NPR Blogs

Wildfire Smoke Becomes The Health Threat That Won't Go Away

NPR Health Blog - Tue, 08/25/2015 - 4:35pm

Smoke rises from a wildfire approaching Twisp, Wash., on Aug. 19. Smoke can damage the health of people hundreds of miles downwind.

Ted S. Warren/AP

I stepped out my parents' front door last Thursday, expecting a typically glorious summer day in southern Oregon. Instead, I was hit with acrid wood smoke that stung my eyes and throat. The air was thick with haze that obscured the mountains. I quickly retreated inside.

Health departments across the West are mobilizing to protect residents from smoke generated by dozens of fires that have sent smoke as far east as the Midwest.

"It's really bad," says Janice Nolan, assistant vice president for national policy at the American Lung Association. "I hadn't seen 'code maroon' days, which is the most hazardous air quality, in years."

A screenshot of fire conditions on, with orange icons showing fires and gray representing smoke.

via AirNow

Lewiston, Idaho, is stewing under "very unhealthy" smoke, with older people, people with heart and lung disease and children urged to "avoid all physical activity outdoors."

And it's hardly the only city affected. Last weekend, Portland, Ore., which typically enjoys crystalline summer skies, was swathed in unhealthy levels of smoke that resembled wintry fog. It had drifted in from fires in Washington state.

"Unfortunately, this may be the new normal for us," says Jim Vannoy, program manager for environmental health programs at the Idaho Division of Public Health. "Not just for a day or two, but for weeks on end."

An extended drought and climate change mean more fires that burn longer, Vannoy says. The public health department is trying to get the word out through the state's smoke blog and social media, so people can learn how to protect themselves.

For schools, that means indoor recess and no outdoor sports practice when air quality levels are unhealthy, according to an advisory the public health department sent to Idaho schools.

Tiny particulates in smoke travel deep into the lungs, where they evade the body's defense systems, Nolen says. That poses an especially big threat to people with asthma, cardiovascular disease or lung diseases. Children are susceptible even if they're healthy, she says, because their lungs are still developing.

Staying inside is the best defense, Nolen says, with air conditioning set to recirculate air. Check the local air quality index before heading out. "If it's anything above a code green, people will be affected."

Face masks don't help, according to both Nolen and Vannoy. Lightweight masks used to fend off germs don't keep out fine particulates, and N95 masks that do are uncomfortable to wear all day. "We really hesitate to recommend face masks," Vannoy says. "We really want people to stay indoors."

The state may also consider establishing clean air shelters where people can get away from the smoke, he says.

If there's any silver lining, it's Vannoy's final recommendation: "We recommend not vacuuming." Most home vacuums don't have HEPA filters that catch tiny particles, he says. So if you're smoke afflicted, ditch the vac for the sake of public health.

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Why Your Doctor Won't Friend You On Facebook

NPR Health Blog - Tue, 08/25/2015 - 12:35pm

Patients of the Minnesota-based St. Cloud Medical Group can follow a public page on Facebook.

Meredith Rizzo/NPR

Doctors' practices are increasingly trying to reach their patients online. But don't expect your doctor to "friend" you on Facebook – at least, not just yet.

Physicians generally draw a line: Public professional pages – focused on medicine, similar to those other businesses offer – are catching on. Some might email with patients. But doctors aren't ready to share vacation photos and other more intimate details with patients, or even to advise them on medication or treatment options via private chats. They're hesitant to blur the lines between personal lives and professional work and nervous about the privacy issues that could arise in discussing specific medical concerns on most Internet platforms.

Some of that may eventually change. One group, the American College of Obstetricians and Gynecologists, broke new ground this year in its latest social media guidelines. It declined to advise members against becoming Facebook friends, instead leaving it to physicians to decide.

"If the physician or health care provider trusts the relationships enough ... we didn't feel like it was appropriate to really try to outlaw that," said Nathaniel DeNicola, an OB-GYN and clinical associate at the University of Pennsylvania, who helped write the ACOG guidelines.

But even the use of these professional pages raises questions: How secure are these forums for talking about often sensitive health information? When does using one complicate the doctor-patient relationship? Where should boundaries be drawn?

For patients, connecting with a physician's office or group practice on Facebook can be a simple way to keep up with basic health news. It's not unlike following a favorite sports team, your child's middle school or the local grocery store.

One Texas-based obstetrics and gynecology practice, for instance, uses a public Facebook page to share tips about pregnancy and childcare, with posts ranging from suggestions on how to stay cool in the summer to new research on effective exercise for post-birth weight gain. Practices have also been known to share healthy recipes, medical research news, and scheduling details for the flu shot season.

"I have people come up to me and say, 'I follow you on Facebook — thank you for posting this particular article. It helped me and my husband and my family,' " said Lisa Shaver, a primary care physician based in Portland, Ore.

But unless they're already friends, she won't add patients to her personal account, where, she said, she posts less health information and more cat videos.

Historically, professional groups including the American College of Physicians and American Academy of Family Physicians have advised against communicating through personal Facebook pages. The American Medical Association notes social media can be a valuable way to spread health information, but urged doctors in its 2010 guidelines to separate their personal and professional online identities to "maintain professional boundaries."

Finding ways to use Facebook and other forms of social media to connect with patients — even if it may just be through professional pages — fits a trend in which patients seek more equal footing with their doctors, said Zack Berger, an assistant professor of medicine at the Johns Hopkins School of Medicine who studies patient-doctor relationships and social media.

It also follows what James Colbert, a hospitalist at Massachusetts-based Newton Wellesley Hospital, described as the growing consumer approach to medicine, including the notion that patients should be able to reach their physicians at all hours. Colbert is also an instructor at Harvard Medical School who researches how patients want to fit social technology into their health care.

Email can be a particularly convenient method, though it isn't without concerns. Eva Schweber, 44, emails her doctor from a personal account and sends messages through an online portal — a more digitally secure system that is being adopted by a growing number of practices. The portal, she said, is for discussing complex, specific information. She'll email her doctor from her personal email for less private concerns: scheduling, filling prescriptions and asking if certain symptoms might warrant a checkup.

"The unsecure email is easier, in that I can do it from my phone, my tablet, whatever," said Schweber, of Portland, Ore.

In a recent study published in the Journal of General Internal Medicine, almost 20 percent of patient respondents reported trying to contact doctors through Facebook, and almost 40 percent through email. "Patients want to communicate with doctors [in whatever way] is convenient," said Joy Lee, a postdoctoral research fellow at the Johns Hopkins Bloomberg School of Public Health, and the study's lead author.

Doctors don't yet seem to share that enthusiasm, Colbert said.

Meanwhile, security questions persist.

Social networking platforms aren't usually digitally encrypted, increasing the odds they could get hacked or shared with third parties. The same worries hold true for other, casual forms of online communication such as email and text-messaging.

That means doctors who discuss specific health concerns with patients through those could break the Health Insurance Portability and Accountability Act, the patient privacy law.

"Those concerns are always going to be there," said David Fleming, past president of the American College of Physicians. "How private is it when we share, when we talk to people? ... Once I've written it or once I've emailed it, it's gone, and I have no control."

But because HIPAA was written before email and social media's ascent, it may not address patient preferences or behavior, Colbert said. With more patients becoming comfortable using personal accounts for health needs, he said, the law perhaps deserves another look.

"Should we allow patients to be able to share or send messages without going through these privacy safeguards if they're willing to do so? Or do we say that that's not safe and even if patients don't care about privacy we need to protect them," he said. "That's an open question."

That public nature is a real worry for patients like Katie Cardenas, 45, who lives in Garner, N.C. She doesn't think Facebook is secure enough for personal medical details. For sensitive information, she'll usually send messages through a patient portal, the more secure website her doctor's practice has set up.

Doctors could address that, several said, by using social media in other ways. These include maintaining active Twitter presences and professional Facebook pages for less-tailored health tips. That way, patients can get useful information and a sense of their doctors as people, but privacy stays intact and physicians maintain distance.

At the Minnesota-based St. Cloud Medical Group, patients can follow a public page. Doctors who are part of the practice post updates with safety tips and seasonal health reminders, or use the page to coordinate and publicize small projects, such as a week-long initiative geared to reducing children's screen time.

Julie Anderson, a family physician who is also part of the practice, sees the value in this option, but doesn't personally befriend patients on Facebook. Beyond patient privacy, she said, she fears blurring her personal and professional lives, or patients using that access to seek extra care when she's off the clock.

"I've known colleagues that have friended somebody and have had inappropriate questions asked online, in terms of kind of abusing service," she said. "Or abusing that ... Facebook friendship, where they're asking medical advice and you're not even their physician."

Copyright 2015 Kaiser Health News. To see more, visit
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Katrina Shut Down Charity Hospital But Led To More Primary Care

NPR Health Blog - Mon, 08/24/2015 - 12:40pm
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Attorney Ermence Parent stands on the porch of her New Orleans home. Two hip replacements eased Parent's pain and got her exercising again, she says. A doctor at one of the city's newly renovated clinics made the diagnosis.

Edmund D. Fountain for NPR

Five years ago, New Orleans attorney Ermence Parent was struggling to find out what was wrong with her leg. She was 58 years old, and her right leg hurt so much that she needed a cane. That was not only painful, but frustrating for a woman who routinely exercised and enjoyed it. Parent sought advice from several doctors and a chiropractor, but got no diagnosis.

Shots - Health News Katrina's Emotional Legacy Includes Pain, Grief And Resilience

Then she made an appointment at the newly renovated St. Thomas Community Health Center, a primary care clinic dedicated to providing quality care for people regardless of insurance status. Most patients, including Parent, are on Medicaid or Medicare. Some pay on a sliding scale. Parent saw internist Dr. Mary Abell, who is now medical director of the clinic.

Abell took a careful medical history, looked at Parent's X-rays and watched as she walked up and down the hallway

"'Baby, your hips are going,' " the doctor told Parent. The attorney had "bone-on-bone" arthritis. Without surgery, the doctor said, "'in about six months you're going to be in a wheelchair.' "

Instead, about a month later, Parent received her first hip replacement, and nine months later, her second.

Today, she's back to exercising, has lost weight and sleeps more soundly. "You know, changing those two hips just rejuvenated me; it gave me years back on my life," Parent says.

When Katrina hit in 2005, many health facilities were destroyed or otherwise shut down, including urgent care centers, nursing homes, pharmacies and hospitals. The renowned and beloved Charity Hospital, a public facility that had served the city's poor for centuries, was forced to close.

Many said the loss of the hospital was devastating. Charity represented a precious connection to health from childhood through old age.

But the attachment people felt to the old institution may have been based more in sentiment than fact, says Abell, especially when it came to primary care. She says patients had to rely on a trip to the emergency room if they didn't have health insurance and had ongoing chronic problems.

