NPR Blogs

Intensive End-Of-Life Care On The Rise For Cancer Patients

NPR Health Blog - Wed, 07/22/2015 - 1:04pm

Maximum care at the end of life for cancer patients has increased.


Conversations about end-of-life care are difficult. But even though most people now take some steps to communicate their wishes, many may still receive more intensive care than they would have wished, a study published in July found.

The findings, published online in JAMA Oncology, came from an analysis of the Health and Retirement Study, a national survey of U.S. residents older than age 50. Researchers looked through the responses from the next of kin, usually a spouse or child, of 1,985 participants with cancer who died between 2000 and 2012.

The patients' family members responded to questions about how frequently patients had signed durable power of attorney documents or living wills or participated in end-of-life care conversations. Researchers then examined the association between those advance-care-planning activities and the treatment patients received at the end of life.

Over the study period, the use of durable power of attorney assignment, sometimes called a health care proxy, grew from 52 percent to 74 percent among participants. Small declines were reported in other planning activities — from 49 percent to 40 percent for living wills and 68 percent to 60 percent for end-of-life discussions. But those changes weren't statistically significant because the levels varied throughout the study period, says Dr. Amol Narang, a radiation oncologist at Johns Hopkins School of Medicine and the lead author of the study.

"Our hypothesis was that we'd see significant increases over the study period in advance directives," Narang says. "What we saw was that important aspects of advance care planning haven't increased."

At the same time, the proportion of patients who were reported to have received "all care possible" at the end of their lives increased substantially over the study period, from 7 percent to 58 percent, even though such intensive treatment may have been counter to their stated wishes.

A durable power of attorney allows consumers to appoint someone to make health care decisions for them if patients are unable to do so. Living wills describe the types of medical care people wish to receive (or don't wish to receive) if they're incapacitated. Neither requires a lawyer, and forms are often available online.

Simply signing a document isn't enough, however. There's no substitute for regular communication with friends and family about end-of-life preferences.

If patients "haven't discussed their preferences with that person the proxy may default to 'all care necessary,'" Narang says. In other words, lacking clear guidance, the health care proxy may choose to err on the safe side and approve more care rather than limit or withhold it.

Living wills spell out which treatments someone would want — specifying that they would want to be put on a ventilator, for example, or fed through a tube. But some experts say treatment-focused specificity may not serve patients' best interests.

Spelling out treatment preferences is only useful in context, says Dr. Diane Meier, director of the Center to Advance Palliative Care.

"Of course you would want to be put on a ventilator if it was going to return you to health," Meier says. The more important question is a qualitative one: What is the quality of life that is unacceptable to you? Would you want every measure taken to treat an illness or injury even if it meant enduring extreme pain with little likelihood of improvement? Or would you rather forgo such intensive treatment and be kept comfortable instead? Those are the conversations that need to happen, experts say.

The issue is front and center these days as policy makers debate the recent federal proposal to reimburse physicians for conversations with Medicare patients about advance care planning.

"It's a significant step in the right direction," says Jonathan Keyserling, senior vice president for health policy at the National Hospice and Palliative Care Organization. "Now that healthcare professionals can soon be reimbursed for these intimate and thoughtful conversations, I think we'll see changes in practice patterns and in decisions by family members."

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Health Effects Of Transitioning In Teen Years Remain Unknown

NPR Health Blog - Wed, 07/22/2015 - 11:18am

Most transgender adolescents go through the same steps during the medical transition from one gender to another. They're given a drug that blocks or pauses puberty. Then, if they and their doctors are sure they want to continue, they are given sex hormones that will resume puberty and give them more male or more female bodies.

This has been going on for just under a decade. "But what are the benefits and adverse effects of starting young kids on these powerful [puberty blockers] and then hormones? We don't know," says Dr. Frederic Ettner, a physician who has worked with transgender patients for over two decades. Since hormone treatment began for transgender youth, there's been a paucity of data on what happens to them in the long term.

What is known about transgender youth health is pretty dismal. A 2007 paper showed that out of a survey of 55 transgender youth, about a quarter had attempted suicide at least once. Drug abuse and depression are common as are high blood pressure, obesity and diabetes. The lack of information also makes it hard for doctors and patients to decide on treatment options.

Many physicians who treat trans youth believe that not giving hormone treatment is unethical, because of the strains of going through their biologically programmed puberty. "There are very compelling data showing very high risk of depression, suicide ideation, suicide attempts, and other risk taking behavior," says Dr. Stephen Rosenthal, a pediatric endocrinologist at the University of California San Francisco Benioff Children's Hospital.

