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Medical Marijuana Is Often Less Potent Than Advertised

NPR Health Blog - Tue, 06/23/2015 - 12:05pm

Marijuana at a medical marijuana dispensary in Los Angeles. Twenty-three states and the District of Columbia have legalized medical marijuana.

David McNew/Getty Images

People who buy medical marijuana products might not be getting what they paid for, a study finds. And evidence remains elusive on benefits for most medical conditions, even though almost half the states have legalized medical marijuana.

The majority of edible cannabis products sold for medicinal purposes have labels that do not accurately reflect the amount of delta-9-tetrahydrocannabinol, THC for short, infused in them. THC is the component that's responsible for the marijuana high. But it's also known as dronabinol, a prescribed medication used to treat nausea and vomiting caused by chemotherapy.

THC and cannabidiol (CBD), another chemical component of cannabis, are believed to be primarily responsible for therapeutic benefits, especially when the THC: CBD ratio is close to 1:1, according to the study.

Of 75 products legally purchased in three cities, only 17 percent were correctly labeled, according to the report, which was published Tuesday in JAMA, the American Medical Association's journal. Accuracy for labeling was defined as the product having THC content within 10 percent of what's printed on the label.

Twenty-three percent were under-labeled, meaning there's more THC than advertised. Sixty percent were over-labeled, where customers were not getting the bang for their buck.

"A couple of products that were supposed to contain 100 milligrams of THC but had only two to three [milligrams]," lead author Ryan Vandrey, an associate professor of psychiatry and behavioral sciences at Johns Hopkins University says. "That was striking – these were not cheap products and were being sold as medicine."

Currently 23 states and Washington D.C. have laws legalizing marijuana for medical purposes. Four states and D.C. allow legal recreational use of cannabis. Some laws are broader than others, and qualifications for medical marijuana vary as well.

Shots - Health News Pot Can Trigger Psychotic Symptoms For Some, But Do The Effects Last?

The rush to legalize medical marijuana tends to obscure the fact that it's not clear if medical marijuana has any therapeutic benefits at all. A review of studies on the topic, also published in Tuesday's JAMA, found "moderate" evidence that cannabinoids help with chronic pain and spasticity. But the researchers found little evidence that they help with nausea and vomiting due to chemotherapy, weight gain in people with HIV, sleep disorders, and Tourette syndrome. About one third of people in the studies reported side effects ranging from probably OK (euphoria) to distressing (vomiting, dizziness, hallucinations.)

Does this mean all the cannabis-infused tea that you've been drinking doesn't help your anxiety disorder at all? It's really impossible to say. There's just not enough scientific evidence to prove that they do work, or to tell us how much THC is needed to treat a certain condition.

Shots - Health News Quality-Testing Legal Marijuana: Strong But Not Always Clean

For the people who are using medical marijuana to treat illnesses, the population affected by mislabeling is not small: an estimated 16 to 23 percent of medical cannabis patients consume edible products, according to the Vandrey study. Losing out on potential benefits is one thing, but potential overdosing poses a much bigger threat, especially when it comes to edibles. Undesirable side effects such as decreased short-term memory, panic, paranoia and even acute psychosis are possible, and the risk increases with higher dosages.

In the natural cannabis plant there is a ceiling amount of THC, but edibles can contain much more. . A pot-infused brownie with over 1200 milligrams of THC can look the same as the brownie with only 50 milligrams of THC.

Marijuana product testing, as Shots has previously reported, is a fairly new phenomenon. Oversight and regulations for testing medicinal cannabis varies from state to state.

Colorado mandated potency testing for marijuana edibles last May, but the rule only applies to edibles for recreational purposes.

The Salt How Marijuana Highjacks Your Brain To Give You The Munchies

As a result, labels for recreational marijuana are getting better at accurately stating THC content, according to Ian Barringer, owner of RM3 Labs in Denver, Colo. Products for both medicinal and recreational uses came in much weaker than labeled in earlier years, Barringer says, but most of the product the lab tests now fall within the acceptable range of 20 percent plus or minus the labeled THC content displayed on the label.

And starting in July 2016, Colorado will require independent testing and certification for medical marijuana and infused products containing medical marijuana, according to a bill approved and signed by Gov. john Hickenlooper on May 29. The state of Washington followed suit, requiring testing for THC and CBD levels, accurate labels and child-resistant packaging specifically for medical marijuana.

Copyright 2015 NPR. To see more, visit
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Disputes Made Prevention Panel Stronger, Says Former Leader

NPR Health Blog - Tue, 06/23/2015 - 11:21am

For its first 25 years, the U.S. Preventive Services Task Force toiled in relative obscurity.

Created by the federal government in 1984, the task force published books and articles in scientific journals that aimed to inform primary care practitioners about which preventive services were effective based on scientific evidence. It assigns preventive services such as screenings, medication and counseling grades from A to D, or an I for insufficient evidence.

In 2010, everything changed.

"It would be disingenuous of me not to suggest that the link between the ... recommendations and insurance coverage hasn't put an additional focus on our work," says Dr. Michael LeFevre.

Courtesy of Michael LeFevre

The massive health care bill that came to be called Obamacare included language requiring that preventive services scoring a grade of A or B from the task force had to be covered by health plans without charging consumers anything out of pocket. In one stroke, this volunteer group of nonpartisan medical experts found themselves thrust into the political hurly-burly. Their recommendations, including a controversial 2009 recommendation regarding breast cancer screening, came under intense scrutiny.

Dr. Michael LeFevre, a primary care physician who is vice chairman of the Department of Family and Community Medicine at the University of Missouri, chaired the task force from March 2014 until March 2015 and was a member of it for a decade. We spoke recently about his tenure and how the task force's role has evolved. The following interview has been edited and condensed.

How did the health law change the role that task force recommendations play in health care?

It would be disingenuous of me not to suggest that the link between the task force A and B recommendations and insurance coverage hasn't put an additional focus on our work. There are people who think we are making a coverage decision. We're not. We evaluate the science; we don't look at the costs. If the science doesn't make clear there's at least moderate certainty of net benefit, we don't recommend it. We know if we give it an A or a B, there will be a link to coverage, but we're not saying it should be covered.

Let's talk about the breast cancer screening recommendation. The task force in 2009 and again several months ago in a proposed update did not recommend mammograms for women age 40 to 49. The task force gave it a C rating, which means they should be offered selectively depending on patient preferences and health history in consultation with a physician. Some say this is a big mistake, that women in that age group won't get mammograms that may help detect breast cancer earlier. How do you respond to critics?

In 2009, when we released our recommendation for breast cancer screening, we were in the middle of the debate in Congress about the Affordable Care Act. And it was already written into the bill being considered that A and B recommendations would be covered without a copayment. So we became the focus of debate about the recommendation and coverage. This created a firestorm of publicity that was, honestly, ultimately good.

We were already working to try to improve our transparency and communication. I'd be dishonest to say that it didn't influence us. We realized that we have to be faster and clearer. Our audience is beyond primary care physicians, there are payers, government bodies and patients to consider.

But what about the charges of critics such as Rep. Debbie Wasserman Schultz, D-Fla., a breast cancer survivor, who wrote in The Washington Post, "We know that mammograms are not perfect, but we also know that deferring them until after age 50 is dangerous."

It's important for us to separate out the issue of coverage from the science itself and the benefits and harms. We are well aware that many payers cover not only C recommendations but also D recommendations. All the ACA really does is set a floor and says that A and B recommendations have to be covered.

How do you decide which preventive services to review?

We try to update existing topics every five years, more or less often depending on events. Occasionally we retire a topic.

Anybody can nominate a new topic at any time. We have a work group that looks at it continuously. We have to decide, is it prevention, and is it something that can be implemented or referred by primary care clinicians? For example, we saw that Vitamin D deficiency screening was being promoted widely. We decided it was an important topic to review.

What other task force recommendations have been publicly controversial?

The 2009 breast cancer screening recommendation was the peak of public scrutiny. But the breast cancer screening recommendation for women 40 to 49 is not negative [since it suggests that mammography can be offered based on the views of the doctor and patient]. In contrast, we recommended against prostate cancer screening. We gave it a D. To my knowledge nobody has stopped covering prostate cancer screening. We got a lot of attention for that. We still get a lot of attention and some advocates still want that to change. I am surprised about the depth of feeling about the recommendations.

In your role as the immediate past chairman of the task force, you're involved as a consultant until next spring. What's on the drawing board going forward? How will the task force change and evolve in the next 10 years?

I look for us to continue to try to be transparent in our work. I can't tell you exactly what shape that will take as we go forward. We're not the wizard behind the curtain that makes decrees. We want people engaged in our work and to know how we do that work. Did we miss something, did we reach the right conclusions?

I look for us to increase communications. We are increasingly putting out tools for consumers on the Web. I'm probably not supposed to tell you this, but what the heck. Part of our method now, after we've reviewed the evidence, we actually have somebody from the communications team get up and grill us. A non-clinician. We feel like if we can't explain it, we haven't done our job. We appreciate that our language has to go beyond what a clinician understands.

Transparency, methodological rigor and communications. That's what we're focusing on.

Copyright 2015 Kaiser Health News. To see more, visit
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Take A Hike To Do Your Heart And Spirit Good

NPR Health Blog - Tue, 06/23/2015 - 4:45am
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Credit: Katherine Streeter for NPR

Fryman Canyon is one of those special places in the city of Los Angeles — a bit of country and canyon nestled just off the crest of Mulholland Drive, with gorgeous views of the valley and mountains.

It's favored by the canine set — my two dogs love it here — and on any given morning I'm sure to run into fellow canyon lovers, like Stacy Maes and her energetic weimaraner, Astrid.

Maes is an independent film producer; she has two kids and works mostly at home. She's not fond of organized exercise classes, so she does some yoga and fast-paced workout videos at home. But, as is the case with many Americans, walking is Maes' most consistent exercise. She's out in the canyon with Astrid three or four times a week.