"Before Katrina, there was no primary care or preventive medicine — really, truthfully — for patients," Abell says. "None. Zero."

Back then, a patient with a medical problem that wasn't acute often had to wait months to schedule an appointment, she says. And once they showed up for the appointment, they might have to wait all day — or even end up with the wrong clinic or with the wrong physician. Abell says the situation was "very disrespectful" to patients.

Today is a "different day," Abell says. In recent years, a network of renovated and newly built primary care health clinics has opened, which she and New Orleans residents hope will bring a new degree of stability to the health care that the city's low-income residents get.

Katrina was devastating, Abell says, but after its ruin, New Orleans received a dramatic infusion of cash from the state and federal governments, and from private foundations. The funds resulted in new hospitals, new clinics and an enormous state-of-the-art facility that replaced the old Charity Hospital.

University Medical Center New Orleans on Aug. 1, when the $1 billion facility welcomed its first patients.

Brett Duke/The Times-Picayune/Landov

University Medical Center New Orleans, which opened this month, is just a few blocks from the shuttered hospital. The new facility's gleaming buildings, hundreds of patient beds and high-tech specialty care, stand in startling contrast to the old institution.

Abell has high hopes the new medical center will provide timely, excellent care for both acute and chronic needs. And her biggest praise is for the new network of primary care clinics.

"Today, a patient can call and get same-day primary care," Abell says, an improvement that Ermence Parent attests to, as well. A few months ago, when Parent's leg became swollen, she called the clinic and was seen right away.

In a recent poll of New Orleans residents by NPR and the Kaiser Family Foundation, 72 percent of adults agreed that progress has been made in the availability of medical facilities and services in the city. But the majority of residents — 64 percent — also said more needs to be done to provide care for people who are uninsured and have low incomes.

And among African-Americans, nearly half said they're very worried that health care services may not be available when they need them. Only 13 percent of white adults said they are very worried in that way.

According to Abell, one of the biggest remaining weaknesses in the current system in New Orleans is timely access to specialty care like orthopedics, neurology and cardiology.

It's a problem, she says, "when you can't get your patient in to be seen for an issue that's evolving, and you know that some specialty advice would be helpful." She says she's had to rely on personal connections ­— and 30-plus years of experience working in the city — to help her poorer patients gain timely access to specialty care. She's anticipating that the new University Medical Center will help remedy that.

That hope extends to mental health care, as well. Rashain Carriere-Williams, who directs program operations at Boys Town Louisiana, a community organization that helps troubled families and children, says the need for mental health treatment in the city is huge.

After Katrina, psychiatrists fled New Orleans, along with many other people. Unfortunately, Carriere-Williams says, most psychiatrists never came back. In the entire city, there are now only two or three psychiatrists who accept Medicaid and are willing to see her patients and their families, Carriere-Williams says.

"A lot of times it's easier to get them in to see a psychologist, because there are more of those," she says. But psychologists can't prescribe the medication some patients need.

Although the new hospital has some beds dedicated to patients in need of mental health treatment, the number of beds isn't nearly high enough, she says.

She's been faced with heartbreaking situations — including one New Orleans boy who recently threatened suicide and had to be placed on suicide watch. The only facility with an inpatient bed was a six-hour drive from the city. The family drove their child there for a 72-hour hold, and the child temporarily got the needed care, says Carriere-Williams. But the experience was grueling, at a time when the family was extremely fragile.

Carriere-Williams says she's hopeful the new clinics and hospitals will begin to fill the big gaps in the community's mental health needs. But, based on Louisiana's and New Orleans' history in that regard, she says, she's skeptical.

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Snooze Alert: A Sleep Disorder May Be Harming Your Body And Brain

NPR Health Blog - Mon, 08/24/2015 - 4:39am
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It's time for consumers to wake up to the risks of sleep disorders, scientists say.

More than 50 million adults in the U.S. have a disorder such as insomnia, restless leg syndrome or sleep apnea, according to an Institute of Medicine report. And it's now clear that a lack of sleep "not only increases the risk of errors and accidents, it also has adverse effects on the body and brain," according to Charles Czeisler, chief of the division of sleep and circadian disorders at Brigham and Women's Hospital in Boston.

Research in the past couple of decades has shown that a lack of sleep increases a person's risk for cardiovascular disease, diabetes, infections and maybe even Alzheimer's disease. Yet most sleep disorders go untreated.

Michael Arnott, of Cambridge, Mass., says he used to have trouble staying awake on long drives. Sleep specialists discovered he has obstructive sleep apnea, though not for the most common reasons — he isn't overweight, and doesn't smoke or take sedatives.

M. Scott Brauer for NPR

Michael Arnott, who is now 67, began having sleep problems in his 50s, he says. As a result, he often found himself having trouble staying awake during long drives on the Massachusetts Turnpike.

"I would get groggy and feel like I've got to keep talking, open the window," Arnott says.

His wife, Mary White, says being a passenger on those drives could be scary.

"All of a sudden there'd be a change in the speed and I'd look over, and his eyes would be starting to close," she remembers.

White thought her husband might have sleep apnea, which interferes with breathing. But Arnott was in denial. He figured he was free of most risk factors for apnea. He wasn't overweight, he didn't smoke or take sedatives, and he has always stayed in great shape.

"I'm a runner. I've run for more than 40 years," he says. "I used to do marathons. Now I just do 5- and 10-kilometer road races."

So his wife took the initiative. "I asked him to see a doctor and he wouldn't," she says. In 2012, though, White persuaded him to take part in a sleep research study that paid for his participation, and took place at a sleep lab in Boston, not too far from the couple's home in Cambridge.

Doctors found a couple of problems. "I've got what they call moderate obstructive sleep apnea," Arnott says. He also has a form of restless leg syndrome that causes him to kick during sleep.

Those conditions, along with his tendency to stay up late and wake up early, meant he wasn't getting enough quality sleep. And research in the past couple of decades has shown that's a problem even if you're not nodding off on the Massachusetts Turnpike.

Much of that research was done in the same sleep lab at Brigham and Women's Hospital where Arnott was diagnosed. The lab includes rooms that are completely isolated from the light, sounds and even vibrations of the outside world. As study participants sleep in these rooms, their brain waves, respiration, oxygen levels and other signs can be monitored from a central control room.

In highly controlled environments like this one, Czeisler and other researchers have shown that sleep affects everything from blood pressure to memory to metabolism.

"Within 2 1/2 weeks we can take someone who is young, healthy and fit and put them in a pre-diabetic state just by putting them on an irregular schedule," Czeisler says.

Research also has shown a strong connection between sleep and the immune system, Czeisler says. "People who are not getting sleep, if they're exposed to a virus like the adenovirus — that causes the common cold — they will have a 200 to 300 percent increased risk of actually catching a cold," he says.

Many studies suggest that a lack of sleep raises the risk of a heart attack or stroke. And most recently, Czeisler says, scientists have found evidence that the brain actually needs sleep to stay healthy.

"It's during sleep that we clear out many of the toxins that build up during wakefulness," Czeisler says. Among those toxins is beta-amyloid, which produces the sticky plaques that appear in the brains of people with Alzheimer's disease.

Most sleep disorders can be treated, but often they aren't. Arnott, the sleepy driver from Cambridge, didn't address his symptoms until his wife pushed him to take part in a sleep study.

When worn at night, the mask of a CPAP (continuous positive airway pressure) machine delivers enough air pressure to keep the upper airway passages open. Blocked passages are behind the poor sleep and other symptoms associated with obstructive sleep apnea.

Dr. P. Marazzi/Science Source

"My whole clinic is full of patients who are brought in by their spouses," says Dr. Andrew Wellman, a sleep specialist at Harvard and Brigham and Women's who has cared for Arnott.

When Wellman is assessing a new patient, he asks a simple question: "Do your eyelids get heavy when you'd prefer to be awake?" If the answer is yes, that is a very specific indication that someone isn't getting enough sleep. Symptoms such as fatigue or feeling tired are less specific, and can have other causes, he says.

Much of Wellman's practice is devoted to sleep apnea, which affects about 1 in 3 adult men and becomes more common with age.

Wellman says a sleep apnea diagnosis usually requires an overnight sleep study to measure the flow of air in and out of the lungs. "If that flow is diminished, then that is the primary measurement that we use to detect these sleep apnea events," he says.

The problem can be in the brain — a condition called central apnea. But more often the airway is getting blocked repeatedly during sleep, a disorder called obstructive sleep apnea.

Arnott has an unusual variant of obstructive sleep apnea, Wellman says. "His airway actually collapses at the epiglottis, which is a structure just below the base of the tongue that prevents food from going down in the airway."

Regardless of the cause, the go-to treatment for sleep apnea is a continuous positive airway pressure (CPAP) machine. Arnott tried one for three months and hated it.

Instead of relying on forced air to keep his airway open when he sleeps, Arnott now wears this soft oral appliance at night. The device is more comfortable than CPAP, he says, and has decreased his apnea symptoms to "negligible" or "mild."

M. Scott Brauer for NPR

"You have to have a mask on your face; you have a machine making noise all night, and you have to have electricity," he says. "We hike. We go to places in the White Mountains of New Hampshire and Maine, where electricity is not always there."

Complaints like those are pretty common among people using CPAP machines, Wellman says. "Somewhere around 50 percent of patients don't adhere to their therapy. Probably there are many people that don't even come to the sleep lab because they know they might get that breathing machine, and they don't want it."

One alternative is surgery to help keep the airway open. Another is an oral appliance that moves the lower jaw forward.

Arnott eventually switched to an oral appliance and has made a series of other changes. He sleeps on his side, which reduces apnea. He tries to get to bed at the same time each night. And he has begun doing yoga before bedtime, which he says helps with his restless leg syndrome.

Those steps have made a big difference, Arnott says. For one thing, he no longer falls asleep at the wheel. And now, he says, "There are times on long trips when Mary actually says, 'I'm getting groggy. You drive.' "

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After A Divorce, What Happens To A Couple's Frozen Embryos?

NPR Health Blog - Sat, 08/22/2015 - 7:29am
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Frozen sperm straws and embryos are stored in liquid nitrogen, in a process known as cryopreservation. One question confronting the courts: Should embryos such as these be treated as property, or as children subject to custody action?

Veronique Burger/Science Source

Soon after their wedding, Dr. Mimi Lee and Stephen Findley decided to create five embryos. Lee had just been diagnosed with breast cancer, and she worried that treatment would leave her infertile. Now that they're divorced, Lee wants to use them; Findley, however, does not.

Those embryos are at the heart of a court case that will soon decide a very modern problem: Which member of a divorced couple gets control of their frozen embryos?

For this San Francisco couple, at least, it would seem to be an open-and-shut case. Findley points to a clinic consent form the two of them signed, which stipulates that if the pair divorced, their embryos would be destroyed.