On the other hand, physicians want to be cautious in administering treatments like puberty blockers and hormones when they aren't sure what the consequences might be, or even the best way of administering treatment. "We have no way of assessing what would be the best way of caring for these people," Rosenthal says.

Researchers are starting to try to answer those questions. For one, it looks like teenagers and young adults who identify as transgender have hormone levels consistent with their birth gender, according to a paper published Tuesday in the Journal of Adolescent Health. The study, begun in 2011, enrolled 101 transgender adolescents between 12 and 24 years old who had not begun hormone or puberty blockade treatment and measured everything from depression to cholesterol and hormones.

Virtually all the participants had typical levels of estrogen and testosterone for non-trans people of the same age and genitalia. "There's this pervasive notion that if I gave a child more of the assigned sex hormone, then they will have that gender experience," says Dr. Johanna Olson, director of the Center for Transyouth Health at Children's Hospital Los Angeles and lead author on the study. Olson says this piece of data shows that's not true, and giving someone more testosterone isn't going to change their gender identity.

Olson has applied for grants to continue the study, plans to follow the group for as long as funding for the study is available. By measuring psychological and physical changes over time, "We're going to know more about these young people as they begin whatever interventions they're going to begin," she says.

Eventually she thinks that will provide insight into how well or poorly the treatments work.

Because the patients are beginning their transitions at different ages, Olson hopes the study will show whether it's a better idea to give trans youths hormones at an earlier age or wait.

At the moment, the Endocrine Society recommends starting at age 16, but Olson argues that's an inappropriately late time to begin puberty for most teenagers. "[We're] looking at the impact of early treatment and how that creates healthier lives," Olson says.

There are researchers who disagree. A paper published in 2008 showed that only a fraction of children who felt their assigned sex was different from their gender continued feeling that way as they grew older. Some researchers feel that means puberty should be blocked until at least age 16 so an individual could learn if they were truly transgender.

But Olson says it's ridiculous to think it would take individuals 16 years to determine their gender identity, and that it's unfair to assume that about transgender people. "That really doesn't apply to people who aren't transgender. You wouldn't ask somebody who's not transgender at 16 or 18 if you're sure you know your gender," she says.

Other gender researchers note that the study might be considered flawed since it assumed all gender-questioning children are the same and lumped them all together in the same analysis.

This paper doesn't put that debate to rest, though Olson is hoping that future data on her patients might help. At the moment, it simply gives something of a snapshot of how transgender youth are doing today through a slew of psychological and physical examinations.

For one, on average, Olson's patients said they knew they were transgender at age 8, but didn't tell anyone until they were 17. "Those years are very important developmentally, psychologically — if you wait to tell anyone about this for so long, that's going to lead to some negative psychological outcomes," says Colt Keo-Meier, a clinical psychologist in Houston who works with transgender patients.

"A young person sitting on what feels like a secret to them, not disclosing their authentic selves because they're scared or ashamed or gotten overt or covert messages that who they are is not okay — that will have an impact on them," Olson agrees. But like so much else in the field, that impact is unclear for now.

That's making the work harder for health care providers, especially as more and more transgender people seek treatment, says Olson. "The demand for clinical care is outpacing the scientific knowledge by – by a lot."

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For Kids With Tourette's, At-Home Training Could Help

NPR Health Blog - Wed, 07/22/2015 - 8:26am

If you've ever had hiccups in a quiet room, you know how embarrassing and completely uncontrollable they can feel. What if, instead of the hiccups, your body jerked involuntarily or you blurted out words without meaning to? That's a rough idea of what living with Tourette syndrome can be like.

Designers of a new computer program called TicHelper hope that they will be able to help children recognize and control these impulses themselves.

People with Tourette's perform repetitive movements or vocalizations called tics. A simple tic might be something like head jerking, eye blinking, or throat clearing, and a complex tic might involve patterns of movement or saying multiple words or phrases.

We don't know exactly what causes Tourette's, says Douglas Woods, a psychologist at Texas A&M University. Woods, who is also co-chair of the Tourette Association of America Medical Advisory Board, is one of the minds behind TicHelper.

Tourette's affects more boys than girls, and symptoms usually start between ages 3-7.

A view of


"Sometimes kids will grow out of [Tourette's]," Woods says. But if the wait-and-see approach isn't working, and the tics are interfering with daily life, there are a few treatment options.

One option is medication. Woods says there are a few different antipsychotic drugs that are used to manage Tourette syndrome, but they have side effects and don't always work. An alternative to pharmaceutical treatment is behavioral therapy.

