has, in its own words, become "the number one dispensed epinephrine autoinjector."

High-profile deaths in several states, particularly among school-age children, have helped fuel demand for consumer-dispensed epinephrine. At the same time, no other company has been able to effectively compete with Mylan's drug-delivery device. Patent rules, and competitors' manufacturing foibles, also have helped the company reign over the consumer epinephrine market.

When someone with a severe allergy goes into anaphylactic shock and can't breathe, "seconds count," Mylan CEO Heather Bresch said in a recent CNBC interview about the EpiPen, which now has a sticker price of $608 per two-pack. That's why, she said, "they need to be everywhere."

Bresch said lobbying is just one way the company has spent hundreds of millions "developing" the EpiPen since it acquired the patent in 2007.

Indeed, Mylan's presence in statehouses across the country has grown exponentially. The company added lobbyists in 36 states between 2010 and 2014, according to the Center for Public Integrity, outpacing every other U.S. company. And it spent more than $1.3 million lobbying in 16 states since 2012, according to the National Institute on Money in State Politics (Those are not the exact states that passed the school requirements, however.)

Just in the past several years, 10 states have passed laws requiring epinephrine in schools. Another 38 states have passed laws permitting them, according to the Food Allergy Research and Education advocacy group (FARE).

Nebraska appears to have been the first state with a school epinephrine requirement. High asthma rates in the state, as well as a couple of school-based child fatalities due to the respiratory illness, created an emergency response protocol that became law in 2006.

In California's case, Huff said he had never even heard of Mylan until the recent uproar over the EpiPen price increases. But the company is listed as a supporter of his bill, and FARE, which is partially funded by Mylan, was an official sponsor.

Heather Bresch, CEO of Mylan, says that EpiPens "need to be everywhere."

Michael Nagle/Bloomberg via Getty Images

FARE asserts that Mylan's money goes toward its education work, not its advocacy. It didn't disclose exactly how much of its funding comes from Mylan, but says funding from corporate partners amounts to less than 10 percent of its budget. (On Wednesday, the organization said it would not take funding from companies selling the devices until there was "meaningful competition.")

"In some states, momentum has been garnered by a fatality," says Jennifer Jobrack, senior national director of Advocacy at FARE, who says local lawmakers and activists call them in for help to craft policy.

"Legislators are looking for something they know will have a positive impact," Jobrack says.

Virginia's law, passed in 2012, came after 7-year-old Amarria Johnson died at a Chesterfield County school from a reaction to peanuts. A Texas teenager's death from fire ant bites led to that state's law permitting epinephrine in schools.

The push to require EpiPens got a high-level boost in 2013, as President Obama disclosed his daughter Malia's peanut allergy when he signed off on the federal law, which gives financial incentives to states that require the medication in schools. Co-author of the federal legislation, Rep. Steny Hoyer, D-Md., cited his 11-year-old granddaughter's peanut allergy when the EpiPen law passed the House. FARE and Mylan supported that as well.

With the help of these laws, Mylan's EpiPens are at 63,000 schools nationwide. The company also has distributed 500,000 of them for free through EpiPens4Schools.

The school giveaway program brings visibility and credibility to the EpiPen brand, building a consumer base beyond schools.

"It's kind of like the first hit's for free," says Nicholson Price, an assistant professor at the University of Michigan Law School. "You want to start people off with your product, and getting these products in at schools is a great way."

New York State's attorney general announced Tuesday it will investigate Mylan to determine whether it introduced "anticompetitive terms" into school contracts. STAT recently reported that participants of Mylan's EpiPen4schools program had to agree not to purchase EpiPen-like products for 12 months in order to get a discount.

Mylan also has a virtual monopoly on epinephrine autoinjectors simply because there are almost no other products like it, either branded or generic.

Mylan has a patent on the drug-device combo until 2025. If companies want to make a generic EpiPen, they have to sue Mylan in court to try to invalidate its exclusive rights on the injector, according to Jacob Sherkow, an associate professor at New York Law School.

Trying to create an EpiPen generic is an expensive and risky endeavor, says Sherkow. Even if a company is successful in court, manufacturing the device, which must be identical to the EpiPen, is also challenging.

Copying a chemical compound, like ibuprofen, is easier than reproducing a piece of hardware like the iPhone, says Sherkow. Patents are publicly available, and can act as an "instruction manual," but a lot can go wrong in the actual production of EpiPen syringes.

"The drug inside can't degrade or leak; they need to withstand shipping; they need to work at a wide range of temperatures; they need to be handled safely — to not accidentally inject the user with the needle," says Sherkow.

Teva Pharmaceuticals took on these challenges. It sued to invalidate Mylan's patent in court so that it could make a generic version of EpiPen, and successfully got the green light to do so through a settlement agreement. But Teva has yet to win FDA approval to release the product.

Other companies have tried to make their own version of the epinephrine injector without attempting to copy the EpiPen. But their efforts haven't been very successful either.

Amedra pharmaceuticals makes Adrenaclick, which has an injector with two caps (EpiPen has only one.) But Amedra has limited manufacturing capabilities for the device and a barely visible market share, according to Price.

Auvi-Q, made by Sanofi, was taken off the market in October 2015 after concerns the device wasn't dispensing the proper dose of epinephrine.

More epinephrine products will be on the market in 2017. Teva's generic version of the EpiPen is expected to be reintroduced then, and Mylan will put out its own generic in the coming weeks.

It's too early to tell if more consumer choices will bring down EpiPen's price.

This story is part of a collaboration between NPR and Kaiser Health News. Former Kaiser Health News intern Zhai Yun Tan contributed to this report.

Copyright 2016 Kaiser Health News. To see more, visit Kaiser Health News.
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