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But while a signed document might help, Judith Daar of Whittier Law School says it's not necessarily decisive. She says that courts have been all over the map on this issue — and points to one Massachusetts case in particular.

"There were seven contracts in that case, because the couple had seven rounds of IVF [In Vitro Fertilization], and all of them provided that she would get the embryos," Daar says. "But in the end, the court said that it would violate the public policy of that state to force the man to become a parent against his wishes."

That reasoning would favor Findley's argument — and Daar says that overall, courts have tended to side with the party who wants to avoid procreation. But Lee in this case has her own compelling argument.

"My client at this point in time is 46 years old, and just simply as a matter of her age she is virtually infertile," says Peter Skinner, the attorney for Lee. "She really doesn't have any other realistic option to have a biologically related child, other than to use the embryos that she created for that very purpose."

Skinner says no court has ruled against someone in that position. He also maintains that what Lee and her ex-husband signed is not a legally binding contract.

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The fertility clinic the couple used disagrees; it has sided with the ex-husband, whose attorneys did not respond to an interview request for this article.

And there's another difficult question at work here: Is an embryo a child? Judy Sperling-Newton, the director of the American Academy of Assisted Reproductive Technology Attorneys, says that courts have struggled to provide an answer.

"Whether an embryo belongs to the people who created it, as property would, as something else they would divide in a divorce," Sperling-Newton explains. "Or whether they're living beings and should be considered the way children would be considered in a custody action."

Daar, the law professor, offers another solution.

"The fact that technology got us into this problem is also suggestive of the fact that technology will eventually get us out of this problem," she says, suggesting that a breakthrough could spare couples the legal wrangling. It's now become possible to freeze unfertilized eggs — so, as with bank accounts, loving couples could choose to keep their gametes separate.

"And if they break up," she adds, "he can have his sperm, she can have her eggs, and they can dispute other matters in the relationship."

In other words, it might make matters not quite so emotionally — or legally — messy.

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Kansas Town Takes Dental Care To School

NPR Health Blog - Fri, 08/21/2015 - 10:38am

To make dental care more accessible, some schools are bringing dentists to students.


Weeks before school started in Olathe, Kan., earlier this month, the town's school district began its annual effort to get low-income students signed up for dental checkups.

When parents register at the elementary schools that serve the district's poorest students, they are asked whether their children have a dentist. "And if they say no, we say, 'We have a program in our school — a dentist is coming to our school this year,' " says health services director Cynthia Galemore.

The goal is to make dental care more accessible for low-income families. The obstacles to care aren't limited to cost.

"A lot of times in these families dental care is not a priority," says Galemore. "It's not that the parents wouldn't want to provide it, but they maybe can't miss work to take their child to the dentist, [or] they may not have transportation."

A lack of preventive dental care for poor children is a national problem. Medicaid and the Children's Health Insurance Program, which cover children from low-income families, both pay for dental services. But fewer than half of children and teens enrolled in those programs received a preventive dental service last year, according to Stacey Chazin, a public health specialist with the Center for Health Care Strategies.

The participating schools in Olathe, a suburb of Kansas City, Mo., are among a few hundred across the country that offer oral health care. "What's nice about the schools is [they're] a place where students already go on a regular basis, whether it's back to school night, or it's a meet-the-teacher, or to pick up or drop off their kids," says Chazin. In some schools, dentists provide care. In others, dental hygienists perform preventive services.

In a recent policy brief, Chazin recommends school-based oral health care as an important children's health strategy. And, as it turns out, the federal government set goals to increase the proportion of children enrolled in Medicaid and the Children's Health Insurance Program receiving any preventive dental service by 10 percent between 2011 and 2015.

Tooth decay is the most common chronic disease among American children, according to the American Academy of Pediatrics.

Some 25 percent of children ages 5 to 19 who live at or below the federal poverty level had untreated tooth decay, according to data from the Centers for Disease Control and Prevention. Only 12 percent of children with family incomes double that of poverty level had untreated tooth decay.

According to Chazin most school-based oral health programs focus on preventive services like cleanings, fluoride varnish and sealants – protective coatings placed over molars to prevent cavities. "The hope in all of it is that they're referred to, and begin to get care from a dentist, where they would subsequently go for regular preventive visits and any needed treatment," says Chazin. Medicaid and CHIP keep tallies of services performed at schools, when they are billed.

But it's difficult to know if parents are scheduling those follow-up dentist visits. That data are hard to track, and to Chazin's knowledge, no insurers or state health departments are taking the time to do it.

Olathe however, does have data on follow-ups. And that helped push the district to take the idea of in-school dental care one step further than most schools. At the start in 2009, the district tracked the number of follow-up appointments scheduled with dentists. The results weren't good. Of the 339 children treated in school by dental hygiene students from the University of Missouri-Kansas City, 63 percent had tooth decay and were referred to a dentist. By the end of the school year, only 11 percent of those referred had had their parents contact a dentist's office to schedule an appointment.

But when a clinic in town became a federally qualified health center in 2013, it opened up a new opportunity. The district now works with the clinic—which receives federal funds to provide free or low-cost care to the underserved— to bring dentists to the schools. These dentists perform the full array of services on site. It's a win-win for the school district: Nurses no longer have to worry about parents scheduling follow-up visits, because they are scheduled at school. And the clinic provides a steady source of funding for the district's growing number of immigrant students, some of whom don't qualify for insurance because of their undocumented status. If a student has no insurance, the service is free.

"We used to think, 'Oh, schools shouldn't do this.' We thought our job was to provide the education for the kids," Galemore says. "We didn't used to feed breakfast to kids at school either. Funding has been cut and cut and cut for schools, but it's part of focusing on the whole child. We know if we have better health for that child there's better learning."

For this school year, the oral health program in Olathe is expanding from 10 to 12 elementary schools, and adding two high schools.

This piece comes from Side Effects Public Media, a public radio reporting collaborative that explores the impacts of place, policy and economics on health. Follow Side Effects on social media here.

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Can Health Care Be Cured Of Racial Bias?

NPR Health Blog - Thu, 08/20/2015 - 4:14pm
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Jane Lazarre was pacing the hospital waiting room. Her son Khary, 18, had just had knee surgery, but the nurses weren't letting her in to see him.

"They told us he would be out of anesthesia in a few minutes," she remembers. "The minutes became an hour, the hour became two hours."

She and her husband called the surgeon in a panic. He said that Khary had come out of anesthesia violently — thrashing and flailing about. He told Lazarre that with most young people Khary's age, there wouldn't have been a problem. The doctors and nurses would have gently held him down.

"But with our son, since he was so 'large and powerful,' they were worried he might injure the medical staff," Lazarre says. "So they had to keep sending him back under the anesthesia."

Khary was 6 feet tall. But he was slim.

"He wasn't the giant they were describing him as," Lazarre says.

Lazarre is white. Her husband is black. Lazarre says there's no doubt in her mind that the medical team's fear of Khary was because of race.

"I understood, certainly not for the first time, that my son — and my sons both — were viewed as being dangerous, being potentially frightening to people who were white," she says.

She's also sure the surgeon didn't see it that way.

"Like most white people, I don't think he was conscious of it at all," Lazarre says.

She and her husband insisted on seeing Khary. They saw right away that he wasn't angry or violent.

"He was scared," Lazarre says. She and her husband leaned over and whispered in Khary's ear: "'It's going to be OK, you can calm down.' And he began coming out of the anesthesia more normally."

Lazarre first wrote about this experience in her book Beyond the Whiteness of Whiteness: Memoir of a White Mother of Black Sons. Though it's been years since Khary's surgery, Lazarre says there's still so much that hasn't changed.

Racial Disparity In Medical Treatment Persists

Even as the health of Americans has improved, the disparities in treatment and outcomes between white patients and black and Latino patients are almost as big as they were 50 years ago.

A growing body of research suggests that doctors' unconscious behavior plays a role in these statistics, and the Institute of Medicine of the National Academy of Sciences has called for more studies looking at discrimination and prejudice in health care.

For example, several studies show that African-American patients are often prescribed less pain medication than white patients with the same complaints. Black patients with chest pain are referred for advanced cardiac care less often than white patients with identical symptoms.

Doctors, nurses and other health workers don't mean to treat people differently, says Howard Ross, founder of management consulting firm Cook Ross, who has worked with many groups on diversity issues. But all these professionals harbor stereotypes that they're not aware they have, he says. Everybody does.

"This is normal human behavior," Ross says. "We can no more stop having bias than we can stop breathing."

Unconscious bias often surfaces when we're multitasking or when we're stressed, research shows. It comes up in tense situations where we don't have time to think – which can happen frequently in a hospital.

"You're dealing with people who are frightened, they're reactive," Ross says. "If you're doing triage in the emergency room, for example, you don't have time to sit back and contemplate, 'Why am I thinking about this?' You have to instantaneously react."

Shots - Health News Medical Schools Reboot For 21st Century

Doctors are trained to think fast, and to be confident in their decisions. "There's almost a trained arrogance," Ross says.

But some medical schools are now training budding physicians and other health professionals to be a bit more reflective — more alert to their own prejudice.

Places like the University of Texas Medical School at Houston, the University of Massachusetts, and the University of California, San Francisco now include formal lessons on unconscious bias as part of the curriculum.

New Approach Teaches Students To Recognize Bias — And Slow Down

At UCSF, all first year medical school students take a workshop led by Dr. Rene Salazar, who coaches other members of the medical team, too.

"A lot of folks come to San Francisco thinking, 'Oh it's such an open-minded place, there are no biases here,' " he tells a class of newly arrived pharmacy residents. "That's not true. You're going to see this in every hospital. It's going to be an issue."

What Salazar wants these students to talk about isn't other people's biases, but their own. And not just the biases they know they have. But the ones they don't know — or don't believe — they have.

"Like it or not, all of us hold unconscious beliefs about various social and identity groups," he says. "Many times we think about bias and unconscious bias — they are incompatible with our conscious values, right?"

Before the class, students were asked to take an implicit association test, a series of timed computer tests that measure unconscious attitudes around race, gender, age, weight and other categories. Salazar asks who wants to share their results.

The students study their fingernails.

Salazar clears his throat.

"Well, I can share with you my story," he says.

When he took the test for the first time, it showed that he had a preference for whites — or a bias against African-Americans. Research shows that 75 percent of people who take the race test show an automatic preference for whites.

"I was struck," he tells the students. "Particularly being in the health professions and wanting to serve diverse communities, to learn that I had these biases — it was a bit disheartening."

So he began to explore where these biases came from.

"I grew up in south Texas — 99 percent Mexican-American. Mostly Latino. In my high school, we had one black student," he tells the pharmacy residents. "And so, up until age 18, you can imagine, a lot of my ideas — a lot of my attitudes, a lot of my beliefs — about folks who were black came from what? The media."