A form of behavioral therapy called comprehensive behavioral intervention for tics, or CBIT for short, is commonly used. CBIT training teaches people with Tourette's to recognize the onset of a tic and to perform a different behavior when they feel one coming on.

"The idea is that when someone has a tic, they tend to have an urge," says clinical psychologist Eric Storch, a professor at the University of South Florida and Clinical Director of Pediatrics at Rogers Memorial Hospital in Tampa. "It's like when you're about to yawn. You know just before it happens that a yawn's coming. [CBIT] teaches a person to be aware."

And it gives them the tools to manage tics. Storch describes a patient whose tic was rubbing two fingers together, to the point of rubbing off skin. With CBIT, the boy was able to recognize the onset of a tic and instead unobtrusively press down on his kneecap until the urge went away.

A typical CBIT training program involves eight sessions with a therapist, spread over 10 weeks. Results, Woods says, can be maintained up to six months.

Both psychologists say that CBIT is at least as effective as medical treatments. The problem is that it requires specially trained therapists — and there aren't that many of them. Which is where TicHelper comes in.

"It's essentially a self-help, self-guided program that leads the patient through a CBIT treatment," Woods says. He and his colleagues received funding from the National Institute of Mental Health to develop TicHelper, which is now being tested. So far, the results look promising. "The kids that go through it, enjoy it," Woods says. They're able to do the skills,"

The program has four main sections: tic education, reducing tic triggers, tic awareness and tic blocking. Videos featuring a friendly actress guide patients thorough each section. The program personalizes treatment based on feedback from the patient. Woods says the testing will help the designers modify and improve it based on user feedback. Though TicHelper isn't available yet, interested patients or doctors can sign up to receive updates on its progress.

The website currently lists the cost of an 8-week program through TicHelper at $150, but Woods says that the price isn't set.

Storch, who is unaffiliated with TicHelper, is enthusiastic about the idea of at-home treatment for tics. "I really think it's an exciting development that has a lot of practicality," he says. "We know what behavioral treatments work well for tics, but the dissemination is really terrible."

Storch says the biggest advantage of TicHelper will be its accessibility. CBIT, he says, works well and is incredibly safe compared with pharmaceuticals. TicHelper would maximize the benefits of CBIT by making it more inexpensive and easier to get to than therapy.

Which is not to say that Storch or Woods would recommend TicHelper as the only form of tic management. Both psychologists suggest that this program might work best as part of a management plan. One option, Woods says, might be to start treatment with TicHelper at first diagnosis and proceed to more intensive care if in-home treatment isn't working.

Storch thinks that ideally the patient would work with the program, but touch base periodically with an experienced therapist or health care provider to check progress. But, he says, "we don't have enough providers." And some treatment, he says, is better than no treatment at all.

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How Vandalism And Fear Ended Abortion In Northwest Montana

NPR Health Blog - Tue, 07/21/2015 - 6:01pm
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Susan Cahill, owner of All Families Healthcare, stands in front of the first building in Kalispell, Mont., where she offered abortion services. After vandalism closed her last clinic down, Missoula became the nearest place for women in the Flathead Valley to find abortion services.

Corin Cates-Carney/MTPR

There has never been a welcome mat for abortion service providers in the Flathead Valley, a vast area that stretches over 5,000 square miles in the northwest corner of Montana. Susan Cahill began providing abortions in 1976 in the first clinic to offer the service in the Flathead.

"But that had an arson fire, and then we rebuilt that," she says. "Then we had the anti-choice people try to arrest me for doing abortions when I wasn't a doctor."

Cahill performed abortions as a physician assistant for 38 years. Police testified in a recent trial that in March of 2014, Zachary Klundt took a hammer to the photos in Cahill's office, poured iodine on the floor and tossed files from cabinets. Klundt damaged the building's heating and plumbing and discharged a fire extinguisher. He said he broke into the clinic looking for prescription drugs.

Everything was destroyed in Cahill's clinic.

"I've worked since I was 17," she says. "Everything I've had, I've worked for."

The clinic was in Kalispell, population 20,000. It's the hub of the Flathead Valley, and the largest employer is Kalispell Regional Medical Center. In a town full of health care professionals, Cahill was the only one providing abortions.

"Because I was the only one, I got targeted," she says.

Cahill's clinic was a general family practice; her patients have had to find other health care. For abortion care, the options are more limited.