Too many people think you have to exercise really, really hard to get a benefit, and nothing could be further from the truth. You're actually getting probably 95 percent or more of the benefits when you're walking as compared to jogging.

"In the morning, it's all about Astrid," Maes explains, and laughs. "Because if she's not tired, then my day can't go the way I want it to go."

Whether it's to help their dogs or themselves, about half of all Americans surveyed in a recent NPR poll say they exercise regularly. And while getting a cardio-aerobic workout on a treadmill, elliptical machine, or stationary bike are all popular, going for a walk is the exercise Americans say they engage in most frequently, according to the poll, which was conducted by the Harvard T.H. Chan School of Public Health, and the Robert Wood Johnson Foundation.

According to the poll, most people who walk for exercise do so a few times a week. About a third say they walk every day.

But are they kidding themselves to think a moderate walk is really helping them much, exercise-wise? Should we all be power-walking or jogging if we want to count that activity as good for us?

Dr. Tim Church, who studies the effects of physical activity at Louisiana State University's Pennington Biomedical Research Center, is reassuring on that score.

Shots - Health News A Look At Sports And Health In America

"Too many people think you have to exercise really, really hard to get a benefit, and nothing could be further from the truth," Church says. "You're actually getting, probably, 95 percent or more of the benefits when you're walking as compared to jogging."

Church says walking has many tangible effects on health — lower blood pressure, lower cholesterol, and an overall lower risk of heart disease.

And, he has the research to back that up. Church headed a study with 464 postmenopausal women who, for six months, came into the lab to walk a treadmill while researchers watched.

One group walked 73 minutes a week; another group walked 136 minutes, and a third group walked for 190 minutes weekly.

These women weren't strolling, but they weren't race walking either. They were walking at a slow to moderate pace, and could easily carry on a conversation.

"One of the things we really learned from the study — and I guess we shouldn't be surprised, but we were — was how often the group that was only doing 73 minutes a week at a very slow pace benefited, no matter what we looked at," Church says.

Probably the most important benefit, he says, was that metabolism of blood sugar improved; that can lower the risk of diabetes.

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"Even a little bit of activity can reduce the amount of that dangerous belly fat," Church says, "and we know that visceral fat is related to the risk of diabetes and the risk of cardiovascular disease."

Church says he often hears patients say they've gotten more physically active from walking. They haven't necessarily lost weight, they tell him, but their pants fit differently.

It's because they have less belly fat, he says, which is a very good thing. This document from the American Heart Association lists dozens of studies showing similar benefits from walking.

And in Church's study of postmenopausal women, participants gained more than physical benefits.

"The majority of benefits of physical activity — in this instance, walking — occur above the shoulders," he says. The walkers reaped benefits like less anxiety and fewer symptoms of depression. They also discovered something many of us yearn for: more energy.

"It wasn't a dose-response — as in, 'the more exercise you did, the more your energy increased,' " Church says. "It was actually what I call 'threshold.' ... All the exercise groups — the 73-minutes-a-week group, the 136-minutes-a-week group and the 190-minutes-a-week group — increased their levels of energy the same."

So there appear to be lots of benefits from walking, no matter what the pace. Federal health officials suggest 150 minutes a week of moderate physical activity. That's about 30 minutes a day, five days a week.

According to those guidelines, a moderately paced walk counts — which would allow you to still carry on a conversation, if you like, with a fellow dog-walker.

Our Sports and Health series continues over the summer, based on the results of our poll with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

Copyright 2015 NPR. To see more, visit
Categories: NPR Blogs

Fraud Still Plagues Medicare's Prescription Drug Program

NPR Health Blog - Tue, 06/23/2015 - 12:03am

Fraud and abuse continue to dog Medicare's popular prescription drug program, despite a bevy of initiatives launched to prevent them, according to two new reports by the inspector general of Health and Human Services.

Their release follows the arrests of 44 pharmacy owners, doctors and others, who last week were accused of bilking the program, known as Part D.

The two reports issued Tuesday provide more insight into the extent of the fraud, as well as steps federal regulators should take to stop it. The first report, which covers data from last year, found:

  • More than 1,400 pharmacies had questionable billing practices last year in the drug program. Some billed for extremely high numbers of prescriptions per patient and others billed for a high proportion of narcotic controlled substances. Collectively, they billed Part D $2.3 billion in 2014.
  • Prescriptions for commonly abused opioids continue to rise, despite warnings about inappropriate use. Between 2006 and 2014, Medicare's spending on them grew to $3.9 billion from $1.5 billion, a 156 percent increase. By comparison, spending for all drugs in the program, including expensive specialty medications, grew by 136 percent during the same period. More than 40 percent of Medicare beneficiaries in Alabama, Tennessee, Oklahoma and Alaska filled at least one prescription for a narcotic in 2014, compared to 32 percent for the nation as a whole.
  • New York and Los Angeles remain hot spots for questionable prescribing, with far higher use of expensive drugs associated with fraud than other parts of the country. The New York metropolitan area, for instance, accounted for half of all prescriptions for the expensive topical ointment Solaraze last year, a disproportional rate. The drug is used for lesions formed as a result of overexposure to the sun. New York and Los Angeles also stood out for prescribing of two omega-3 fatty acids, used to help reduce very high triglyceride levels. The two regions accounted for nearly half of all prescriptions for Vascepa and about a third of those for Lovaza.

The inspector general's findings come two years after ProPublica reported on how weak oversight by the Centers for Medicare and Medicaid Services (CMS) allowed abusive prescribing and outright fraud to proliferate in Part D. Medicare promised a more aggressive approach to analyzing its own data.

People can use Prescriber Checkup, a tool created by ProPublica, to look up doctors and see how their prescribing patterns compare to peers in the same specialty and state.

Medicare Part D provides drug coverage for 39 million seniors and disabled people, at a cost of $121 billion in 2014. It is the fastest-growing component of the Medicare program. Part D is administered by health insurers under contract with the federal government, but CMS is responsible for overseeing it.

For years, the inspector general, an internal watchdog that evaluates HHS programs and investigates wrongdoing, has dinged Medicare for its failure to keep a close enough eye on doctors, pharmacies, beneficiaries and even its fraud contractors. That's beginning to change, officials say.

Shots - Health News How Fraud Flourishes Unchecked In Medicare's Drug Plan

"CMS has made progress on a number of recommendations we've made, as well as on the initiatives that they've had," said Jodi Nudelman, regional inspector general for evaluation and inspections in the New York office. "They're starting to use data to drive their strategies."

At the same time, she said, "There are still concerns. More needs to be done. We can't stop here."

A second report from the inspector general says that Medicare needs to adopt a number of reforms that it has so far resisted. They include:

  • Requiring health plans to report all potential fraud and abuse to CMS and its fraud monitoring contractors. Right now, the agency encourages plans to voluntarily report suspicions of fraud but it doesn't mandate it. Last year, the inspector general found that less than half of Part D insurers voluntarily reported data on potential fraud and abuse.
  • Expanding reviews for questionable drug prescribing beyond controlled substances to other commonly abused drugs, including antipsychotic medications, respiratory drugs and those for HIV.
  • Restricting patients suspected of doctor shopping—visiting multiple doctors in search of controlled substance prescriptions—to a limited number of doctors and pharmacies. CMS said it doesn't have legal authority to do this, but the inspector general said it should seek the authority, which is commonly used by private insurance companies and state Medicaid programs for the poor.

During last week's Medicare fraud takedown, 243 people total were charged, including 46 doctors, nurses and other licensed health professionals. Forty-four of the people arrested were charged with fraud related to Part D.

In Miami, for example, a number of pharmacy owners were charged with health care fraud and conspiracy to commit fraud. In one case, the government charged several people with paying Medicare beneficiaries for their personal identification numbers, which they used to file fraudulent claims for drugs that were never dispensed. They worked with a clinic owner, who forged and altered prescriptions and sold them to the pharmacies. This scheme alone defrauded Medicare of $21.2 million, the government alleges.

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Last year, CMS announced that it was granting itself potent new authority to expel physicians from Medicare if they are found to prescribe drugs in abusive ways. The agency also said it would compel health providers to enroll in Medicare to order medications for patients covered by Part D. Currently, that isn't required.

The changes were supposed to take effect on June 1, but have since been delayed twice, most recently until January 1.

CMS spokesman Aaron Albright said Monday in a written statement that Medicare "works diligently with our law enforcement partners to prevent fraud in the first place and to recover payments for wasteful, abusive or fraudulent services."

In addition to requiring 400,000 prescribers to enroll in Medicare by next year to order to retain the ability to prescribe in Part D, Albright said, officials are helping health plans decrease overuse of dangerous drugs and taking action against providers and pharmacies with potentially fraudulent billing practices.

In April, CMS launched a web-based tool to allow CMS, law enforcemen, and health plans to share information and coordinate actions against pharmacies deemed high risk. CMS also said it is monitoring potentially fraudulent activity in geographic hot spots like the ones identified by the inspector general.

Copyright 2015 ProPublica. To see more, visit .
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Painfully Skinny Jeans Land A Woman In The Hospital

NPR Health Blog - Mon, 06/22/2015 - 6:33pm

Skinny jeans: fashion statement or health threat?


If you've wondered whether there's a downside to wearing superskinny jeans, this story's for you.

A 35-year-old Australian woman wound up in the hospital after wearing skinny jeans while helping a family member move.

The move involved "many hours of squatting while emptying cupboards," according to a report published Monday in the journal Neurology, Neurosurgery & Psychiatry.

As the day went on, those jeans were making her increasingly uncomfortable. But it wasn't until that evening that the situation went south. As she walked home, the woman found herself struggling to lift her increasingly numb feet.

She fell to the ground, and lay there for several hours before she was found and taken to the Royal Adelaide Hospital.