Shots - Health News Medical School Hopefuls Grapple With Overhauled Entrance Exam

A student named Amanda raises her hand. She asks that we not use her last name because she's afraid that what she learned about herself could harm her career.

Amanda explains to the class that her parents made their way to the U.S. from Iran, and settled in Marin County, north of San Francisco. She took the version of the test that measures bias against Muslims, and another on light and dark skin tone.

"I kind of went in thinking that these are two areas that I would probably not have a bias, and that's kind of why I chose them," she says.

But the results were not what she expected.

"It was like, actually, 'You're biased and you don't like brown people and you don't like Muslims,' " she says. "Which is interesting for me — because that's, kind of, the two things that I am."

Traditional Diversity Training Didn't Work — And Sometimes Backfired

The UCSF curriculum is based on a training program designed by Howard Ross, the diversity consultant. He says he developed the new "unconscious bias" approach to sensitizing people to their own predjudices after realizing that the traditional diversity training he was doing in the '80s and '90s wasn't working.

"People who seemed to have transformative responses to those [earlier] trainings, to have that kind of 'aha' moment — particularly people in the dominant group, [of] whites, men, heterosexuals — often, if you talk to them a month or two later, they actually felt quite wounded by the experience," Ross says. In some cases, he adds, participants seemed to become more defensive and hardened in their biases after those early trainings, not less prejudiced.

A 2007 study described in the Harvard Business Review examined diversity training programs at more than 800 companies over 30 years, and the results underscore Ross's point. Overall, such programs seemed to do nothing to change people's prejudices or improve diversity. Instead, in some cases, they reinforced bias.

"What happens is, ultimately, we feel bad about ourselves, or bad about the person that made us feel that way," Ross says.

So rather than making people feel bad or awkward, Ross and Salazar say that, more than anything, they want people to accept that having biases is part of being human.

"You know we all have them," Salazar tells his class in San Francisco. "It's important to pause for a second and normalize this. And be OK with this."

Salazar emphasizes that unconscious bias can't be eliminated, but it can be managed.

"So how do we address our bias? What do we do?"

One student says, "Slow down."

"Yeah," Salazar responds. "A trick that I use is that I pause before I walk in, take 10 seconds even, 15 seconds, just to try to clear your mind and go in with that clean slate."

It's too early to know if these new types of trainings that explore unconscious bias are actually having any effect on what goes on in the exam room. Participants fill out evaluation forms after the class, and these anecdotal self-reports are often positive. But, so far, there have been no formal studies to measure if anything in patient care has actually changed.

"What happens when that door closes? What happens in the interaction when I can't see the patient and the doctor talking?" Salazar says. "That's a little hard to capture."

Still, UCSF is betting the technique will help. Salazar and other leaders believe the younger generation of health care providers could help shift medicine — by learning early how to keep their own biases in check.

Copyright 2015 KQED Public Media. To see more, visit
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Does This Phylum Make Me Look Fat?

NPR Health Blog - Thu, 08/20/2015 - 10:35am

Bacillus subtilis may look like pasta under the microscope, but the bacteria are common in the gut of humans. Could the microbes be contributing to our belly fat? Too soon to tell, scientists say.

BSIP/UIG via Getty Images

We would all love a simple weight-loss plan. Beyond carbs and fats, some studies have hinted that a key group of gut microbes — from the phylum Firmicutes — might be more common among people who are overweight.

Thinner people, these studies suggest, might have more bacteria from the phylum known as Bacteroidetes. Maybe we just need to reestablish a Bacteroidetes-favoring gut to more easily lose weight, some people have said. A stack of diet books has already jumped on the notion.

But a computer analysis led by Katherine Pollard, a biostatistics professor at the University of California, San Francisco and a senior investigator at the Gladstone Institute, recently sifted through an ocean's worth of detailed data that's been collected on gut bacteria. Her analysis found no link between Firmicutes and obesity, after all.

If there's any real link between gut microbes and the size of your gut, it's not just the phylum of bacteria that matters, or maybe even the species, according to Pollard's results. A host of other factors that scientists are only beginning to understand probably contribute, too, she says.

Pollard discussed her team's analysis this month at a meeting of scientists in Seattle.

The technology for investigating the microbiome has been improving fast. Researchers can now detect and identify many of the different species of bacteria in your gut — not just phylum, class, order, family or genus.

But, that's created a new problem, Pollard says. It's one thing to identify the whole cast of microbial characters, and quite another to figure out what the microbes are actually doing in there. The same species of bacteria might act differently in my gut than in yours and the technology used in these big studies doesn't detect that level of detail.

"What matters to the human host," Pollard says, "is not the Latin names of the microbes" but what each microbe produces — whether that's anti-inflammatory molecules, vitamins, or factors that speed the conversion of extra calories we eat into body fat. (The scientists published a formal description of some of their data-crunching finds late last year in the journal PLOS ONE.)

"Individual microbial species can have widely variable genomes," says William Anton Walters, a researcher in molecular biology and genetics at Cornell University. Any given bacterium may share less than half of its genes with another member of the same species. These genetic differences, rather than phylum or even species designations, Walters says, "could explain the differences between the obese and lean gut microbiota."

Greg Gloor, a professor of biochemistry at the University of Western Ontario, agrees that Pollard and her team are on the right track, as they analyze massive amounts of data of all sorts, looking for trends. The results indicate "that there is more strain-level variation in the microbiome than we have appreciated," Gloor tells Shots in an email.

We know, for example, that some strains of E. coli can be harmless to humans, but that others can sicken or even kill us. Why should we expect other strains of gut bugs to be more uniform? "Bacteria are very diverse," Gloor says.

Gut bacteria may yet be found to play an important role in the extra pounds that plague some people, the scientists say. Walters points to work from studies of fecal transplants that have shown there are meaningful differences "in the gut microbiome of lean and obese individuals." The trick, he says, will be in figuring out more precisely what those differences are.

Katherine Harmon Courage is a contributing editor for Scientific American and a freelance journalist. Her next book, about the microbiome and diet, will be published by Random House in 2016. Follow her on Twitter: @KHCourage

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Price Rises For Ticket To A Quicker Drug Review By FDA

NPR Health Blog - Wed, 08/19/2015 - 3:20pm
Drew Kilb/Duke University's Fuqua School of Business

A deal struck between drugmakers AbbVie and United Therapeutics Wednesday set a record price for a voucher that can be redeemed for a fast-track review of a new medicine by the Food and Drug Administration.

AbbVie, marketer of Humira and AndroGel, has agreed to pay $350 million to United Therapeutics, a company specializing in treatments for rare diseases, for a ticket to the regulatory fast lane.

The tickets, or priority review vouchers as they're known, were created by Congress in 2007 to encourage the development of drugs for neglected tropical disease and rare illnesses affecting children.

Drugs like those aren't usually lucrative for companies. The priority review voucher was conceived of as a prize that would be given to companies that brought medicines for certain overlooked diseases to market.

The voucher entitles its holder to move a drug through the review line faster. FDA has to make a decision about a voucher drug in about six months rather than the 10 or so for a drug submitted without one.

There's no guarantee the FDA's decision will be an approval; the agency could just reject a drug faster.

Oh, there's one other important feature of the vouchers: They can be kept by the companies that won them or they can be sold to the highest bidder.

United Therapeutics got its voucher in March when the FDA approved a drug called Unituxin to treat pediatric neuroblastoma, a rare cancer in kids. Rather than keep the ticket, the company sold it. "We are very pleased to monetize our [voucher], and hope that this transaction will encourage others to join us in focusing development efforts on rare pediatric diseases," Roger Jeffs, president and co-CEO of United Therapeutics, said in a statement.

AbbVie, for its part, confirmed the terms of the deal in an email to Shots but declined to say what the company's plans are for the voucher.

Additional Information: $(function() { var pymParent = new pym.Parent( 'responsive-embed-voucher-prices-20150819', '', {} ); });

Duke University's David Ridley, whose academic work with two colleagues helped lay the foundation for the vouchers, told Shots in an email that the prices fetched by vouchers in 2015 "were in line with our expectations." A 2006 paper co-authored by Ridley pegged the value of a voucher at more than $300 million for a drug with the potential for blockbuster sales.

In May, French drugmaker Sanofi paid $245 million for a voucher. Last November, Gilead Sciences paid $125 million to Knight Therapeutics for a voucher that was awarded for the approval of a drug to treat leishmaniasis. All told, four vouchers have been sold.

Ridley said that "while the value of some vouchers might be around $300 million, the price might be lower if there are many sellers." He added, "United Therapeutics was lucky and/or smart that it was the only seller at a time when a buyer was eager to have a voucher."

On a related note, the FDA is expanding the illnesses that can earn companies a voucher. Chagas' disease and neurocysticercosis, a parasitic infection that can lead to epilepsy, have been added to the list of eligible conditions.

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Scientists Create Vomiting Machine To Learn How Norovirus Spreads

NPR Health Blog - Wed, 08/19/2015 - 2:04pm

The vomit machine.

Courtesy of Grace Tung-Thompson

Norovirus is a huge public health problem, sickening as many as 21 million people a year in the U.S. But for all the gastric distress it causes, there are still some basic, unanswered questions about the virus.

One biggie: When an ill person vomits, does norovirus become aerosolized? That is, can an ill person's vomiting launch tiny viral particles into the air, where they might waft into your mouth or onto surfaces that you would later touch?

If you're now grossed out, you have good reason. Studies of the infection patterns that occur in outbreaks suggest that norovirus can indeed be aerosolized. And now there's some experimental evidence to add to that.

Researchers at North Carolina State and Wake Forest universities wanted to know what happens to norovirus when it's vomited out. "We first talked to a gastroenterologist and looked through the literature about what's known about vomiting," says Lee-Ann Jaykus, a food microbiologist at N.C. State and an author of the study. Not as much as you might think, it turns out. So the researchers worked with a civil engineer to construct a one-quarter scale vomiting device based on what is known about pressure, volume and other vomit metrics.

The device allowed the researchers to control the volume, viscosity and pressure of the simulated vomiting incidents. Jell-O instant pudding was added to make the lab vomit thicker.

Then they ran a series of experiments, changing the variables to simulate a range of vomiting behavior. They even ran one series of incidents with post-vomit retches.

The vomit machine and vomit chamber.

Courtesy of Grace Tung-Thompson

Though they conducted the experiments in a sealed Plexiglas box under a biosafety hood, norovirus was still too dangerous to use. A person sick with norovirus can spread billions of infectious particles, and only 18 are enough to make another person ill, the Centers for Disease Control and Prevention says.

So the researchers enlisted a harmless stand-in, a bacteriophage that is often used in place of norovirus in experiments. Only a fraction of virus particles were aerosolized during a typical vomiting incident. But there were definitely enough to make you sick.