According to the Guttmacher Institute, in 2008 about a third of American women seeking access to abortion services traveled more than 25 miles to get them. Today, a woman in Kalispell has to drive 120 miles — each way — to Missoula to get an abortion. And some women are doing just that, says Melissa Barcroft, of Planned Parenthood of Montana, in Missoula.

"Anytime a provider stops providing services, the need doesn't go away," Barcroft says. "Patients still need that care."

The loss of Cahill's clinic has been frustrating, Barcroft says.

"I know from talking with our providers that we have seen a definite increase of patients from the Flathead area," she says.

Cahill says she worries most about poor women, or those from the town of Browning, on the Blackfeet Indian reservation.

"The disadvantaged are always the ones that lose," Cahill says. "Now you've got people who are on Medicaid, or who are from Browning, and are teenagers." It can be much harder for them to get to Missoula, she says. "I used to give gas money for people to go home. Now ... it is just a harder struggle for them."

Cahill says plenty of local physicians can perform abortions, but they're afraid.

Samantha Avery trained under Cahill at All Families Healthcare. At the time, Avery thought about going to medical school to pursue a career like Cahill's.

"I know that she wanted me to be the one to take over her clinic," Avery says. "End even before all of this, I told her, 'I just don't know if I could do that to my family — my future family. I can't be the Susan Cahill. I'm not that brave of a person.' "

Zachary Klundt and his sister in court.

Corin Cates-Carney/MTPR

Avery decided instead to work for the Public Health Department in Flathead County. She says it was hard for her to watch Cahill lose everything so quickly. The weight of the community's opposition to abortion is difficult to counter, she says — citing Zachary Klundt, who was convicted in the attack against the clinic, as just one example.

Klundt's mother was on the board of Hope Pregnancy Ministries, which advocates for alternatives to abortion. She resigned after the attack.

Michelle Reimer, the executive director of Hope Pregnancy Ministries, says that what happened to Cahill and her clinic was terrible, and totally against her group's mission.

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"There is not a place for it in a Christian organization," Reimer says. "There is always going to be the outlier, the one who represents us poorly, or who says the wrong thing, or — as we all would with a very volatile topic like abortion — expresses [himself or herself] passionately rather than logically. And I think we see that on both sides."

Reimer says at the core of her faith is compassion — and telling a woman that regardless of what she chooses, she is loved.

In June, Klundt was sentenced to 20 years, with 15 years of that suspended. He was also ordered to pay restitution. In the courtroom, Klundt read Cahill an apology.

"I cannot even believe I did that to another soul," he says. "But I did that to you. I know what it's like to live with fear, and for me to do that to you is awful. And I am truly so sorry."

He said his actions do not represent his faith.

For women in the Flathead Valley, Susan Cahill says, getting reproductive care is not any easier now that Klundt is sentenced. Her clinic is still gone.

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

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Women's Brains Appear More Vulnerable To Alzheimer's Than Men's

NPR Health Blog - Tue, 07/21/2015 - 4:21pm
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Women with mild cognitive impairment, which can be a precursor to Alzheimer's, tend to decline faster than men.

Lizzie Roberts/Getty Images/Ikon Images

There's new evidence suggesting that women's brains are especially vulnerable to Alzheimer's disease and other problems with memory and thinking.

Women with mild cognitive impairment, which can lead to Alzheimer's, tend to decline faster than men, researchers reported this week at the Alzheimer's Association International Conference in Washington, D.C.

Another study showed that women's brains tend to contain more amyloid, the substance that forms sticky plaques in Alzheimer's. And a third study found that women who have surgery with general anesthesia are more likely than men to develop long-term problems with thinking and memory.

The studies help explain why women make up two-thirds of all Americans with Alzheimer's. And the results challenge the notion that more women have Alzheimer's simply because they tend to outlive men, says Kristine Yaffe of the University of California, San Francisco.

"There's something else going on in terms of the biology [or] the environment for women," Yaffe says.

The research on women with mild cognitive impairment was part of a large ongoing study called the Alzheimer's Disease Neuroimaging Initiative. Researchers studied up to eight years of records on about 400 men and women in that study who had mild cognitive impairment, a condition that often leads to Alzheimer's.

"We found that women decline at almost twice the rate of men and we also found that women have faster acceleration of decline over time," says Katherine Amy Lin, part of a team at Duke University Medical Center. So many women who had subtle memory problems at the beginning of the study period had major deficits by the end.

Another study presented at the Alzheimer's meeting used PET scanning to measure levels of amyloid in about 1,000 people, including many with cognitive impairment or Alzheimer's disease. Amyloid is the substance that forms sticky plaques in the brains of Alzheimer's patients.