At the hospital, the woman's legs were so swollen that staff had to cut off her jeans.

Neurologists tried to figure out what had gone wrong. Tests revealed that she had almost no muscle strength in her ankles and toes, while the muscles of her hips and knees were normal. A CT scan of her legs showed signs of muscle damage in the calves.

Tests of the tibial nerves, which provide movement and sensation to the calf and foot, and the peroneal nerves, which run from the outside of the knee down to the foot and ankle, showed they weren't sending signals properly.

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That was the clue. Nerve damage can be caused by pressure. In the case of the peroneal nerves, that can include pressure from crossing the legs, wearing high boots or squatting. (Previous research refers to "strawberry pickers' palsy.")

"The wearing of 'skinny' jeans had likely potentiated the tibial neuropathies by causing a compartment syndrome as the lower leg swelled," the report concluded.

Not good. The swelling of compartment syndrome can lead to permanent muscle and nerve damage, or amputation.

In this case, the victim fared better. After four days in the hospital on intravenous fluids, she regained her ability to walk and went home. No word on whether she's ever donned skinny jeans again.

This isn't the first time we've reported on the perils of excessively tight trousers. In 2011, a doctor in Tarrytown, N.Y., told us about a 15-year-old soccer player who had numbness and tingling in her leg caused by wearing compression shorts.

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In some cases, the only damage tight clothes will do is to your wallet.

Last fall, the Federal Trade Commission ordered to two companies to stop selling caffeine-infused shapewear, saying that the amped-up skivvies would not, as one firm claimed, "reduce the size of your hips by up to 2.1 inches and your thighs by up to one inch, and would eliminate or reduce cellulite and that scientific tests proved those results."

The FTC disputed that claim, and ordered the companies to fork over $1.5 million to customers who had been lured in by the promise of effortless shrinkage.

Copyright 2015 NPR. To see more, visit
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California's Medicaid Program Fails To Ensure Access To Doctors

NPR Health Blog - Mon, 06/22/2015 - 1:25pm

Long waits and lack of access to doctors is a continuing problem with California's Medicaid program, an audit finds.


Terri Anderson signed up for California's Medicaid program earlier this year, hoping she'd finally get treatment for her high blood pressure. But the insurer operating her Medicaid plan assigned the 57-year-old to a doctor across town from her Riverside, Calif., home and she couldn't get there.

"It was just too far away," says Anderson, adding that she cares for her 90-year-old ill father and can't leave him alone to make an hour round-trip drive to the doctor. Now she's crossing her fingers that a health clinic near her house will accept her new insurance.

She's not alone. In an effort to control costs in its rapidly expanding Medi-Cal program, California has relied heavily on managed care insurance companies to treat patients like Anderson.

The state pays insurers a fixed amount per enrollee and expects the companies to provide access to doctors and comprehensive care. But a scathing state audit released last Tuesday shows that California is failing to make sure those plans deliver. Many enrollees have insurance cards but often have trouble getting in to see a doctor.

The state didn't verify that insurers' directories of doctors were accurate, the audit found, or that the plans had enough doctors to meet patients' needs. The state Department of Health Care Services also didn't do its own required annual audits of the plans.

And thousands of phone calls to an ombudsman's office — created to investigate complaints — went unanswered every month.

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The audit focused on three health plans, but underscores a broader problem in California: the lack of sufficient oversight of a program that now serves about 12 million beneficiaries, three quarters of whom are in managed care. Advocates and analysts say the state has moved too quickly to shift enrollees into managed care plans and given too much unsupervised responsibility to the companies.

While people enrolled in the old, fee-for-service Medicaid system sometimes had difficulty finding doctors, especially specialists, the difference is the managed care plans have a legal responsibility to provide sufficient access to their consumers.

The sheer number of enrollees, along with the complexity of their health care needs, means the state needs to do a better job tracking the plans responsible for caring for them, said Gerald Kominski, director of the UCLA Center for Health Policy Research.

"The audit indicates now that so many Californians are enrolled, how important it is for the state to have adequate oversight," Kominski says. "The state has a long way to go to reach that goal."

Aimee Mejia, a single mother in South Gate, just a few miles southeast of downtown Los Angeles, said finding specialists to treat her diabetes and psoriasis was challenging. Some didn't accept her Medi-Cal insurance and others were too busy to see new patients. She finally found doctors, but driving to one takes about 40 minutes and the other, more than an hour.

"I thought that was normal, to be rejected by doctors or to wait for care," Mejia says. "But there is something wrong here."

New proposed federal regulations designed to improve Medicaid managed care could help by requiring states to ensure that patients have enough access to doctors and hospitals. The regulations also would limit profit margins and establish a quality rating system for plans. In addition, a proposed bill in California would require plans to provide accurate and up-to-date provider directories.

Officials at the state's Department of Health Care Services say they already have made some changes and are monitoring doctor networks more thoroughly than the audit found.

But even if oversight improves, many argue that the only way to get more doctors and other providers to participate in Medi-Cal is to increase payments. A coalition of unions, doctors and hospitals are pushing to raise rates in California. If that doesn't happen, more regulation will only go so far, says Sean Wherley, spokesman for SEIU-United Healthcare Workers West.

"If there still aren't doctors taking new Medi-Cal patients, how is that any better for patients?" he said.

The issue of managed care oversight isn't limited to California. Several states have transferred responsibility to managed care insurers but aren't closely tracking whether Medicaid patients are getting the care they need, says Joan Alker, executive director of the Georgetown University Center for Children and Families.

"This is a national problem," Alker says. "More beneficiaries with chronic and difficult health conditions and more public dollars are going into managed care. We absolutely need more accountability."

Shots - Health News States That Expand Medicaid Detect More Cases Of Diabetes

Oversight has been hurt by state budget cutbacks and the loss of seasoned employees, Alker says. In addition, for-profit companies running managed care plans have a responsibility to return profits to their shareholders. "That comes up against the responsibility of dealing with a population of people who have a lot of health care needs," Alker said.

California has been moving large numbers of poor patients into managed care for decades. Over the past few years, however, the pace has accelerated. Many newer beneficiaries, including seniors and people with disabilities, have multiple chronic illnesses. And people who gained Medi-Cal coverage through the Affordable Care Act also may have gone without treatment for a long time and have serious health needs.

Each transition has been rocky, with patients and advocates raising concerns about patients' inability to find primary care doctors or specialists.

Linda Lindsey, 60, lives in Weaverville, a rural town outside Eureka in far northern California that has a limited number of doctors. Lindsey says she was moved into a Medi-Cal managed care plan a few years ago, and has even fewer options for doctors and pharmacies than she did before.

At one point, Lindsey, who has Crohn's disease, said she drove about 50 miles to see a specialist only to be told that the office didn't accept her plan. "I was upset, to say the least," she said.

Some of the issues have arisen because Medi-Cal grew much faster and bigger than anybody predicted, says Stan Rosenstein, a consultant and former chief deputy director at the state health care services department. The numbers jumped from 6.6 million enrollees in 2007 to 12.2 million to this year.

But caring for people through managed care is a vast improvement over the old fee-for-service system, Rosenstein says. In that, doctors got paid per visit. In managed care, he says, "There is a lot more measurement, a lot more accountability and a lot more contractual requirements than there ever had been."

There are numerous laws on the books requiring state monitoring and sufficient access to doctors. For example, California is required to determine that plans have enough doctors and that patients don't have to travel too far to reach them. State officials also must do regular assessments of plans to determine whether they can meet their contractual obligations.

But just having laws isn't enough to ensure that patients' needs are met, says Abbi Coursolle, a staff attorney at the National Health Law Program. "Those standards are only as good as the state's ability to enforce them," she said.

Copyright 2015 Kaiser Health News. To see more, visit
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To Ease Pain, Reach For Your Playlist

NPR Health Blog - Mon, 06/22/2015 - 4:44am
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We all know that listening to music can soothe emotional pain, but Taylor Swift, Jay-Z and Alicia Keys can also ease physical pain, according to a study of children and teenagers who had major surgery.

The analgesic effects of music are well known, but most of the studies have been done with adults and most of the music has been classical. Now a recent study finds that children who choose their own music or audiobook to listen to after major surgery experience less pain.

The catalyst for the research was a very personal experience. Sunitha Suresh was a college student when her grandmother had major surgery and was put in intensive care with three other patients. This meant her family couldn't always be with her. They decided to put her favorite south Indian classical Carnatic music on an iPod, so she could listen around the clock.

It was very calming, Suresh says. "She knew that someone who loved her had left that music for her and she was in a familiar place."

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Suresh could see the music relaxed her grandmother and made her feel less anxious, but she wondered if she also felt less pain. That would make sense, because anxiety can make people more vulnerable to pain. At the time Suresh was majoring in biomedical engineering with a minor in music cognition at Northwestern University where her father, Santhanam Suresh, is a professor of anesthesiology and pediatrics.

So father and daughter decided to collaborate on a study. And since Dr. Suresh works with children, they decided to look at how music chosen by the children themselves might affect their tolerance for pain.

It was a small study, involving 60 patients between 9 and 14 years old. All the patients were undergoing big operations that required them to stay in the hospital for at least a couple of days, things like orthopedic, urologic or neurological surgery. Right after surgery, patients received narcotics to control pain. The next day they were divided into three groups. One group heard 30 minutes of music of their choice, one heard 30 minutes of stories of their choice and one listened to 30 minutes of silence via noise canceling headphones.

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Children chose beforehand what they wanted to hear. For the book group, it was stories like James and the Giant Peach. For the music group, there were pop choices including Miley Cyrus, Taylor Swift and Justin Bieber for the younger kids, Jay-Z and Alicia Keys for the older ones.

To measure pain, the researchers used the Faces Pain Scale depicting illustrations such as a smiling, frowning or crying face. The children pointed to which picture best illustrated their level of pain before and after the audio therapy. After a 30-minute session, the children who listened to music or a book reduced their pain burden by 1 point on a 10-point scale compared to the children who listened to silence. That might not sound like much, but Sunitha Suresh says it's the equivalent of taking an over-the-counter pain medication like Advil or Tylenol.