The results appear in the journal PLOS ONE.

Another recent study collected air samples from eight health care facilities during norovirus outbreaks and found viral particles outside patient rooms.

"Taken together, they start to paint a pretty good picture of why norovirus is so atrociously infectious," says Andrew Pavia, chief of the division of pediatric infectious diseases at the University of Utah and a spokesman for the Infectious Diseases Society of America.

Of course, though the researchers did their best to simulate human vomiting, they didn't do a complete mock-up of the human digestive system. (A robot named Vomiting Larry is more anatomically accurate, but is less precise with regard to pressure, says Pavia.) And while the bacteriophage was chosen because of its similarity to norovirus, it may not behave the same way when aerosolized, he says.

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

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FDA Approves First Drug To Boost Women's Sexual Desire

NPR Health Blog - Tue, 08/18/2015 - 6:46pm
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A daily pill called Addyi is the first medicine to be approved for the purpose of boosting women's sexual desire.

Allen G. Breed/AP

The Food and Drug Administration approved the first drug designed to increase a woman's libido.

The controversial decision was hailed by some doctors and advocates as a long-sought victory for women's health, but was condemned by others as irresponsible and dangerous.

The little pink pill, known generically as flibanserin, will be sold under the brand name Addyi beginning Oct. 17, according to its maker, Sprout Pharmaceuticals. The medicine is to be taken daily to treat premenopausal women suffering from hypoactive sexual desire disorder, which is essentially a sudden, unexplained loss of any desire to have sex.

"Addyi is a game changer, in my opinion, for women's health," said Cynthia Whitehead, Sprout's CEO. "For decades, millions of women have been waiting for a medical solution to restore their sexual desire. And I'm thrilled that today the decision is finally being turned over to women and their health care providers regarding their sexual health."

The pill has long history of controversy. The company and its supporters had essentially accused the FDA of being sexist for rejecting the drug twice before while approving Viagra and other drugs to help men with their sexual problems.

"For far too long we've reduced all things in the bedroom for men to biology, as witnessed by countless treatment options, and we've reduced all things for women to psychology," Whitehead says.

In June, Sprout finally convinced an FDA advisory committee to recommend the drug's approval by providing new studies to show it can safely boost a woman's sex drive, enabling them to have more satisfying sexual experiences.

The decision was welcomed by some doctors and women's advocates, who said they hoped it would open to the door to more drugs to help women with sexual problems.

"Clearly we need more than just one medication — women need to have an array of choices that meets their specific medical needs," says Terry O'Neill of the National Organization for Women. "So with this success I think there will be more development of more medications. And that is all to the good."

But the FDA's approval was being denounced by critics. They say Addyi doesn't work very well, if at all, and can cause troubling side effects.

According to the documents released in conjunction with the advisory panel's June meeting, three studies that compared Addyi with a placebo found that women using the drug had a median of 0.5 or 1.0 more satisfying sexual events a month, depending on the study. The median number of satisfactory sexual experiences each month before the drug test was two or three.

Some women faint when they take it. Others wake up so groggy the morning after it could be dangerous for them to drive to work. And there could be long-term risks from taking a psychoactive drug daily for years. Addyi works by altering the levels of three important neurotransmitters — norepinephrine, serotonin and dopamine.

"To have any chance of benefit from this drug they're going to have to take it every day for months on end, years," says Cindy Pearson of the National Women's Health Network. "We just don't know what the long-term effects will be of changing brain chemistry in this way."

In addition, some say the campaign to win approval for the drug has oversimplified human sexuality. They say Addyi is just another example of the pharmaceutical industry making what is normal human behavior for some people something people need to take a pill to fix. Some women naturally lose interest in sex, they say, or may lose interest in sex for other reasons, such as being in a bad relationship.

"This decision to approve flibanserin is a triumph of marketing over science," Pearson says.

The FDA is requiring the company and doctors to warn women not to drink alcohol while taking Addyi, to cut the risk they'll faint or wake up woozy. Women should also avoid taking Addyi with certain other drugs, including some medications used to treat yeast infections.

As part of the approval, Sprout has also agreed to conduct additional safety studies.

The company hopes many insurance companies will cover the new drug to the same level they cover drugs like Viagra. If so, Whitehead estimated it would cost women between $30 and $75 a month in out-of-pocket costs. The company is also planning to offset the expenses for women who don't have insurance so it doesn't cost them more than that, she said.

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High Cost Of Diabetes Drugs Often Goes Overlooked

NPR Health Blog - Tue, 08/18/2015 - 12:51pm

After the blood sugar check, it may be time for a diabetes medicine whose price has jumped.


When it comes to treating chronic conditions, diabetes drugs aren't nearly as sexy as say, Sovaldi, last year's breakthrough hepatitis C drug that offers a cure for the chronic liver infection at a price approaching six figures.

Yet an estimated 29 million people in the U.S. have diabetes — about 10 times the number of people with hepatitis C — and many of them will take diabetes drugs for the rest of their lives. Cost increases for both old and new drugs are forcing many to scramble to pay for them.

"Every week I see patients who can't afford their drugs," says Dr. Joel Zonszein, an endocrinologist who's director of the clinical diabetes center at Montefiore Medical Center in New York City.

Although some of the top-selling diabetes drugs like metformin are modestly priced generics, new brand-name drugs continue to be introduced that act in different ways to control blood sugar. They may be more effective and have fewer side effects, but the advances come at a price.

For the fourth year in a row, per person spending on diabetes drugs in 2014 was higher than it was for any other class of traditional drug, according to the Express Scripts 2014 drug trend report. Fewer than half of the prescriptions filled for diabetes treatments were generic.

"The cost of diabetes treatment has been increasing pretty rapidly," says Dr. Glen Stettin, senior vice president for clinical, research and new solutions at Express Scripts, which manages the pharmacy benefits for many companies.

An analysis of per capita health care spending in 2013 for people with diabetes found average costs were $14,999, roughly $10,000 higher than the average $4,305 in per capita spending for people without the disease. The study by the Health Care Cost Institute examined the health care claims of nearly 40 million people under age 65 who had employer-sponsored insurance with one of three large insurers.

Insurers and pharmacy benefit managers have increasingly devoted resources toward managing patients' prescription drugs. Requiring patients to try an older, cheaper drug before approving a newer one is common practice as are rules that require providers to get approval before prescribing pricey drugs.

Diabetes occurs when the body can't control the amount of sugar in the blood because of problems making or responding to the hormone insulin. High levels of blood sugar can cause damage to the heart and blood vessels, nerves, kidneys, eyes and feet, among other things.

About 90 percent of people who have diabetes have type 2 diabetes, which is linked to lifestyle factors such as obesity and inactivity. Type 1 diabetes, once called juvenile diabetes, commonly develops among children.

Insulin was considered a wonder drug when it was discovered in 1921. It remains a mainstay of treatment for millions of patients, and yet decades after its introduction there are still no generic forms of insulin available.

And while it's true that the lack of generic insulin has hindered price competition for the key diabetes medicine, some readers and listeners of an earlier NPR story on insulin prices pointed out that Wal-Mart pharmacies carry a house brand of insulin that costs about $25 a vial.

Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.

Copyright 2015 Kaiser Health News. To see more, visit
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Medicare Says Doctors Should Get Paid To Discuss End-Of-Life Issues

NPR Health Blog - Tue, 08/18/2015 - 4:48am
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Jo Ann Farwell, a retired social worker, has a brain tumor; she wanted to make sure her sons were clear about her end-of-life wishes. So, after talking with her doctor, she filled out a form that Oregon provides to ease those family conversations.

Alan Sylvestre/Kristian Foden-Vencil/Oregon Public Broadcasting

Remember so-called death panels?

When Congress debated the Affordable Care Act in 2009, the legislation included a provision that would have allowed Medicare to reimburse doctors when they meet with patients to talk about end-of-life care.

But then Sarah Palin loudly argued that such payments would lead to care being withheld from the elderly and disabled.

Her assertions greatly distressed Dr. Pamelyn Close, a palliative care specialist in Los Angeles.

"It did terrible damage to the concept of having this conversation," she says.

Amid the ensuing political uproar, Congress deleted the provision. And that, says Close, further discouraged doctors from initiating these talks.

"We just are not having these conversations often enough and soon enough," Close says. "Loved ones who are trying to always do the right thing end up being weighed with tremendous guilt and tremendous uncertainty without having had that conversation."

Shots - Health News Knowing How Doctors Die Can Change End-Of-Life Discussions

When done right, Close says, these nondirective counseling sessions often delve into end-of-life treatment options and legal documents, such as advance directives and living wills. The issues to be covered are complex and typically require a series of discussions.

Right now, Medicare pays for this sort of advanced care planning only if it happens during the first visit for new Medicare enrollees. But now the government is proposing that Medicare reimburse doctors for including these conversations in their practice, whenever they occur.

Already, some private insurance companies are starting to do just that.

Meanwhile, the Alliance Defending Freedom, a conservative Christian organization, has formally opposed Medicare's proposal.

"By paying doctors for these conversations, what we're doing is opening the door to directive counseling and coercion," says Catherine Glenn Foster, an attorney with the group. Foster says her organization supports end-of-life counseling and planning, but not in a doctor's office.

"A doctor is not really the person you'd want to be having it with — particularly not a general practitioner who would not be able to advise on the nuances of end-of-life care in the first place," she says.

But patients do seem to want these talks. A 2012 study by the California HealthCare Foundation found that 80 percent of Californians want to have an end-of-life conversation with their physician, but fewer than one in 10 has done so.

Many doctors who do initiate the discussions often do so on their own dime. More often, they don't have them at all, says Dr. Daniel Stone, an internist with Cedars-Sinai Medical Center in Los Angeles.

"When a doctor has patients scheduled every 15 minutes, it's difficult to have a face-to-face conversation about values and goals related to the end of life, which is one of the most sensitive topics that you can possibly discuss with a patient," Stone says.

Dr. Susan Tolle, an internist with the Center for Ethics in Health Care, at the Oregon Health and Science University, says the informality with which such conversations are held now means that family members may not be included. She's all for the proposed change.

"What it does is it gives this really important conversation dignity and standing," she says.

In Oregon, doctors have been squeezing end-of-life discussions into regular medical appointments for decades, under less-than-ideal circumstances. Over the past five years a quarter of a million Oregonians registered their wishes with a state registry. They use what's known as a POLST form, which stands for Physician Orders for Life Sustaining Treatment. A version been adopted by some other states, including New York, Washington and West Virginia.

Jo Ann Farwell, a retired Portland social worker, has completed one such form in Oregon.

Shots - Health News In Oregon, End Of Life Orders Help People Avoid The ICU

"I had surgery and had a prognosis of four to six months to live," she says, after she was diagnosed with a brain tumor.