There was a clear difference between men and women, regardless of their age, says Michael Weiner of UCSF, the study's senior author. "Overall, women had more amyloid in their brain than men," he says, which suggests they are at higher risk of developing Alzheimer's.

What's still not clear, though, is why women's brain cells are more vulnerable than men's to Alzheimer's and other memory problems, Weiner says.

One possible explanation is that every cell in a woman's body carries two X chromosomes, instead of an X and a Y, Weiner says. "But there are other differences," he says, such as hormones, lifestyle, childbearing, diet, and exercise.

If scientists can figure out the mechanism that causes more Alzheimer's disease in women, Weiner says, they might be able to develop treatments that halt the process.

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2 Gene Studies Suggest First Migrants To Americas A Complex Mix

NPR Health Blog - Tue, 07/21/2015 - 3:45pm
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The area around the confluence of the Silverthrone and Klinaklini glaciers in southwestern British Columbia provides a glimpse into how the terrain traveled by Native Americans in Pleistocene times may have appeared.

David J. Meltzer/Science

The first people to set foot in the Americas apparently came from Siberia during the last ice age.

That's the conventional wisdom.

But now there's evidence from two different studies published this week that the first Americans may have migrated from different places at different times — and earlier than people thought.

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The human race has walked or paddled or sailed until it covered the globe. Scientists can trace those migrations from the stuff these people left behind: tools, dwellings or burial grounds.

Geneticists can now trace these patterns of travel, too — by examining the genes of living people and comparing them to each other, as well as to genes extracted from ancient bones. Rasmus Nielsen of the University of California, Berkeley and a large, international team of scientists have done just that for native people of the Americas. And they think they've figured out how the very first people got here.

"They came in a single migration wave into the Americas," Nielsen says — "people who diverged from people originally in Siberia and East Asia about 23,000 years ago."

Now, that confirms the standard view that people first got here across a frozen "land bridge" between Siberia and Alaska, albeit a few thousand years earlier than many had assumed.

But there's long been a lingering puzzle: Some ancient skulls found in the Americas look rather like Europeans, or maybe Polynesians. Did another group come from somewhere else?

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Writing in this week's issue of the journal Science, Nielsen says no. Genetically, no Native Americans match up with Europeans or Polynesians, in terms of these markers of ancient migration. Instead, he says, there was just one major, founding wave of people moving into the continent; any diversification of Native American groups must have evolved on its own after the first bunch of people got here.

"Diversification of modern Native Americans happened in the Americas," Nielsen says — "not because people came from all over the world into the Americas."

But there's often a twist when you're teasing apart the threads of ancient history with genetic tweezers. David Reich, a geneticist at Harvard Medical School, says his research — published Tuesday in the journal Nature — suggests a more complicated story.

When Reich studied groups of indigenous people in South America, he found that some of them had a peculiar genetic fingerprint. He searched the world for other copies of that fingerprint and found it far away — in modern Australasia.

"What we found," says Reich, "was that Native American people from Amazonia — from present-day Brazil — are more closely related to some populations in Asia than are other Native Americans, for example from Mexico, or from western South America and many parts of North America."

The Amazonians' modern relatives — the Australasians — are native Australians, and people of New Guinea and the Andaman Islands.

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Reich says what may have happened is this: Members of a now-extinct population of people in what's now Southeast Asia — Reich calls them Population Y — crossed the land bridge as well, either before or after the first wave of people made it to the Americas. This splinter group from Population Y kept going, and some members got all the way to Brazil. Meanwhile, those who stayed behind in Asia populated what is now Australasia. But the two groups still are linked genetically.

Says Reich: "We now have the possibility of there being two different streams of ancestry penetrating south of the ice sheets, so that's a very exciting new observation."

That observation adds yet another branch — or root — to the American family tree.

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With Pap Tests Less Common, Women May Miss Out On STD Tests

NPR Health Blog - Tue, 07/21/2015 - 2:14pm

The chlamydia bacteria can cause pelvic inflammatory disease and fertility problems, but women often don't know they're infected.

David M. Phillips/Science Source

Changes in how women are screened for cervical cancer mean they're getting Pap tests less often. But that may also mean young women are not getting tested for chlamydia, the most common sexually transmitted disease.

As the number of teens and young women getting annual Pap tests declined, so did the number getting screened for chlamydia, according to a study published Monday in Annals of Family Medicine.