The findings suggest that doctors may be able to use less pain medication for their pediatric patients. And that's a good thing, says Santhanam Suresh, as children don't tolerate such medication as well as adults. Children are smaller and are more likely to suffer side effects such as trouble breathing, nausea, itching and constipation. So the less pain medication, he says, the better.

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When it comes to distracting people from pain, music has special qualities, says Dr. Lynn Webster, a pain specialist and past president of the American Academy of Pain Medicine. "It can generate not only a focus and reduction in anxiety, but it can induce a feeling of euphoria," he says. That can help drown out the pain.

The researchers plan follow-up studies to see if music can decrease the amount of pain medication needed once children get out of the hospital and are back at home, listening to their favorite tunes.

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Fitness App Aims To Deliver Live Feedback From A Personal Trainer 24/7

NPR Health Blog - Sun, 06/21/2015 - 7:03am

In the current version of the Fitnet App, the camera of an exerciser's smartphone captures data from him (upper left), while a prerecorded trainer guides him through a workout. A clock (bottom center) shows elapsed time. The orange dots (upper left) indicate he's following her routine well, as judged by the camera and phone's app. The app can also estimate the exerciser's number of steps.

Courtesy of FitNet

It would be easier to exercise, I've told myself, if I had a personal trainer. Maybe one that came to my house. Whenever I wanted. For free.

My dream of a live trainer who won't judge my outfit and is available at my beck and call — like a Jillian Michaels who knows my name — is being developed as an app called Fitnet.

It falls within a family of apps that deliver prerecorded videos from personal trainers to your palm, like Nike+ Training Club or FitOrbit. But, unlike the others, Fitnet is trying to deliver that trainer in real time — coaching you, via smartphone or tablet, while you exercise.

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I tried the early version myself in my living room. I placed the phone angled toward me on the floor while a video of an appropriately enthusiastic woman coached me, like any other exercise video would do. As I lifted and hopped through the six-minute "Fire & Ice Workout," my phone's camera was watching. Fitnet's algorithm analyzed how well I was doing.

That's similar to existing technology like the Microsoft Kinect. But with Fitnet, that's just the beginning.

The next phase of the app will drop the camera analytics, and instead will use wearables like a Fitbit or Jawbone to send data in real time to a personal trainer, according to Bob Summers, CEO of Fitnet. There would be an actual person watching me (and likely hundreds of others), advising each of us how to get the best stretch.

Fitnet's algorithm is intended to help personal trainers determine who needs help at that moment by processing participants' exercise data simultaneously.

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The real-time feedback to exercisers will give someone using the app an experience that feels more like an in-person session with a coach, says Joe Barnhart, a master trainer with the National Association for Fitness Certification. "When you're one-on-one with a client, it needs to be interactive," he says.

For the low price of "free," Fitnet will certainly beat the average hourly rate trainers charge, which can range from $45 to $200 per hour, according to Barnhart. (Eventually, the developers hope the app will make money through extras — like offering users the chance to take part in a social fitness challenge for $1.99 per month.)

Fitnet is partially funded by the National Science Foundation, which has a project called GENI that explores innovative applications. GENI is a nationwide gigabit network hosted by computer researchers — essentially a giant cloud computing network, kind of like Amazon or Google, which researchers can use to develop applications that need superfast Internet speeds. GENI offers "Internet 2" with speeds 40 to 100 times faster than current broadband.

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Fitnet is being used to test whether real-time interaction is possible on a faster, next-generation Internet. It's a lot more complicated than a group video chat, explains Summers, and it requires an infrastructure like GENI's to test.

"We don't appear to be very aggressive in this country about providing bandwidth to users at an affordable price, and I think this is holding us back from being able to develop these kinds of applications," says Mark Gardner, a network research manager at Virginia Tech and one of Fitnet's research partners on the NSF grant.

But there are pockets of the country with superfast Internet — like Kansas City, Missouri, which was involved in the rollout of Google Fiber — that give broadband enthusiasts hope. Summers is optimistic that a real-time streaming trainer — with all of the buff, but none of the buffering — will be available in three to five years.

"It seems pretty clear that our future is more Internet and faster Internet," Summers says. "We feel health and fitness will drive the demand."

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The Neighs Have It: Horse Outruns Man, But Just Barely

NPR Health Blog - Fri, 06/19/2015 - 4:31pm
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Horses, riders and runners crossed three streams in the course of their 22-mile race through the hills of central Wales. The average finish time was the same for both species — four hours.

Ryan Kellman and Adam Cole/NPR's Skunk Bear

The Man v. Horse Marathon starts out like a typical cross-country race. Hundreds of runners stream past the starting line, through the town of Llanwrtyd Wells and then up into the Welsh hills.

But 15 minutes later, a second set of competitors takes off. Fifty horses and their riders chase the runners up and down ridges, across streams, and past hundreds of bewildered sheep.

This bizarre race was created in 1980 to settle an argument between a local pub owner and an opinionated customer. The outcome seems obvious — horses are bigger, stronger and much faster in a sprint. They've been bred for centuries to help humans get around faster.

Humans, on the other hand, aren't that speedy. Sprinter Usain Bolt — the world's fastest man — would have trouble outrunning a lot of house cats, let alone a cheetah.

But scientists say when it comes to marathon distances, humans might actually have an edge.

"We're essentially the tortoises of the animal world rather than the hares," says Dan Lieberman, a professor of human evolutionary biology at Harvard University. "We have a series of adaptations that are literally from our heads to our toes that make us superlative at long distance running."

Specialized structures in our inner ears keep us balanced as we lope along; our springy arches and long elastic tendons make running more efficient, and our big muscular bottoms help stabilize our trunks. And then there's the way we keep our cool. Millions of years ago we traded in fur for a naked body covered in sweat glands. The result: We can lose heat while we run.

Losing heat's not so easy for quadrupeds like antelopes, zebras and horses. They need to pant to really cool off, and that's difficult to do when they're moving at top speeds.

"The guts — the huge viscera — slams into the diaphragm with every step and prevents the animal from panting while galloping," Lieberman says.

When it's hot out, quadrupeds need to slow down to cool down. Humans sweat and keep going. And all that sweating probably helped our ancient ancestors survive.

Meet a few of the competitors: Paul Sorrell, Russ White and Tim Clayton of the North Derbyshire Running Club, and Claire Trafford with her horse Santo.

Adam Cole and Ryan Kellman/NPR's Skunk Bear

"Running was important because it helped us become better hunters," Lieberman says.

His research supports the theory that early humans were "persistence hunters." On hot days, he says, people would chase animals across the African savanna. Unable to rest, the animals would eventually collapse from heat exhaustion, and the hunters would have fresh meat.

The Man v. Horse Marathon is a less violent analogue of persistence hunting. Horses are the ones chasing humans over a 22-mile trail, but temperature still plays an important role.

"The few occasions where humans have beaten the horses have been on hot days," Lieberman says. "And that makes total sense."

This year, the Man V. Horse Marathon took place in a light, refreshing rain — bad news for humanity. Still, the first racer to reach the finish line was human: a 30-year-old civil servant named Hugh Aggleton.

This was Aggleton's third time entering the race, and in previous years he's had some close encounters.

"When you are overtaken by horses you can feel the ground sort of start to shake, as the galloping horses come up behind," Aggleton says. "Then you hear their breathing and you think, 'All right, gotta get going.' "

This year, Aggleton managed to stay ahead of the cavalry, completing the course in 2 hours and 30 minutes. But that wasn't quite fast enough. Leo the horse, ridden by Geoff Allen, reached the finish just five minutes after him. After subtracting the human's 15-minute head start, the horse had a time of 2:20, and it was crowned this year's champion.

Still, Aggleton managed to beat a lot of the other horses in the race.

"I might make that a sort of tag line," Aggleton says. "Faster than 46 out of 50 horses."

That means if he had lived long ago, he probably would have been able to chase down dinner.

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Hunting Ways To Keep Synthetic Estrogens Out Of Rivers And Seas

NPR Health Blog - Fri, 06/19/2015 - 12:09pm

Removing micropollutants from wastewater isn't cheap or easy.


Millions of women around the world take synthetic hormones via birth control pills or hormone replacement therapies. Not all of the estrogen-like compounds from these and other treatments are used by the body — small amounts are excreted and end up in municipal wastewater. And there's been no good way to completely remove these hormones before they head to rivers and seas.

But a team of scientists in the U.S. and Britain now think they may have hit upon a solution based on the combination of a common household chemical — hydrogen peroxide — with a special ingredient to make it work faster.

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Once wastewater is released into the environment, these synthetic hormones can have negative effects on wildlife. Synthetic estrogen is a type of endocrine disruptor, a chemical that affects the endocrine system either by acting like a hormone or by blocking the action of natural hormones. It has caused some species of male fish to become feminized, even causing them to produce eggs in their testes.

One possibility researchers have explored for neutralizing these estrogens before they escape into the environment is based on activated carbon, which works a lot like a water filter you might use at home: The carbon sucks up pollutants and allows pure water to pass through.

Some other scientists see ozone as a better option for treating wastewater. This gas is efficient for filtering water, and works by giving up one of its three oxygen atoms to bind with contaminants. Using ozone can, however, create toxic byproducts like bromate, which the World Health Organization labels a possible carcinogen. Treating water in this way would require an extra step to remove those byproducts.

Demonstrations have shown both ozone and activated carbon treatments to be viable, but implementing them full-scale at wastewater treatment plants is complicated.

In Switzerland, recent regulations aim to reduce micropollutants in waterways, and the country has already begun upgrading its water treatment plants to use ozone or activated carbon. Swiss scientists have estimated that water treatment costs will increase by 10 to 20 percent for systems serving populations of more than 80,000 people, and will increase by 20 to 50 percent for systems serving between 8,000 and 80,000 people. Energy consumption, they say, will also increase.