Farwell talked to her doctor, and then filled out a POLST form to make sure her last hours are as comfortable as possible.

"I wouldn't want to be on tube-feeding," she says. "I wouldn't want to be resuscitated, or have mechanical ventilation, because that would probably prolong my dying, rather than giving me quality of life."

In the 1990s, health care workers all over Oregon recognized that the wishes of patients weren't being consistently followed. So the health care establishment worked with the state and with ethicists to prioritize end-of-life talks; the result was the POLST form.

Congressman Earl Blumenauer, a Democrat from Portland, has introduced the Medicare reimbursement legislation every session since 2009. Until now, he says, the federal government hasn't placed any value on helping people prepare for death, and he finds that ironic.

"The Medicare program will pay for literally thousands of medical procedures, many of them very expensive and complex, even if the person is at the latest stage of life and it may not do any good," he says.

From a purely financial point of view, the change could save money. But Blumenauer says that's not what's driving him.

"I don't care what people decide," he says. "If they want to die in an ICU with tubes up their nose, that's their choice. What we want is that people know what their choices are."

Farwell well remembers when her sister was dying from cancer.

"She never talked about death or dying," she says, "never talked about what she wanted at the end. It was very, very difficult for me to try to plan and give her care."

Farwell wants her sons to be in a better position when it comes to carrying out her wishes.

The federal government is now accepting public comment on the Medicare reimbursement proposal. It's expected to make a decision in November.

This story is part of NPR's reporting partnership with KPCC, Oregon Public Broadcasting and Kaiser Health News.

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Can You Teach A Computer To 'Feel' Suspense?

NPR Health Blog - Mon, 08/17/2015 - 3:21pm
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Daniel Craig plays James Bond in the film Casino Royale. Dramatis, a computer program, can detect suspense from this scene and rates it even higher as the plot thickens.

MGM/United Artists/Sony/The Kobal Collection

Siri is just the beginning.

Soon enough — like it or not — we are all going to be talking a lot more with computers, at least according to Brian O'Neill, a professor of computer science at Western New England University. They will be tutoring our students and tending to us in our old age. And a big part of their job will be telling stories.

It's about more than just entertainment. Teachers use storytelling in all subjects, including science and math classes. Doctors say understanding patients' stories improves health care. There's even evidence a good yarn can treat high blood pressure.

But O'Neill says there is a problem: Computers are boring storytellers.

"Right now we can get them to tell things that maybe are like very simple stories, but they're not interesting," he says. "And we're going to want those stories to be interesting."

The first step toward fixing this problem, as O'Neill sees it, is to teach computers how to recognize one of the key features of an entertaining story: suspense. To do that he needs a simple definition of suspense that he can program into a computer.

Here is the one he likes most: "We feel suspense when we have less and less hope for a character escaping a bad situation. The less hope we have, the more suspense we feel," he says.

Last year O'Neill wrote a computer program called Dramatis that he hoped, operating from that narrow definition, would be able to detect suspense in a Hollywood blockbuster. Dramatis can't actually watch a movie, but it can read a dumbed-down version of a script.

When the hero reaches a dangerous point in the plot, Dramatis asks itself: "If I were in this position, what could I do to get out?" In essence, it tries to imagine an escape plan. And the more implausible that plan seems, the more suspense Dramatis registers.

O'Neill and his colleagues put his computer program to the test by feeding it suspenseful movie scenes, including Grace Kelly's confrontation with a murderous neighbor in 1954's Rear Window, a very fateful moment for Professor Dumbledore in 2009's Harry Potter and the Half-Blood Prince and James Bond's treacherous poker game in 2006's Casino Royale.

Dramatis began dutifully reading and calculating.

In the Casino Royale scene, for example, Dramatis tracks 007 as he is poisoned by his archenemy during a poker game. Bond excuses himself, then swallows copious amounts of salt water to try to induce vomiting. But this first plan fails.

There is now less hope for a peaceful resolution for our protagonist and, accordingly, Dramatis increased the scene's suspense rating.

Next, Bond staggers out to his gadget-rigged Aston Martin and phones MI5 in London. The spy agency's doctors tell him to use a defibrillator to jump-start his heart immediately before he passes out. Bond hooks up the leads, and tries pressing the button to release a charge. But, over and over again, that doesn't work.

Dramatis, Brian O'Neill says, starts "feeling more suspense because we know what the plan was," and that plan is proving unsuccessful.

Finally, we learn that a wire is accidentally loose. And before Bond can reconnect it, he collapses from the poison.

"Now we have a much harder task, and we're going to feel even more suspense now," O'Neill says, "because it's much harder to come up with somebody else who can save James Bond."

In the end, Bond's sidekick Vesper Lynd zaps him back to life. But as things became worse for Bond, the Dramatis delivered higher and higher suspense ratings.

Since Dramatis had only been reading a written description of the scene, not watching it, O'Neill was later able to tweak the script to create a new version where Bond's escape is easier. O'Neill also created alternative, easier-to-escape versions of the Rear Window and Harry Potter sequences.

Finally, O'Neill had both Dramatis and human test subjects read both versions of the movie scenes and compare them. (Since Dramatis can only read — not watch — a movie, O'Neill gave the humans written descriptions of the movie scenes to level the playing field.) At the end of the experiment, the computer and the people were in agreement: The versions where heroes escape easier were less suspenseful to both readers.

So, does this mean Dramatis understands suspense as a human does?

Livia Polanyi, a professor of linguistics at Stanford University who specializes in narrative says this work is a meaningful advancement for computerized storytelling; Dramatis does a lot right.

But, she says, the computer still does not fully grasp what makes us feel suspense. It cannot detect music, anguished faces and, most importantly, the way we humans connect with the characters. If we don't care about them, we don't care what happens to them.

"I think we have to really account for what actually causes us to identify, to empathize and to care," Polanyi says.

Teaching empathy to a computer will take considerably more time, but for Brian O'Neill and other researchers trying to develop a less boring computer, Dramatis is a good first step.

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Microbe Mix May Play Role In Preterm Birth Risk

NPR Health Blog - Mon, 08/17/2015 - 3:03pm

Microbial diversity could be a factor in premature births.


The assortment of microbes in a pregnant woman's vagina appears to play a role in her chances of giving birth prematurely, new research suggests.

The study of 49 pregnant women, published in this week's Proceedings of the National Academy of Sciences, found that those who had a diverse array of microbes were more likely to give birth prematurely.

Though the study is small, the findings are the latest in a flood of new insights into the roles that microbes may play in human health.

In the latest study, David Relman, a professor of medicine, microbiology and immunology at Stanford University and his colleagues, took samples from 49 women weekly during their pregnancies and monthly after they had their babies.

Fifteen of the women ended up giving birth prematurely. Most of the women had microbes dominated by lactobacillus bacteria, which has previously been associated with better health. Those whose microbes were more diverse — having high levels of gardnerella and ureaplasma microbes and low levels of lactobacillus — were at increased risk for giving birth more than three weeks early, the researchers found.

In addition, all the women's microbes tended to change significantly after they had their babies, becoming significantly more diverse. That shift could help explain why women who have babies close together are more likely to have the subsequent baby prematurely, the researchers said.

Babies born prematurely are at increased risk for a host of health problems. While the findings need to be confirmed in a bigger study, the researchers say the findings may eventually help doctors identify women at risk for giving birth prematurely and find ways to prevent that from happening. For example, researchers may be able to find probiotics women could take to reduce their risk for premature births.

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A Change To Out-Of-Pocket Health Insurance Limits Irks Employers

NPR Health Blog - Mon, 08/17/2015 - 1:55pm

One of the health law's key protections was putting a cap on how much people can be required to pay out of pocket for medical care each year. Now some employers say the administration is unfairly changing the rules that determine how those limits are applied and that the changes will be costly.

In addition, the employers and some Republicans on Capitol Hill are questioning whether federal officials have the authority to modify those rules.

Under the health law, the maximum that a consumer with individual coverage can be required to pay in deductibles, copayments and coinsurance for in-network care is $6,600. People with family plans max out at $13,200. These limits apply to all plans except those that have grandfathered status under the law. Once someone hits the spending limit, the health plan pays 100 percent of the cost of medical care for the law's 10 essential health benefits, which cover most services.

Next year, the spending limits increase to $6,850 and $13,700, respectively.

In a rule published in February, the administration said that starting next year individuals must not be held financially responsible for more than the individual annual maximum spending limit, regardless of the type of plan they're in.

So under the provision for next year, even if a family plan has a $13,700 maximum out-of-pocket limit, no one in the family can be on the hook for more than $6,850 before the employer or insurer starts covering that person's medical bills at 100 percent.

As an example, consider the situation where a mother, father and child will be covered by a family plan with a $13,700 out-of-pocket spending limit. If the mother gets sick and has $10,000 in out-of-pocket spending, the health plan would have to start covering her care after she spent $6,850, even if the total family medical spending hadn't yet hit the plan's $13,700 out-of-pocket maximum.

Some family health plans already have per-person spending limits. But 68 percent of workers with a maximum out-of-pocket limit were in plans with a single, aggregate limit, according to the Kaiser Family Foundation's 2014 employer health benefits survey. (Kaiser Health News is an editorially independent program of the foundation.)

"The new cost-sharing limit shifts medical costs to employers for individuals who have not reached, and might never reach, the umbrella limit," according to a letter sent to the administration in June by the ERISA Industry Committee, a group representing large employers. "Many employers face a major plan design change or revision to the pricing structure to accommodate the additional cost."

The group wants the administration to withdraw its ruling.

In an August letter to Health and Human Services Secretary Sylvia Mathews Burwell, the chairmen of the House committees on Ways and Means, Energy and Commerce and Education and the Workforce also discussed the rule, questioning the administration's authority to institute the changes. The federal health law, the letter said, states that there are two distinct types of coverage, each with its own out-of-pocket limit.

"We have become increasingly concerned about agencies' actions to implement the law that appear to exceed the authority delegated to them by Congress," the Republican chairmen said in the letter.

The Department of Health and Human Services declined to comment on whether it is reconsidering its position on the issue.

Whether the administration will do so remains uncertain, but the effect on consumers is clear.

"This is an incredibly important protection for people who have significant health care costs," says JoAnn Volk, senior research fellow at Georgetown University's Center on Health Insurance Reforms. "This brings a whole new level of assurance that they didn't have before the Affordable Care Act."

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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'Play This Video Game And Call Me In The Morning'

NPR Health Blog - Mon, 08/17/2015 - 4:42am
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Can playing the Project Evo game really improve the brain's ability to deal with distractions? Its manufacturer thinks so.

Courtesy of Akili

I'm driving through a frozen world, where the roads are paved in ice. As I swerve left to avoid a miniature iceberg, a red fish flashes at the top of my screen. I'm supposed to tap all the red fish that pop up, but not the green fish or the blue. And I have to do this without crashing the car.