Chlamydia infects an estimated 2.86 million men and women annually, according to the Centers for Disease Control and Prevention. It's most common in young women from the age of 15 to 24, and if left untreated, can cause pelvic inflammatory disease and make it difficult for women to get pregnant. It can cause preterm delivery, and conjunctivitis and pneumonia in newborns.

It's also easily cured with antibiotics. But because people with chlamydia often don't have symptoms, most people are diagnosed via screening tests. The CDC recommends yearly chlamydia screening for all sexually active women younger than 25, as well as older women with risk factors.

The research team looked at patient data of some 3,000 teenagers and young women aged 15 to 21 years old who made visits to five family medicine clinics at the University of Michigan, and identified young who had no symptoms for either cervical cancer or chlamydia but were tested for either or both.

In 2009, the American College of Obstetricians and Gynecologists recommended of starting cervical cancer screening at age 21, irrespective of sexual activity. And in 2012, the American Cancer Society and the United States Preventative Services Task Force recommended against routine yearly testing, but the study doesn't look into the impacts of this newer change.

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They compared two groups: those who made visits before the 2009 guidelines change for Pap tests (from 2008 to 2009), and those who visited after the change (from 2011 to 2012). They looked at patients who came in for a Pap test or for chlamydia screening, and also those who received chlamydia screening while getting a Pap test. Before the change, about 30 percent of the women in that age group got tested for chlamydia. Afterwards, less than 1 percent did. The number of women getting Pap tests dropped, too, from about 24 percent to less than 1 percent.

Were patients just not going to the doctors as frequently as before?

Not true, says Allison Ursu, lead author of the study and women's health fellow at University of Michigan Medical School.

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"The number of visits per patient were roughly the same," Ursu says, "We had chances to screen them; we just weren't doing it."

It's not hard to link a shift in guidelines with a decrease in Pap tests getting done, since evidence shows that annual screening isn't necessary and can lead to needless treatment, Shots has reported. But what do Pap smears have to do with screening for chlamydia in the first place?

Until 2000 or so, chlamydia screening was mostly done with a sample taken from the cervix, often at the same time that a Pap smear was performed, according to Michael Policar, associate clinical professor of obstetrics and gynecology at the University of California, San Francisco. Policar is not part of the study.

Ursu believes that one reason women aren't getting screened for chlamydia is the lack of knowledge about noninvasive screening methods, including a urine sample or vaginal swab. Pelvic exams aren't necessary.

"Uncoupling is the way we should approach the patient, to separate cervical cancer screening from sexually transmitted infections screening," Ursu says. At the University of Michigan's family medicine department, her team has started using its electronic medical record system to alert patients when they're due for testing for chlamydia. She says patients find the reminder to be helpful.

The "uncoupling" of Pap smears and chlamydia screening is not a new concept.

"This concept has been stressed by the CDC and the U.S. Preventive Services Task Force in their guidelines for at least a decade, and most providers already have unlinked chlamydia screening from either the performance of a Pap smear or a screening pelvic exam at the time of a well woman visit," says Policar. "A rallying cry following the change in 2009 guidelines was 'pee not Pap.' "

Policar also stressed the importance of what doctors call opportunistic screening — something that Ursu's team is doing and that the paper mentions.

"The concept is that some people never come in for preventive visits, like checkups, so we should use problem visits (acne, headaches, a sprained ankle) as an opportunity to perform desirable screening tests, including chlamydia screening in young women," Policar told Shots via email. "Highly functional provider groups, like Kaiser, are achieving chlamydia screening rates in the mid to high 80 percent range, based on an excellent electronic medical record."

National screening rates for chlamydia as reported by the National Chlamydia Coalition found that in a state-by-state analysis, most rates did not change as dramatically as found in the study. Policar said that's probably due to the limitations in scope of the family practice clinic where data was collected.

At the end of the day, the take-home message is "Chlamydia is easily treated and curable," Ursu says. And appropriate screening can greatly reduce this infection among young people.

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IRS: 7.5 Million Americans Paid Penalty For Lack Of Health Coverage

NPR Health Blog - Tue, 07/21/2015 - 11:19am

The IRS released preliminary figures that show about three-quarters of taxpayers indicated they had qualifying health insurance in 2014.

Carolyn Kaster/AP

About 7.5 million Americans paid an average penalty of $200 for not having health insurance in 2014 — the first year most Americans were required to have coverage under the Affordable Care Act, the Internal Revenue Service said Tuesday.

By contrast, taxpayers filing three-quarters of the 102 million returns received by the IRS so far this year checked a box indicating they had qualifying insurance coverage all year.