Peroxide-based water treatment might be a way around the obstacles of the other approaches, say researchers from Carnegie Mellon University in Pittsburgh and Brunel University in London. They've collaborated to test a small version of such a system in the lab, and published their promising findings earlier this month in the journal Scientific Reports.

When the scientists combined a concentrated version of hydrogen peroxide with specially-created catalysts — small molecules that act like enzymes to speed up a chemical reaction — the mixture was able to break down synthetic estrogen in laboratory water, synthetic urine and small amounts of real wastewater. What's more, feminized male fish put in the treated water began to make less vitellogenin, a protein normally made by female fish.

Terrence Collins, the chemist at Carnegie Mellon who led the effort, thinks the peroxide-based treatment method could eventually trump both activated carbon and ozone treatments.

"We're coming in with a strong-looking alternative," he says. "It's more effective and cheaper." He hopes to team up with Swiss scientists to continue evaluating the safety and efficiency of his group's method, which so far has only been tested in the lab.

"I think this study is very interesting," says Urs von Gunten, who runs the Laboratory for Water Quality and Treatment at the École polytechnique fédérale de Lausanne in Switzerland, and was not involved in the study. "However, a lot more information is needed to use [the catalyst] in full-scale applications," he tells Shots in an email. The main problem, von Gunten says, is the large amount of peroxide required, which would then need to be removed.

Getting rid of synthetic estrogen in wastewater is the easy part, von Gunten says.

"If one does a similar experiment with ozone, the loss of the estrogenicity takes a fraction of a second and not minutes to hours." What's needed, he says, are further experiments to show that the catalyst/peroxide treatment can eliminate compounds that are even harder to remove — and remove them from real wastewater.

Collins says his group is in the process of testing the byproducts of this proposed water treatment. He thinks the team's efforts will pay off.

"I feel very confident," he says, "that we can make a major impact on water treatment."

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Worried You Have An STD? This App Helps You Quietly Find Out

NPR Health Blog - Fri, 06/19/2015 - 7:03am

A screenshot from Planned Parenthood's new app, which tests for chlamydia and gonorrhea by mail.

Meredith Rizzo/NPR

You can use an app to buy a new dress, rent a room or pay your bills. Now, you can use an app to discreetly find out if you have a sexually transmitted disease.

It's a little more complicated than shaking your phone like a Magic 8 Ball, but just a little. And, for now, only California residents can use it. But the Planned Parenthood Direct app, released this week as pilot program in California, puts the answers to potentially embarrassing medical questions at your fingertips.

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After downloading the app and creating a profile (you must be at least 16 years old and have a California mailing address), you review information about testing for chlamydia and gonorrhea, the two most common STDs. For $149, an STD test kit is mailed to your house along with a prepaid return package. The fee also covers lab costs and analysis of test results.

You collect your own urine sample. The prepaid envelope means you don't have to answer awkward questions at the post office (Anything fragile, liquid, perishable or potentially hazardous?). Several days after mailing your sample you will have the test results, which come via secure messaging in the app.

So what if this particular Magic 8 Ball comes back with a 'YES?'

If you test positive for chlamydia, Planned Parenthood can write a prescription for antibiotics and help you find a local pharmacy to get it filled. If you test positive for gonorrhea, the best treatment may include an antibiotic shot, so the app will direct you to a Planned Parenthood health center. If you prefer, you can instead to go to your own doctor's office for the injection.

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Chlamydia is one the most commonly reported STDs in the United States, affecting almost 2 million people under age 40, according to the Centers for Disease Control and Prevention. Although it's easy to cure, it's often symptomless, and if left untreated can make it difficult for women to become pregnant.

Gonorrhea may not have symptoms, or you might have discharge and a burning sensation when you urinate. Gonorrhea is also curable, but waiting too long can cause serious health consequences, such as infertility in both women and men. Having gonorrhea may also make it easier for you to get HIV.

Due to the health risks of going untreated, the CDC recommends that sexually active women under 25 and older women with new or multiple sex partners get tested for both of these STDs every year.

The STD app is a pilot project, according to Jill Balderson, vice president of health care innovation at the Planned Parenthood Federation of America.

"We're starting with chlamydia and gonorrhea in California, and we would love to see that expand," Balderson says.

This isn't Planned Parenthood's first foray into mobile apps. Six months ago the organization launched another pilot app called Planned Parenthood Care. This one, only available in Minnesota and Washington, allows users to video chat with a health care provider and receive birth control or STD test kits through the mail.

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Apps can help make health care a lot more accessible, Balderson says. "Being able to be with someone all the time on their phone means that wherever they are, they can access it immediately." The format might particularly appeal to the age group most at risk for chlamydia and gonorrhea: men and women under 25.

And a cell phone is a lot easier to fit in your pocket than an actual Magic 8 Ball.

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DNA Confirms Kennewick Man's Genetic Ties To Native Americans

NPR Health Blog - Thu, 06/18/2015 - 2:34pm
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This clay facial reconstruction of Kennewick Man, who died about 8,500 years ago in what's now southeast Washington, was based on forensic scientists' study of the morphological features of his skull.

Brittney Tatchell/Smithsonian Institution

New genetic evidence suggests that Kennewick Man, an 8,500-year-old skeleton found in Washington state, is related to members of a nearby Native American tribe.

The DNA may help resolve a long-running scientific mystery, while at the same time reigniting a debate over who should have custody of the remains.

We can see very clearly that Kennewick Man is more closely related to present day Native Americans than he is to anybody else.

Kennewick Man was discovered accidentally in the mud flat along the Columbia River in 1996. He's caused a ruckus ever since.

Physical anthropologists said his facial features and cranium didn't look Native American. Researchers suspected he might have come from Asia or Polynesia.

But Native American groups insisted he was their ancestor and deserved a proper burial. The federal government agreed and locked up the skeleton. Scientists then sued to "release" it. And they won. Kennewick Man has been studied since then, and his remains are kept in a museum in Washington.

Up until now, the best-documented scientific hypothesis was that Kennewick Man is a relative of the Ainu, a group in Japan, or perhaps Polynesians. That was based on analysis of the skeleton and its features.

But new DNA evidence from a Danish group shows that Kennewick Man is genetically related to members of local tribes.

"We can see very clearly that Kennewick Man is more closely related to present day Native Americans than he is to anybody else," says Eske Willerslev from the University of Copenhagen. He specializes in the study of ancient DNA and led the research.

'Kennewick' Case Fails to End Battle over Bones
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Willerslev's team extracted DNA from one of the skeleton's hand bones. They compared it to DNA from various groups around the world, including Native Americans from North and South America.

They found that Kennewick Man is not related to the Ainu of Japan or Polynesians. But he does share a close genetic affinity with members of the Confederated Tribes of the Colville Reservation. These tribes stem from the Pacific Northwest, and are among several Native American groups that demanded custody of the skeleton.

These results were published Thursday in the scientific journal Nature.

But if that sounds like "case closed," it isn't.

Willerslev acknowledges that there is very little genetic information about modern Native Americans to make comparisons. There might be other tribes more closely related to Kennewick Man. And it also could be that Native Americans are descendants of some relative of Kennewick Man who lived 10,000 to 15,000 years ago.

"We probably will never be able to say who is, in fact, the closest living relative of Kennewick Man," Willerslev says.

And there's at least one scientist who isn't convinced by the genetic evidence. Physical anthropologist Douglas Owsley of the Smithsonian Institution has edited a 700-page study of the skeleton.

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Owsley is an expert on bones, not genes. At his laboratory, he displays a cast of Kennewick Man's skull — alongside skulls of three Native Americans. Clearly, Kennewick Man does look different.

"It is a much narrower and longer — relatively longer — cranium, and the way the base of the cranium is configured," he says. "It is different from what we see in Native Americans."

Owsley doesn't dispute that Kennewick Man, or his people, passed on genes that now show up in Native American populations. But he doesn't think the evidence is sufficient to satisfy the repatriation law that requires Native American remains to be turned over to tribal authorities.

And there's still the mystery of where Kennewick Man came from. Owsley says his bone chemistry reveals things about his diet. Apparently he was a coastal dweller and a wanderer. His ancestors could have been from far away — no one knows yet.

So what now? Well, groups of Native Americans say the skeleton is theirs. Some scientists, including Owsley, say there's still too much to learn about where Kennewick Man came from to bury him now.

Clearly, Kennewick Man isn't dead yet.

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Surprise! Some Job-Based Health Plans Don't Cover Hospitalization

NPR Health Blog - Thu, 06/18/2015 - 11:51am

Hospital bills can be as painful as the injury that lands you there — especially if insurance doesn't cover the costs.


Marlene Allen thought she had decent medical coverage after she fell in December and broke her wrist. She had come in from walking the dogs. It was wet. The fracture needed surgery and screws and a plate.

Weeks later, she learned her job-based health plan would cover nothing. Not the initial doctor visit, not the outpatient surgery, not the anesthesiology. She had $19,000 in bills.

"Make sure you find out what kind of plan it is" when employers offer coverage, advises Allen, who lives in northern Minnesota. "I thought health insurance was health insurance."

A complex health law and bad information helped cause the trouble.

When her employer offered the health plan late last summer, Allen thought she had to sign up. That was wrong.

Once she was on the employer plan, she thought she had to drop the better, more comprehensive coverage she had bought through MNsure, the state's online insurance marketplace. That was also wrong.

After she learned that her work plan covered hardly anything, and she tried to get back on a marketplace policy, MNsure told her she's not eligible for subsidies to buy it. Wrong again.

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"Horrible situation," says Sabrina Corlette, project director at Georgetown University's Center on Health Insurance Reforms. It "does make you wonder about the training these call-center folks are getting."