An unidentifiable, omnipresent game-meister says: "Doing one thing at a time is easy, but doing them both at the same time is where the magic happens!"

As I get better at the game, my brain is being trained to ignore distractions and stay focused — or, at least, that's the hypothesis of the neuroscientists who designed it.

The brain networks that control multitasking overlap with networks that control working memory and attention span. So some scientists believe that by playing this game — Project Evo — you can improve a range of cognitive skills and, by extension, relieve a range of symptoms associated with cognitive disorders.

"We've been through eight or nine completed clinical trials, in all cognitive disorders: ADHD, autism, depression," says Matt Omernick, executive creative director at Akili, the Northern California startup that's developing the game.

Shots - Health News Will Doctors Soon Be Prescribing Video Games For Mental Health?

Omernick worked at Lucas Arts for years, making Star Wars games, where players attack their enemies with light sabers. Now, he's working on Project Evo. It's a total switch in mission, from dreaming up best-sellers for the commercial market to designing games to treat mental health conditions.

"The qualities of a good video game, things that hook you, what makes the brain — snap — engage and go, could be a perfect vessel for actually delivering medicine," he says.

In fact, the creators believe their game will be so effective it might one day reduce or replace the drugs kids take for ADHD. But this kind of goal requires a totally different business model; before they can deliver their game to players, they first have to go through the Food and Drug Administration — the FDA.

"The first time those three letters were uttered in a group setting, everyone's like, 'Oooo, that's scary, do we want to do that?' " Omernick recalls.

Silicon Valley companies routinely avoid government regulation if at all possible; the process for FDA approval can be slow and expensive.

"If it says 'FDA approval needed' in the business plan, I myself scream in fear and run away," says Tim Chang, managing director at Mayfield Fund, a venture capital firm. He has never backed a company that wanted to go through the FDA.

Most startups can bring a new video game to market in six months. Going through the FDA approval process for medical devices could take three or four years — and cost millions of dollars.

A screenshot of Project Evo.

Courtesy of Akili

"That's what's been scary about going the regulatory path," Chang says. "You're waiting and waiting and waiting for FDA approval, going through all these different clinical tests, and you could run out of money easily before you get through that."

The worst fear is that the technology will become outdated by the time the FDA process is complete. Tech companies are constantly redesigning their software to keep up with competition and consumer habits. Chang says in four years a game could be obsolete.

"It's really out of sync with the way we think of product iteration," he says. "We're more on the order of days and real-time changes, where you're pushing out app updates every week."

On the other hand, Chang admits that going the regulatory route could really pay off. If the FDA gives its stamp of approval, doctors could prescribe the game. And that opens the door for insurance companies to pay for it.

"Then you're going into the land of the big, big budgets," Chang says.

Within in the health care field, some executives believe the commercial successes of online games like Angry Birds and Candy Crush could translate into the medical world. They see the potential of these games to not only make money — but to save money, too.

"When you look at the percentage of individuals that are playing video games [59 percent] and overlay that with the percentage of individuals that have chronic conditions or need some assistance from the medical perspective [45 percent], the relationship is pretty strong," says Willis Gee, director of information technology strategy and innovation at health insurer Cigna.

On one level, it's about competition. The Affordable Care Act has made it a lot easier for people to switch health plans. Cigna has to find ways to stand out.

"People want to do things that are fun," says Gee. "So, we have to be there with them."

It might seem like a strange vision for an industry known best for issuing denial letters. But Gee believes reimbursing patients to play games could cut other health costs — by promoting exercise and preventing disease, for example, or even reducing the amount of expensive drugs people take.

"As an industry, we're going to have to reorient ourselves around what it is we're really trying to do," he says. "And if, at the end of the day, the goal is about improving health, then we may need to revisit the way we are quantifying outcomes."

Drug companies are keeping an eye on these games, too. Pfizer partnered with the Project Evo team to see if the game could help improve the diagnosis of Alzheimer's disease. The drug manufacturer believes it could alleviate some of the problems with drug trials — helping to make them faster, cheaper and more efficient.

Right now, screening for Alzheimer's is subjective. Patients and families fill out forms on mood and attention. The results are often inaccurate. Some of the people recruited for drug trials end up not having Alzheimer's at all. Dr. Michael Ehlers, Pfizer's chief scientific officer for neuroscience, says Project Evo could help them identify better candidates more quickly.

"I'd like to think we could cut down standard clinical trials, in size and length of time, by half or more," he says.

In terms of the game replacing drugs someday, though, Ehlers isn't so sure. He has a different analogy.

"It's just essentially a digital version of otherwise typical kinds of psychological and cognitive behavioral therapy," he says.

But, Ehlers still thinks game designers should go through the same FDA tests and trials as drug manufacturers.

"Quite important is that we hold them to the same standard of evidence that they actually work," he says.

Here, Ehlers touches on a broader controversy around games like Project Evo. There are several scientists who say this field is so new that it's lacking in good evidence that brain changes actually occur.

Randall Engle of the Georgia Institute of Technology believes giving the game FDA approval could hinder good science.

"Because it's a proprietary thing at that point — and that's a problem. If it becomes proprietary, the only people who can do unfettered research on it are the people who own the procedure," he says.

But, then again, that's exactly how it works with drugs.

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When Rehab Might Help An Addict — But Insurance Won't Cover It

NPR Health Blog - Sun, 08/16/2015 - 7:41am
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Cris and Valerie Fiore hold one of their favorite pictures of their sons Anthony (with the dark hair) and Nick. Anthony died from a heroin overdose in May 2014 at the age of 24. Cris Fiore's eulogy described his son's death as a shock, but "not a surprise." Anthony had been addicted to heroin for years.

Ben Allen/WITF

The latest numbers show that deaths from heroin-related overdose more than tripled nationally between 2002 and 2013. Opiate addiction touches every demographic: white, black, Hispanic, rural, suburban and urban.

Shots - Health News Heroin Use Surges, Especially Among Women And Whites

Proposed solutions nationally include more government funding for treatment, tougher penalties for dealers, and proactive interventions to stop people before they start.

Now, a couple of parents who lost their son to a heroin overdose are pointing out that drug addiction doesn't tend to be treated like a disease in the United States — which means that when drug users want to get treatment, health insurance coverage often comes up short.

And until the prevailing thinking changes, these parents say, progress will only be made on the edges.

'Your Insurance Will Not Cover Any More'

Growing up in the Philadelphia suburb of Warrington, Anthony Fiore checked all the boxes for a typical American guy. He'd go to the gym, play video games and watch football — in his case, the Eagles. His mom, Valerie Fiore, was proud of him.

"Anthony was very intelligent," she says. "He breezed through his high school, Central Bucks South — he never studied. He aced his SATs. He got right into Penn State's main campus."

But before he could get to Penn State, the powerful painkiller Oxycontin got hold of him. Soon afterward, he moved on to heroin.

In May 2011, Anthony tried a 21-day rehabilitation stint in Florida. About a year later, he checked in to another facility, but only for 11 days. By the third attempt at inpatient rehab, Anthony said he really wanted to get help and would stick it out.

"That was a 21-day treatment. And that's when I had Premera Blue Cross," Fiore says. She begged the staff at the rehab-center to keep treating her son at their facility for longer than 21 days. "And that gentleman said to me, 'Your insurance will not cover any more.' "

The family couldn't afford to foot the bill for a longer stay, Valerie Fiore says. So Anthony left that facility in November 2013. Six months later, he was dead of a heroin overdose.

In a written response to the case, Premera Blue Cross said that its medical policies are informed by national experts.

Every case is different, but for most severe addiction problems, many treatment professionals recommend a sober inpatient stay of three to six weeks, plus intensive outpatient treatment that can include drugs like suboxone or methadone to ease the effects of cravings.

Clare Krusing with the trade group America's Health Insurance Plans says that when making a decision about whether or not to pay for a particular treatment, insurance plans are looking at effectiveness.

"It's taking into account the patient's health and how they respond to those treatments," she says. "There are many cases where, if patients need additional care and support, that is provided to them."

Valerie Fiore is skeptical; she says Anthony met the criteria for a longer stay.

Do Insurers Treat Addiction Like Other Illnesses, As Required?

Deb Beck, who represents the Drug and Alcohol Service Providers Organization of Pennsylvania, says she hears stories like Anthony's all the time. Facilities battle insurers to cover longer stays for patients, she says.

"The whole thing about who is worthy to have insurance coverage gets tangled into this," Beck says. "But if I had a heart problem, and I didn't do everything I was supposed to, I would not be denied coverage. In fact, if I got sicker, you would increase the coverage for me."

Under a 2008 federal law, insurers have to consider drug and alcohol addiction the same as any other medical problem, as far as access to treatment goes. The Department of Labor says it has investigated at least 140 claims in which a patient's parity rights were violated. All those claims have been resolved through discussions with the insurers, the agency says.

But advocates say the information isn't public, and no fines have been issued.

Krusing, with the insurance industry's trade group, says when treatment for addiction is so different from treatments for medical issues, it's hard to figure out exactly what parity looks like.

"When you're comparing those treatment plans, it's essentially comparing apples and oranges," she says. "And that's an inherent challenge for health plans, and for patients and for their providers."

But Sam Ball, the CEO of CASAColumbia, a substance abuse and addiction research organization, says insurance companies should recognize a longer inpatient stay that allows people to break away from bad influences.

Shots - Health News What Heroin Addiction Tells Us About Changing Bad Habits

"[It] ... gives more time for planning about where they should be living after they get out of treatment," he says. "It also gives more time to be doing more extensive training on coping skills that they'll need once they leave the hospital or the program."

Meanwhile, Valerie Fiore is trying to cope with her son's death from overdose. She says she cries herself to sleep every night. Sometimes she sleeps in his bed. "I don't know," she says. "It maybe just makes me feel closer to him."

She says she's pushing for a change to the Affordable Care Act that would require insurance firms to offer at least 90 days of inpatient treatment in similar cases of drug addiction.

So far, Fiore has collected more than 30,000 signatures online. Many of the petitioners say they're endorsing the change on behalf of a relative, or a friend or themselves.

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Engineers Make Narcotics With Yeast. Is Home-Brewed Heroin Next?

NPR Health Blog - Fri, 08/14/2015 - 5:10am
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This genetically modified yeast can convert sugar into powerful opioid drugs. Scientists working with the modified yeast strains are required to register them with the Drug Enforcement Administration and keep the yeast under lock and key.

Courtesy of Christina Smolke/Stanford University

When bioengineer Christina Smolke started her own research lab, she was only 29-years-old. But that didn't stop her from setting colossal goals.

Smolke immediately began to work on what many considered to be a holy grail in bioengineering: yeast that can literally brew narcotic drugs. Achieving that, she knew, could open the door to the quick development of better medications of all sorts.