Counting another 7 million dependents who weren't required to report their coverage but also filed returns, the proportion with qualifying insurance rises to 81 percent, the IRS said.

The government had estimated in January that from 3 million to 6 million households would have to pay a penalty: 1 percent of their annual income or $95 per adult in 2014, whichever is greater.

Final figures for the tax year aren't available yet. The IRS has so far processed about 135 million of the estimated 150 million returns expected. IRS Commissioner John Koskinen said the agency was reporting preliminary figures because it has received "numerous requests" from members of Congress.

In addition to penalty totals, the IRS reported Tuesday on tax subsidies the health law provided for people who were buying coverage through the state or federal online exchanges and who qualified based on income. People had a choice of filing for credits in advance — money the government paid to their insurers — or when filing tax returns.

About 2.7 million taxpayers claimed approximately $9 billion in subsidies, reporting an average subsidy of $3,400. About 40 percent claimed less than $2,000, 40 percent claimed $2,000 to $5,000, and 20 percent claimed $5,000 or more.

Among taxpayers who claimed a subsidy, about 1.6 million, or half of taxpayers who claimed or received a subsidy, had to pay money back to the government because their actual income was higher than projected when they applied for the subsidy. The average amount repaid was about $800.

When looking at the individual mandate, the report said the vast majority of people automatically satisfied the individual mandate because they were insured last year. Another 12 million had exemptions, including people whose incomes were too low and Native Americans.

In all, the IRS said it has collected $1.5 billion from the individual mandate penalty included in the health law. About 40 percent of taxpayers who paid a penalty paid less than $100.

About 300,000 taxpayers who made an individual mandate penalty payment should have claimed an exemption but did not, the government said. The agency is sending letters to these taxpayers telling them they generally have three years to file an amended tax return.

More than 5 million taxpayers did not check the box on their tax form saying had coverage, claim a health care coverage exemption, or pay a penalty. "We are analyzing these cases to determine their status," the government said.

Copyright 2015 Kaiser Health News. To see more, visit
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How Sporty Is Your Sport?

NPR Health Blog - Tue, 07/21/2015 - 10:02am

When it comes to sports, there seems to be something for everyone.

There are team sports and activities you can do alone. There's exercise that requires equipment, or none at all.

But how much benefit you get from each one depends on a lot of factors, including how much you weigh, how long you play and the intensity of the activity.

People play sports for personal enjoyment and health, according to NPR's poll on sports and health in America. The poll, done in collaboration with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, finds that other reasons include losing weight and staying in shape.

So how athletic are some of the sports Americans play? Playing golf burns almost as many calories as baseball. But how does dancing compare with playing darts?

We looked at the caloric expenditures of a variety of sports to see how moderate levels of activity stacked up for the average American woman.

Join us on the video tour created by California animator Ben Arthur.

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

Expanding, Not Shrinking, Saves A Small Rural Hospital

NPR Health Blog - Tue, 07/21/2015 - 5:01am
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One of the first signs drivers see on the way into Unionville, Mo. is this billboard advertising cardiology at Putnam County Memorial Hospital. Offering specialty services, like cardiology and psychiatry turned the hospital around, community leaders say.

Bram Sable-Smith/KBIA/Side Effects Public Media

Missouri cattle farmer Greg Fleshman became so concerned about keeping his local hospital open that in 2011 he joined its governing board.

"I mean they've saved my dad's life twice," Fleshman says. "He had a heart attack and a stroke and they life-flighted him out of here both times." Keeping the doors open at Putnam County Memorial Hospital in Unionville, Mo., seemed crucial to the community — but maybe an impossible task.

"Things were just falling apart, is really what it was," Fleshman says — "financially, and morale of the employees. And it just seemed to get worse and worse."

Putnam County Memorial was ailing from the same conditions squeezing the finances of many of the nation's rural hospitals. At least 55 have closed since 2010 across the U.S., with another 1 in 10 at risk of going under, by one talley. Only about 5,000 people live in Putnam County, and they tend to be older, poorer, sicker and less insured than the rest of the state.

Health care analysts says Medicare and Medicaid's relatively low reimbursements, combined with dwindling populations in rural regions, are forcing many hospitals like Putnam to operate with tighter profit margins than suburban institutions — and sometimes even at a loss.

Like a lot of institutions, Putnam County Memorial initially looked to cut costs by reducing staff and services. But eventually, as more and more patients went to bigger towns for treatment, the hospital came to the brink.