Last September, with an impending January deadline for employers to provide some sort of health insurance, in accordance with the federal health law, Allen's employer introduced a plan that covered only vaccines, blood-pressure tests and other preventive care.

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Skimpy though they are, such benefits meet one of the law's tests — the one that says employers must offer "minimum essential coverage" or pay a fine of about $2,000 per worker. (The skimpy benefits do not, by the way, pass a second requirement — that employer coverage offer "minimum value," including hospitalization. Flunking that test can result in a different fine of up to $3,000 per worker.)

Allen works for Independence Plus, a home-care agency. She takes care of her disabled son, who has multiple sclerosis, and gets paid through a state program as the company's employee.

Last fall, she joined the agency's minimum essential coverage plan and dropped her comprehensive MNsure plan. She knew the new coverage wasn't great, but she thought it would at least cover surgery. She believed she was obligated to take the coverage, and didn't notice that the insurance card says, "Preventive Services Only."

She was shocked when she learned it covered none of the charges for her broken wrist. She had always been careful to have medical insurance. Suddenly she faced hospital bills equal to more than half her annual income.

"I don't even want to call it a health plan," she says. "It should be illegal."

Minimum essential coverage policies, also known as "skinny plans," spread last year as lower-wage employers — such as temp agencies and hotels — adopted them as a shield against the $2,000 federal fine. Unlike Independence Plus, many employers supplement skinny plans with other health insurance, although even some of those lacked hospitalization benefits until federal regulators moved to ban them.

"There aren't too many companies that are doing just [these skinny] plans," said George Reardon, a Houston benefits lawyer who works with staffing companies.

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Ruby Baranski, who heads Independence Plus, says her firm can't afford more comprehensive benefits or even get insurers to offer them because of high worker-turnover. She blames President Barack Obama and the Affordable Care Act for forcing her to offer a minimal plan to avoid the fine of $2,000 per employee.

"I kind of got slapped with this," Baranski says.

Faced with no way to pay her huge bill, Allen applied for assistance from the health system that fixed her arm. Sanford Health would not comment on her case, but on June 3, it sent Allen a letter agreeing to wipe out its entire, $17,200 bill. That would leave her with only a $1,800 charge from the anesthesiologist.

Allen is grateful. But she's also worried, because the skinny, preventive-only plan is still her only health insurance. In February she told a representative of MNsure that she wanted to get back on a marketplace plan.

Allen explained to MNsure that her workplace plan doesn't cover hospitalization. She asked whether she could get subsidies to buy a comprehensive MNsure plan — the only way, with her $37,000 annual income, that she could afford the comprehensive policy's monthly premiums.

No, MNsure said. Because Allen was offered an affordable plan at work, MNsure said, she could not get tax credits to help subsidize the premiums she'd pay for a marketplace plan.

That's the wrong answer. All consumers in Allen's income range do qualify for subsidies unless an employer plan is both affordable and meets the minimum value test with hospital, doctor and drug benefits. (There's one more special case: Consumers eligible for a government program like Medicare are ineligible for subsidies aimed at defraying the cost of marketplace plans.)

Independence Plus's plan is affordable, but because of its skimpy, preventive-only benefits it falls far short of "minimum value" under the law.

Once Allen learned she had gotten bad information, MNsure's regular enrollment period for 2015 was over; it was too late to sign up. She applied for an exception so she wouldn't have to wait until next year to get covered.

MNsure spokesman Joseph Campbell acknowledges the error, but says it was a rare exception. The marketplace's employee training manual addresses both affordability and minimum value, he says.

But on Wednesday Allen got a letter stating again that she is ineligible for tax credits because she has access to insurance elsewhere.

"Boy, something is so wrong with this," she says.

The bigger lesson, Allen says, is this: Don't assume insurance offered by your employer is real medical coverage.

"You think when the word 'insurance' is said, it should cover you for everything," Allen says. Now she knows that's not true.

Copyright 2015 Kaiser Health News. To see more, visit
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When Should Surgeons Stop Operating?

NPR Health Blog - Thu, 06/18/2015 - 7:03am

A program based at Sinai Hospital in Baltimore offers a two-day series of assessments for older surgeons, evaluating "physical and cognitive" function.


Increased fatigue, forgetfulness, and reduced eyesight — these are some of the declines that can come with aging.

Certain professions keep a close watch for these sorts of changes, in hopes of protecting the public. And some jobs even have a firm age cutoff: Airline pilots are required to retire at 65, for example, and some firefighters must step down by 57. But there are no nationwide age-related cutoffs, required assessments or guidelines to make sure doctors can do their jobs safely.

We all know 80-year-olds who can play an intense game of tennis and others who can't even walk to the mailbox. Surgeons are the same; many still do great work in their 70s, but others should not be practicing anymore.

This month the American Medical Association took a step toward changing that, moving to convene a group of physician members to come up with guidelines for assessing the skills and abilities of late-career doctors. (No word yet on who would be charged with conducting such assessments of competency.)

One of every four licensed U.S. doctors is older than 65, with two-fifths of them actively practicing, the AMA estimates. The goal of creating guidelines, the organization says, is to head off calls for a mandatory retirement age while still safeguarding patients.

Dr. Mark Katlic, a 63-year-old thoracic surgeon at Sinai Hospital in Baltimore, was not involved in the AMA report but is a strong proponent of guidelines tied to competency, particularly for surgeons.

"We all know 80-year-olds who can play an intense game of tennis and others who can't even walk to the mailbox," says Katlic. "Surgeons are the same; many still do great work in their 70s, but others should not be practicing anymore."

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Katlic points to several worrying anecdotes he has heard of excellent surgeons who ran into trouble as they got older. One needed to be led back to his office after an operation. Another began showing up to work sloppy and unclean. Still another surgeon fell asleep while performing a procedure.

"I think the general public would be very interested to know that [surgeons] don't police [themselves] well as a profession," Katlic says. "It often takes a bad complication that hurts a patient before something serious is done."

Surgery requires solid mental and physical capabilities that some older surgeons may be lacking, he says. Fine motor skills are needed to wield sharp scalpels; endurance is essential for long procedures, and quick reaction times are a must, too. If a problem arises in the operating room, surgeons need to analyze the situation swiftly and make decisions on the fly.

Dr. Roger Perry, a surgical oncologist at Eastern Virginia Medical School, says this key problem-solving ability, known as fluid intelligence, can decline with age.

No operation is ever the same as any other, Perry says. "You need to be able to figure things as you go, and when problems arise, recognize an alternative."

But how do you determine whether a surgeon can no longer be trusted with the scalpel?

Since people age differently, a mandatory retirement age for surgeons is unfair, Katlic and Perry say. The key is creating a series of tests and guidelines that check capabilities, instead of using chronological age. The Aging Surgeon Program at Sinai Hospital is one example of this.

Created by Katlic in 2014, the program invites surgeons from around the world to come Baltimore to take a two-day test that rates their physical and cognitive abilities. Among the many skills and attributes examined, the test evaluates hearing, vision and hand-eye coordination.

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Surgeons who are concerned about their health can opt to take the test, but hospitals can also request evaluations of their surgeons. The results and recommendations — good or bad — are entirely confidential and supplied solely to the individual who requested the evaluation.

While it may sound like a good option for senior surgeons, the program has had its difficulties. For one, not a single doctor has stepped forward to take the test.

"However, we've learned that a number of physicians have opted to retire when threatened to be put through our program," Katlic says.

Stanford Health took a similar approach in 2012 when it created the Late Career Practitioner Policy, requiring physicians over the age of 75 to be screened every two years. The policy has faced opposition among Stanford faculty members, though, with some arguing that there is no research proving older physicians are more likely to make mistakes than younger doctors.

On Aging 'Silver Tsunami' And Other Terms That Can Irk The Over-65 Set

Some critics of these sorts of tests and guidelines say they are needlessly discriminatory and should focus on competency, not age. Others point out that physicians, of all people, have the training and experience to evaluate their own health and shouldn't need outside oversight. But that's not good enough, Katlic and Perry say. Doctors are human, too.

"Most people, regardless of the field they fall into, fail to recognize that they are not doing as well as they used to," Perry said. "We all know people in our families who are driving that shouldn't be — but if you speak to them, they think they are perfectly fine."

Perry thinks that, with time, the need for competency tests will become accepted by doctors.

And with that acceptance, he says, participation in the Aging Surgeon Program will increase, too.

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Why Some Teen Brains May Be Hardwired To Make Risky Choices

NPR Health Blog - Wed, 06/17/2015 - 1:55pm

Teenagers aren't exactly known for their responsible decision making.

But some young people are especially prone to making rash, risky decisions about sex, drugs and alcohol. Individual differences in the brain's working memory — which allows people to draw on and use information to make decisions — could help explain why some adolescents are especially impulsive when it comes to sex, according to a study published Wednesday in Child Development.

"Working memory is the ability to keep different things in mind when you're making decisions or problem solving," explains Atika Khurana, an assistant professor of counseling psychology at the University of Oregon who led the study.

Khurana and her colleagues rounded up 360 adolescents, ages 12 to 15, and assessed their working memory using a series of tests. For example, the researchers told the participants a string of random numbers and asked them to repeat what they heard in reverse order.

"We basically tested their ability to keep information in mind while making decisions," Khurana says.

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The researchers then tracked all the participants for two years, and asked about the teens' sexual activity. And through another series of tests and surveys, the researcher tried to gauge how likely each teen was to act without thinking, to make rash decisions and take risks.

There was a correlation between weaker working memory and the likelihood that a teen would have sex — including unprotected sex — at a younger age. And they were more likely to act without much deliberation. That trend held true even after the researchers accounted for the teenagers' age, socioeconomic status and gender.

Working memory develops throughout our childhood and adolescent years, Khurana says. But it seems this development can happen at different rates. This means some teens are more vulnerable than others to making unhealthy choices.