"When we started this work, you know, there were people and experts in the field who said this was impossible, that it would never be done" Smolke says.

Now, just a decade later, she has officially done it.

In the current issue of Science, Smolke and her team at Stanford University, report that they have created yeast that can convert sugar into hydrocodone, the active ingredient in Vicodin. Another yeast strain makes a compound called thebaine — which can easily be turned into many opioids, including oxycontin, codeine and morphine.

Making the yeast took a herculean effort. The team took more than 20 genes from rats, bacteria and a bunch of plants, such as the California poppy, the Iranian poppy and Goldthread. Then they inserted the genes into a microbe similar to Brewer's yeast, and coaxed the cells to synthesize the drugs.

By engineering yeast to synthesize opioid drugs, scientists at Stanford University hope to make morphine more available in developing countries, where there's a shortage of painkillers. The research team included (left to right) Isis Trenchard, Christina Smolke, Stephanie Galanie and Kate Thodey.

Rod Searcey/Courtesy of Stanford University

Right now the yeast can brew only tiny, tiny amounts of the drugs. You would have to drink thousands of liters of the "brew" to get one dose of hydrocodone, Smolke says.

But once the process has been optimized, she explains, these modified yeast strains should make it much easier and cheaper to manufacture new painkilling medicine and improve the painkillers we already have. "We can leverage this technology to reduce some of the narcotics' side effects, or make medications that are less addictive," Smolke says.

Goats and Soda Home-Brewed Morphine Is Around The Corner

The yeast could also make morphine more available in poor countries, where there's a terrible shortage of pain medicine, Smolke says.

Still, the genetically modified yeast strains have triggered a heated debate about how to regulate these organisms — and the possibility of "home-brewing morphine."

"We're just talking fermentation and brewing here," says Kenneth Oye, who studies technology policy at the Massachusetts Institute of Technology, and says he's concerned. "This is not a technology that's difficult to handle."

Oye's worry is that the genetically modified yeast could, one day, be grown at home and used to turn sugar into heroin — which is easily made from morphine or thebaine. Home-brewing, Oye says, could put more drugs on the street.

"Unfortunately, one of the implications, in my judgment, is that addicts would have easier access to something that threatens health in very serious ways," he says. "We are not talking marijuana here."

Oye acknowledges — and emphasizes — that the problem of slapdash, home-brewed morphine is likely years away. It's not possible with the strains of yeast that Smolke has. Those microbes produce tiny quantities of narcotic, and only do it under highly-controlled conditions — not in your average garage. (Smolke and her colleagues have even tested this out.)

Parallels How Heroin Made Its Way From Rural Mexico To Small-Town America

But Oye thinks U.S. drug officials need to start planning now, before the lid of Pandora's box opens wide. He recommends that the Drug Enforcement Administration start to track these microbes by "barcoding" them, and perhaps even prohibit the production of certain versions — such as the yeast strains that make heroin directly.

"Once a robust, easy-to-grow, heroin-producing yeast strain is out there, its control would be, in my view, virtually possible," Oye says.

At DEA headquarters in Washington, D.C., special agent Eduardo Chavez says he shares some of Oye's concerns about using yeast for home-brewing. But the agency is also worried about large drug cartels.

"It's concern that [the technology] will fall into the wrong hands," Chavez says. "That they'll find a way to increase production, increase their profits — all on the backs of people who are addicted to opiates."

So the DEA is treating these yeast like they do any organism that makes a controlled substance — such as poppies. Researchers need a special registration to handle, store and distribute the yeast. And Smolke and other scientists working with the modified organisms have to keep them locked up.

But right now, the DEA isn't planning to introduce any new regulations for the yeast. The microbes just make way too little of the compounds to be a threat, Chavez says. And drug cartels already have large and steady supply of opioids from poppy production in Mexico and Afghanistan.

"We can't see the drug cartel making a 180-degree turn, [to] start to exploit this particular market," Chavez says. "It would be much more labor-intensive."

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Katrina's Emotional Legacy Includes Pain, Grief And Resilience

NPR Health Blog - Fri, 08/14/2015 - 4:43am
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Dyha Gresham (front, left), her older sister Briceshanay (in back) and Briceshanay's daughter Uri stand in their New Orleans home with the family's cat Sugar-Pepper and dog Selena. After Katrina, Briceshanay says, she relied on theater and the arts to help her "move through terrible and difficult times."

Edmund D. Fountain for NPR

When hurricane Katrina hit New Orleans in 2005 most residents evacuated safely. But thousands lost homes, careers, and the lives they had known. Since then, many seem to have recovered emotionally from the trauma. But some have not.

A recent poll from NPR and the Kaiser Family Foundation finds that today some people who survived Katrina say they still have difficulty sleeping and controlling emotion. Others have suffered strains on their marriage or had trouble with drugs or alcohol. Many trace the lingering difficulties to their experiences during Katrina.

Ermence Parent, for example, is a self-assured outgoing New Orleans attorney, and mother of two grown daughters. But today, 10 years after the storm, she's still grieving.

"I still have depression — major," she says.

When Katrina came crashing into the city 10 years ago, Parent was frantic over the whereabouts of her 87-year-old mother. The nursing home where her mother lived had told her before the storm that they had an evacuation plan. But then communication went down.

"I found out on CNN that my mother's nursing home had not evacuated," Parent remembers. "Several did not. And at one all the residents drowned — and we didn't know which one."

She called officials from the city, state and nursing home to see if her mother had survived. There was no word. Days passed. Finally, she turned to the Red Cross, who told her, "they had some lady who fit my mother's description — they didn't know her name."

The nursing home patients had been quickly transported with no identification documents, Parent learned.

"So they faxed me a photograph," she says. "And it wasn't my mother."

Later that day, Parent learned that the nursing home hadn't evacuated its residents after all, and 22 patients died. Her mother survived the immediate flooding; she'd been moved to the second floor to escape the water.

"They had been there all that week with no water," Parent says. "No air conditioning, no electricity, no food, no medicine — the whole week."

Eventually her mother was airlifted to a nursing home in Tennessee. When Parent and her siblings arrived at that facility, their mother's condition shocked them. The older woman wasn't speaking, and didn't recognize any of them.

Briceshanay Gresham (center) takes her daughter Uri (right) and sister Dyha to their neighborhood playground in New Orleans. Briceshanay was in college during Katrina and escaped swirling, waist-high water with only the clothes she was wearing that day.

Edmund D. Fountain for NPR

"She just wasn't there anymore — mentally or emotionally,' Parent says. "She was just so frail."

Parent's mother never recovered, and died within months. When Parent returned to her own home — which had been flooded with nearly 8 feet of water — it was destroyed.

Her law office downtown was also ruined. She and her husband Israel struggled to get insurance claims paid and get loans to rebuild. But they had no luck.

For her husband, Parent says, the stress was huge. Just months after her mother died, Israel Parent died of a massive heart attack. He was just 58 years old.

Ermence Parent has struggled with depression and grief ever since.

"The problem with mental health issues is they don't go away," she says. "You can try to bury them if you like, but they only get worse."

New Orleans health officials worry that the 10th anniversary, with all its media attention, will provoke terrible pain with the memories. So they've set up a city campaign of PSAs and hotlines to help residents find counseling. And therapists and psychologists, including Kim Vangeffen, are running workshops to help residents cope.

"My friends and I have been talking," Vangeffen says. "How much do we really want to pay attention to the anniversary — watch the news shows or not? Do we want to do something totally unrelated to the hurricane?"

She sees in her patients, her friends and herself a desire to escape every aspect of the commemoration.

"Particularly when so many things can bring back feelings of panic and grief," she says. Images, sounds — even smells.

"There's a smell we call the 'Katrina smell,' that was related to mold and mildew that grew on things," Vangeffen says. "I still have things in my garage that I have never fully gone through. And if I open those boxes you can still smell those smells — and it just brings you back to those times."

Still, overall, according to federal statistics, mental health problems aren't greater in New Orleans today than elsewhere in the country.

And the NPR-Kaiser poll of New Orleans residents includes some positive findings. Seventy-two percent of African American adults surveyed, and 79 percent of white adults, say they're better able to cope with stress today because of their experiences with Katrina.

Briceshanay Gresham, a New Orleans elementary school teacher, considers herself someone who emerged from the storm even stronger.

Ten years ago, Gresham was a freshman at the University of New Orleans. With the city's history of surviving hurricanes, she wasn't worried about Katrina — until school officials forced Gresham and her fellow students to evacuate.

Gresham recalls walking with her roommate down the street as the water started rushing — first around her ankles, then her knees, then her waist.

"I had the shirt on my back and the shoes, pants on my body," Gresham remembers. "That's all I had."

With help from her roommate's father, Gresham enrolled at a college in the state of Washington that offered scholarships to students evacuated from New Orleans.

Once there, she focused on the arts, and wrote a one-woman play. Writing and performing it helped her work through what had happened, Gresham says.

In her play, every character had a different pair of shoes. Gresham would switch from character to character by stepping into the different shoes.

And when it came to the question of returning to New Orleans, every character had their say.

"I had lined all the shoes up," Gresham says, "and the audience really didn't know if each character was going to come back. And then, I finally said, 'I am all these people — these are me, and these are my feelings. And I decided to come back because this is my city.' "

Gresham says she returned to New Orleans because she wanted "to be the person that's going to help rebuild, using the arts."

Alongside her work as a teacher today, Gresham is also studying — music therapy.

Briceshanay Gresham laughs with her daughter Uri (wearing shorts) and sister Dyha. Ten years after escaping Katrina, Gresham teaches elementary school in New Orleans and is studying to become a music therapist.

Edmund D. Fountain for NPR

"I want to help kids to be able to do the same thing Katrina helped me to do," she says. "To use the arts to move through terrible and difficult times — use the arts to heal."

Recent research suggests that trauma can build strength. When Katrina hit, psychologist Jean Rhodes, at the University of Massachusetts and Harvard sociologist Mary Waters happened to be in the middle of a national study looking at social support and mental health issues among low-income single mothers.

The researchers were able to track down 334 of the study participants who had been living in New Orleans at the study's start. They found that 10 years after the storm, more than 60 percent of the women in the study had bounced back emotionally to where they were before Katrina. And more than half of these survivors of the storm had gone on to experience significant emotional growth — making positive life changes.

Before Katrina, "many of them had never expected to leave New Orleans or the relationships they were in," Rhodes says. But many did end up making those big changes after the storm — "because they lived through it," she says.

"And because they were able to be strong for themselves, their mothers, their children — they have a greater sense of their own strength, heightened spirituality and a stronger sense of new possibilities," says Rhodes. "An appreciation for life."

In fact, Rhodes says, many of the women who faced the greatest amount of difficulty seemed to go on to develop the greatest amount of strength.

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