That's why basic sex education doesn't help all teenagers, Khurana notes. "You can give teenagers information about safe sex, but lot of times teens don't have the cognitive capacity to actually use that information and apply it in their lives."

The results add to a growing body of research that suggests that differences in teenagers' and young adults' brain development can affect their ability to make good choices, says Hugh Garavan, an associate professor of psychiatry at the University of Vermont who wasn't involved in the recent study. "But there are, of course, a lot of other factors in play. There are peer influences and personality factors. And there are genetic predispositions for impulsivity."

What scientists are still figuring out is how big a role working memory plays — and whether teenage brains can be trained to make more considered decisions.

"We know that working memory is malleable, and people can get better at it," Garavan says. Some researchers, including Khurana, are developing different activities and games that may help improve working memory. But at this point, there's little evidence to show whether these are effective.

The best parents can do try to be understanding — after all, some adolescents are biologically hardwired to act reckless, Garavan says.

The study also found that kids with very involved, engaged parents tend to make safer decisions about sex, regardless of the status of their working memories.

"So in this way, parental involvement can have a protective effect," Khurana says. "Especially for kids who have weaker working memories."

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When It Comes To SPFs And Sunscreens, We're Still In The Dark

NPR Health Blog - Wed, 06/17/2015 - 11:31am

Do you know what broad spectrum means? What about SPF? No need to be ashamed if you can't answer those questions, because you're not alone.

In a survey of 114 people, a mere 7 percent knew that "broad spectrum" on a sunblock label means it defends against early aging.

And only 23 percent understood the SPF, or sun protection factor, signifies the level of protection against sunburns. The findings suggest that despite recent efforts by the Food and Drug Administration to clarify sunscreen labels, they remain a mystery to many.

"There are hundreds of options when [people] go in front of an aisle, so it's hard to know what's best," says Roopal Kundu, a dermatologist at Northwestern University who led the study. It was published Wednesday in JAMA Dermatology.

But a large portion of those surveyed had a family member with skin cancer — and they still lacked understanding. "I thought they would be more knowledgeable," Kundu told Shots.

Tip: To know if a sunscreen helps ward off skin cancer, look for the term "broad spectrum" on the label. That means the product offers protection against both ultraviolet A (UVA) and ultraviolet B (UVB) rays — two types of radiation that are both associated with cancer. An SPF of 15 or higher is recommended, but the FDA says there's no evidence that SPFs of higher than 50 provide additional protection.

So what do consumers spring for when buying a sun lotion?

Nearly half of those surveyed said a high SPF value is most influential while browsing. That's important, Kundu says, but just not enough.

"This tells us there's a heavy reliance on SPF values, which only account for UVB rays; it has no affect on UVAs," she says. And UVAs Kundu argues, are possibly more worrisome than UVBs. UVAs can penetrate clouds and windows. They are present year round and throughout the day, and they penetrate the skin more deeply than UVBs.

Exposure to UVAs is a major cause of skin aging, wrinkling and tanning, while UVBs are the chief culprit behind sunburns. However, both types of radiation play roles in the development of skin cancers including melanoma, basal cell cancer and squamous cell cancer.

These two bad guys (UVAs and UVBs) can be prevented if broad spectrum is on the tag, but consumers seemed to lack understanding of the term's meaning, stating that it was not as influential in their product decision.

David Leffell, a dermatologist at Yale University who was not involved with the study, was not surprised by the lack of knowledge out there.

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"The concept of SPF and sun protection, in general, is very complicated for people to understand," he says. "[And] the truth is that the phrase 'broad spectrum' doesn't mean anything to anyone."

Leffell and Kundu agree that consumers should try to educate themselves more about the terminology before making a purchase, but they also say further FDA changes to sunscreen labels could be beneficial.

"I think a simplified type of labeling would be helpful," Leffell says. "We could translate the complex by using graphics."

Kundu thinks the key is highlighting the importance of UVAs on labels.

"A piece of the puzzle will be trying to create a better label for UVAs," she says. "Saying 'broad spectrum' is unclear to readers."

The FDA has tried to address UVAs on sunblock labels in the past. In 2011, they established the term "broad spectrum" so that consumers could recognize if a product offered protection against UVAs as well as UVBs.

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Documents Reveal Secret Legal Battle Over Medicare Overbilling

NPR Health Blog - Wed, 06/17/2015 - 5:03am

Federal officials have spent years locked in a secret legal battle with UnitedHealth Group, the nation's biggest Medicare Advantage insurer, after a government audit detected widespread overbilling at one of the company's health plans, newly released records show.

The audit found that Medicare paid too much for nearly half of a sample of patients enrolled at PacifiCare of Washington state, a subsidiary of UnitedHealth Group. The audit was part of a cache of heavily redacted documents released to the Center for Public Integrity through a court order in a Freedom of Information Act lawsuit.

Matt Burns, a UnitedHealth spokesman, declined comment on the audit documents. However, during more than three years of confidential — and previously undisclosed — negotiations, the insurer argued that the audit was unfair and the results were flat out wrong.

The PacifiCare audit offers a rare look at government oversight of the popular and fast growing Medicare Advantage industry. These privately run alternatives to the basic fee-for-service Medicare program treat more than 17 million Americans at a cost topping $150 billion a year.

These audits test the accuracy of a billing tool called a risk score. Medicare uses risk scores to pay health plans higher rates for sicker people and lower rates for those with few medical needs. But federal officials concede that some health plans may overstate how sick their patients are, a practice known as "upcoding" that wastes billions of tax dollars every year. The audits are designed to recover those overcharges.

It is clear that officials at the Centers for Medicare & Medicaid Services knew years ago that risk scores rose much faster among Medicare Advantage plan members than for people who remained on traditional Medicare, a worrisome signal of creeping billing abuse. A major 2009 government study that was not made public suggested some plans "gamed" the system by exaggerating how sick patients were, for instance.

So in June 2008, officials picked five health plans, including PacifiCare of Washington, Inc., for pilot audits. Details on the four other audits appear to have been redacted in records released to the Center for Public Integrity. CMS officials said only that the pilot audits "recovered" $3.4 million.

Under the audit rules, two sets of auditors combed over medical records for 201 patients to confirm they had the illnesses the government had paid to treat. If these conditions are not properly documented in the medical charts, Medicare asks for a refund. By contrast, plans can get credit when underpayments are discovered.

Among the PacifiCare audit findings:

  • Medicare paid the wrong amount for 128 of the 201 patients, an error rate of nearly two thirds. Payments were too high for 98 of the patients, too low for 30 of them. In total, the plan was overpaid by $381,776 out of $3,795,527 in payments in 2007.
  • One in five medical conditions could not be confirmed, and most of these errors triggered higher payments than justified. CMS officials blacked out large chunks of the audit documents released, including the names of the medical conditions.
  • Auditors cited a "lack of sufficient documentation of a diagnosis" most often as the cause for either denying or slashing payments. However, in more than a third of the errors, payment was denied because the medical file was missing the required signature of the doctor who treated the patient.
Inside A Medicare Advantage Audit

Federal auditors reviewed 786 diagnoses based on medical records from 201 people enrolled in a PacifiCare of Washington Inc. plan — a subsidiary of insurance giant UnitedHealth Group.

Source: 2012 CMS audit

Credit: Center for Public Integrity

CMS records show that the audit dragged on for years because officials changed some rules in the middle of the game and set up a lengthy and bureaucratic appeals process for health plans to follow.

CMS shared "preliminary" audit findings with the company in December 2010, but took nearly two years more to present a final version.

In a letter on Aug. 21, 2012, CMS officials said UnitedHealth owed the government $381,776. CMS said that it would deduct the money from upcoming payments to the plan, and reminded the company it could appeal.

Scott Theisen, UnitedHealth Group chief financial officer, filed an appeal in a Sept. 20, 2012, letter. He argued that the audit ample was too small and that the insurer didn't give the company enough time to secure sufficient medical records to justify its billing.

"Thus the amount of the overpayment claimed to be due by CMS cannot be accurate," Theisen wrote.

On March 14, 2014, a CMS hearing officer remanded the case to the agency for further negotiations.

CMS wouldn't say what happened next. In a statement, the agency wrote: "CMS takes seriously program integrity and payment accuracy in Medicare Advantage, and is taking steps to protect taxpayers, Medicare beneficiaries and the Medicare program. CMS is exploring how to make RADV hearing officer decisions public in such a way that safeguards the protected health information of Medicare Advantage enrollees."

Back in 2008, CMS had announced that it would start applying penalties known as "extrapolation," which have been widely used in other types of Medicare fraud investigations.

This meant that the billing error rate found in the sample of 201 patients would be applied to the PacifiCare of Washington plan. That could have dramatically boosted the extrapolation penalty.

But somewhere between 2008 and 2012, officials changed their mind and let Medicare Advantage plans off the hook.

CMS officials have never explained fully why they decided against extrapolating the audit findings.

But a confidential CMS presentation dated March 30, 2011, perhaps offers a clue. One slide estimates payment errors in Medicare Advantage at $13.5 billion for 2010, and notes that health plans "have an incentive to submit more diagnoses" in order to raise their payments.

When CMS sought opinions on the audits in December 2010, the presentation notes, it received more than 500 comments. "These comments express significant resistance to the implementation of the [Risk Adjustment Data Validation] audits and payment recovery based on extrapolated payment error estimates," the presentation states. "Successful payment recovery based on payment error identified in these RADV audits will depend on CMS' ability to address the challenges raised."

One slide said that CMS was "expecting to respond to the comments and finalize the payment error calculation methodology and overall strategy shortly."

As of last month, more than four years later, that still hasn't been done.

The secrecy surrounding Medicare Advantage payments has prompted a stern rebuke from Senate Judiciary Committee Chairman Charles Grassley.

"The public's business ought to be public, with few exceptions. An agency shouldn't withhold internal deliberations unless there's a really good reason for it, like a risk to national security. It seems to me that a discussion of a Medicare overpayment problem and what to do about it ought to be public," the Iowa Republican said in an email.

"What is CMS worried about disclosing and why?" Grassley added.

Last month, Grassley wrote to Attorney General Loretta Lynch and CMS administrator Andrew Slavitt asking how many of the risk score fraud audits had been launched over the past five years and their results.

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In a separate letter, Sen. Clare McCaskill, the senior Democrat on the Senate Aging Committee, asked CMS officials what's being done to curb billing fraud and abuse alleged by Medicare Advantage whistleblowers, calling it "an issue that must be investigated further."

Congress authorized the use of risk scores starting in 2004. It's essentially an honor system in which health plan doctors assess every patient's health risks (and thus the associated payments) based on specific medical conditions they have, such as diabetes. Exactly what's permissible under the billing rules, however, remains confusing even to many health plan professionals.

"I think there's really not a very good understanding of how this works," said Holly Cassano, a medical coding consultant in Florida.

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. To follow CPI's investigations into Medicare and Medicare Advantage waste, fraud and abuse, go here.

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Updated Training Of Birth Control Counselors Boosts Use Of IUDs

NPR Health Blog - Tue, 06/16/2015 - 9:35pm

When health care providers have the latest information on various birth control methods, research suggests, more of their patients who use birth control choose a long-acting reversible method, like the IUD.


Just over half of all pregnancies in America are unplanned.

The most effective reversible birth control methods are hormonal implants and intrauterine devices. Less than 1 percent of women using these long-acting contraceptive methods will become pregnant over the course of a year. That's compared to 9 percent of women using the pill who will get pregnant, and to 18 percent of women whose partners use a condom.

Yet fewer than 12 percent of women who report using birth control have an IUD or hormonal implant.

Researchers from the University of California, San Francisco had an interesting idea about how to increase that rate. Instead of directly educating women about IUDs and implants, they conducted a study to see if educating health care workers about the latest innovations and statistics regarding contraceptives would make a difference.

It did. Unintended pregnancy rates among young women in the study dropped by almost half.

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"Providers were much more likely to counsel them on these highly effective methods — IUDs and implants," says Cynthia Harper, the UCSF professor and family planning researcher who led the study. "Women had demonstrated greater knowledge of these methods. They were more likely to select them." Details of the findings were published Tuesday in the Lancet.

Harper says a number of new contraceptive methods have come out in the last few years, including the hormonal IUD and the contraceptive implant. The training administered in the study helped clinicians understand technicalities of each method, including their benefits, side effects, and which method might be most appropriate for patients with various needs.

UCSF partnered with 40 Planned Parenthood clinics across 15 states in the study. Workers at half the clinics received the latest training about birth control methods; half did not.

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The discussion of IUDs and implants was starkly different in clinics where counselors got the extra training compared to clinics without the training: 71 percent of providers who received training brought up these long-term birth control methods with their patients, versus 39 percent of providers in the control group.

Fifteen-hundred women, ages 18 to 25, were enrolled in the study. They were eligible only if they said they wanted birth control counseling and that they did not want to become pregnant. Those who received counseling from health care workers who had undergone the recent update training on contraceptive methods chose an IUD or implant 28 percent of the time. Only 17 percent of women at the control clinics chose those methods.

Harper says a major barrier for many women in choosing an IUD or implant was cost. IUDs can cost up to $1,000. But they actually are more cost-effective than other methods over time, since their effectiveness lasts for years.

The study was done from 2011-2013, before the Affordable Care Act — and its coverage of birth control — took full effect, and 38 percent of the women studied did not have health insurance.

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"I'm hopeful that if the ACA is in place and if women are more likely to be insured for contraceptives, then they'll be able to afford these methods that have higher upfront costs," Harper says.

The pregnancy rate dropped from 15 percent to 8 percent over the course of the study. But for reasons the researchers say they can't explain, that drop only occurred among women who came to the clinic specifically seeking contraception and family planning counseling. There was no change in the pregnancy rate among women who sought birth control after an abortion.

The researchers found that fewer women who wanted to use an IUD or implant after an abortion were actually able to get them. Nearly a quarter of these women were pregnant again within a year.

Only 44 percent of the women who chose IUDs or implants after an abortion actually obtained them, Harper says.

"Now we're looking at why," she says. "What were the restrictions?" Harper notes that there are restrictions in the use of public money for birth control in clinics that provide abortions.

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

Copyright 2015 KQED Public Media. To see more, visit
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Defeat By Deductible: Millennials Aren't Hip To Health Insurance Lingo

NPR Health Blog - Tue, 06/16/2015 - 1:10pm
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Coinsurance? Premium tax credit? HMO and PPO?

Swimming through the health insurance word soup can be frustrating for anyone. Even though I cover health, I couldn't define "cost-sharing reduction plan" until I Googled it just now.

And it seems I'm not the only clueless 20-something here. Young adults, who generally have little experience managing their own health care expenses, are finding it especially hard signing up for insurance under the Affordable Care Act, according to a study published Tuesday in the Journal of Adolescent Health.

Researchers at the University of Pennsylvania wanted to see how well young people would fare navigating through So they rounded up about 30 young adults, aged 19 through 30, who were interested in enrolling for insurance. They were all college-educated, and based in Philadelphia.

The researchers sat them in front of computers and observed as they navigated through the online enrollment process. "We asked them to think out loud, so we could really capture their experience," says Charlene Wong, a pediatrician at the University of Pennsylvania who lead the study.

Wong and her colleagues interviewed the participants right after they completed their enrollment and again a month later.

"Many of them said, 'You know, I've never tried to do this before and it feels a little bit overwhelming because there's so many different options,' " Wong says.

Half of the participants couldn't define "deductible," and three quarters couldn't explain "coinsurance."

Plus most of them were unaware of subsidies for insurance, and they didn't have an idea of how much insurance plans generally cost. Most thought that an affordable plan cost less than $100 a month — but the cheapest plan in Philadelphia cost $187 monthly, without tax credits.

The study involved college-educated, tech-savvy young people, Wong points out. "Considering that, we were really surprised at just how much they didn't know."

Previous surveys have turned up similar findings. The recent study is small, Wong says. But it takes a more in-depth look at how young people feel about the enrollment process.

The results suggest that the government as well as insurance companies need to do a better job of educating people about the basics, Wong says. Making the process easier for young people is crucial to the success of Obamacare, she points out, since more healthy young Americans need to pay into the insurance system to help cover the costs for older, sicker people.

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Of course, getting anyone to retain information about insurance isn't easy. "It's dry material," says Erin Hemlin the health care campaign director at Young Invincibles, an advocacy group that helps educate young people about health policy.

Young Invincibles has tested out some creative ideas to get people interested, like sponsoring concerts. They conduct weekly Twitter chats. And they've developed an app that helps guide people through the enrollment process.

If the process is confusing for the young people in this study, Hemlin says, it's even harder for demographic groups.

"I spent about four months in Texas during the first open enrollment period helping a mostly low-income, Latino population apply for insurance," she says. "It was so disheartening, because these insurance terms are confusing in English. And they don't translate well at all."

Lots of young people she encounters are intimidated by the process so they're not able to take advantage of the services available to them, Hemlin says. "This lack of health insurance literacy is the biggest barrier right now. I want more young people to realize 'Oh, wait, I actually can afford this.' "

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Insurance Still Doesn't Cover Childbirth For Some Young Women

NPR Health Blog - Tue, 06/16/2015 - 5:48am

If you're getting insurance through a parent's plan, don't presume the hospital bill for childbirth will be covered.


Although the federal government recently clarified that most insurance plans must cover prenatal care as a preventive service without charging women anything out of pocket, it didn't address a crucial and much pricier gap in some young women's coverage: labor and delivery costs.

Perhaps that shouldn't come as a surprise.

Insurers and some employers have long tried to sidestep paying for maternity care, which includes prenatal, delivery and postpartum services. Individual plans typically refused to pay for pregnancy-related services until the Affordable Care Act established that maternity and newborn care are both essential health benefits that must be included in individual and small group coverage.

Large employers that provide health insurance are required to cover maternity care for employees and their spouses under the Pregnancy Discrimination Act of 1978. But that protection doesn't extend to dependent children, even though under the health law, adult children can now stay on their parents' plans until they turn 26.

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In May, the federal government clarified that preconception and prenatal care is covered without cost sharing for dependent children in all plans, except for plans that were grandfathered under the law.

But prenatal care is a small portion of the cost of having a baby, and families that have to pay for an adult child's labor and delivery charges could be on the hook for thousands of dollars.

Insurers paid $18,329 for a vaginal birth and $27,866 for a cesarean birth on average in 2010, according to a study by Truven Health Analytics. Consumers paid an average of $2,244 and $2,669, respectively, out of pocket. The payment totals include all maternity care.

Hospitalization made up between 81 and 86 percent of the total cost of pregnancy and childbirth, the study found.

"The payments that are made are highly concentrated in that little window," says Carol Sakala, director of the Childbirth Connection, one of the organizations that commissioned the study. The Childbirth Connection is a program of the National Partnership for Women and Families, a women's health advocacy group.

Although there are no data on how many large employer plans refuse to cover maternity care for dependent children, benefits analysts say it's common.

In 2013, the National Women's Law Center filed sex discrimination complaints with the Office for Civil Rights of the Department of Health and Human Services against five employers that exclude pregnancy-related coverage for the dependent children of their employees.

The law center brought the complaints under Section 1557 of the health law, which protects people from discrimination on the basis of sex, race, color, national origin, age, disability, gender identity and sex stereotypes.

"Pregnancy discrimination is per se sex discrimination," says Dania Palanker, senior counsel at the National Women's Law Center. The center is still awaiting a response from the civil rights office.

The HHS Office for Civil Rights can't comment on open cases or compliance reviews, a spokesperson there said.

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