Fleshman vividly recalls those darkest days: "We had about $8,000 in the bank," he says, and faced a payroll of about $70,000 or $80,000. Two CEOs quit, and the board started calculating what it would cost to close down the facility.

"We didn't think we could get anybody to come in," Fleshman says.

We think that's the way forward for rural hospitals, rather than just sort of a bunker mentality — saying that we can't proceed.

Then a key phone call and strikingly different strategy turned everything around. A doctor in the area called Jerry Cummings, who was then running a medical consulting business with his wife Cindy in central Missouri. Instead of closing its doors, Putnam County Memorial should expand, the couple advised.

The hospital could convert an unused 10-bed unit into a psychiatric wing to bring in new revenue, suggested the Cummings, and offer other medical services that Putnam County residents were driving hours away to get.

The board was convinced, and hired the couple to run the hospital — Cindy Cummings as CEO, and Jerry as COO. The two packed up their home in Jefferson City, Mo., and moved three hours north to Putnam County.

One of the first moves Jerry Cummings made, after becoming Putnam County Memorial's COO in 2012, was to hire more doctors and renovate an unused unit to become a psychiatric wing.

Bram Sable-Smith/KBIA/Side Effects Public Media

"Immediately, within 30 days, I brought in three other brand new physicians" Jerry Cummings says. He and Cindy brought new specialties to the hospital: anesthesiology, gynecology and cardiology. They also rallied the county to pass a roughly $7 million dollar bond initiative to buy out the hospital's old debt and renovate.

And patients started coming back.

"Our revenues went from $4 million to $22 million — a huge increase," Jerry Cummings says. "Our average daily [patient] census, it was less than 1 patient per day. Our average daily census now is around 11 to 12 patients."

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And, according to a report published by the health panel of the Rural Policy Research Institute last November; more cash-strapped rural hospitals could thrive by taking the same tack.

"We think that's the way forward for rural hospitals, rather than just sort of a bunker mentality — saying that we can't proceed," says Tim McBride, a health care economist at Washington University in St. Louis, and one of the study's authors.

In some ways the Putnam County story is unique McBride says. But expanding certain services instead of contracting, might work to save other hospitals, too.

"We believe that rural hospitals often can provide very high quality services," he says.

The community in Unionville had to have that same faith, says Greg Fleshman, that they weren't just throwing good money after bad.

"I think, people had to decide, Fleshman says. " 'Are we going to have a hospital or not?' — and they wanted it here."

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

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

More Health Plan Choices At Work: What's The Catch?

NPR Health Blog - Mon, 07/20/2015 - 2:44pm
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Steve Heller has worked for Minnesota's John Henry Foster company for 15 years. He says he likes the greater choice of health plans he now has because of the private exchange.

Mark Zdechlik/MPR

Until recently, John Henry Foster, an equipment distribution firm based in Eagan, Minn., offered its employees only a couple of health plans to choose from. That's common in companies across the United States.

"They just presented what we got," says Steve Heller, a forklift operator who has worked at John Henry Foster for 15 years.

But these days the company's employees have dozens of choices. And something else is new: Each worker now receives money from the company (from $350 to $1,000 a month, depending on whether Heller and his co-workers are buying insurance for a single person, a couple or a family) to buy a health plan.

Shots - Health News To Changing Landscape, Add Private Health Care Exchanges

Employees are then directed to an online exchange — a private, secure website that offers the selection of plans for side-by-side comparison. Workers can choose high-deductible plans with relatively low monthly premiums or they can pay more each month to have more of their care and medications covered.

Just as before, the company determines the insurance companies listed, and the scope of the treatments and procedures covered by each plan.

Three years after the switch, Heller says he's happy with his insurance and the exchange. The company's managers are happy with it, too.

In 2012, the company was facing a big increase — 30 percent in its costs for employee medical benefits. "Unlike anything we had ever seen before," says Jan Hawkins, co-owner of John Henry Foster.

Jan Hawkins, one of the co-owners of the equipment distribution firm John Henry Foster, says going to a private exchange has given the company much more flexibility in budgeting for health care costs.

Mark Zdechlik/MPR

So, Hawkins says, company leaders decided to sign up for a private exchange run by Medica, a Minnesota insurer, because they could choose to spend only about 10 percent more on health benefits in the first year, instead of that 30 percent increase projected under the old plan.

Since then, the firm has increased the money it gives employees to spend on health insurance by roughly 10 percent each year.

"I think it definitely helps us from an operational budget standpoint," Hawkins says. "We've just seen only positives from this."

Despite the benefits to a company's bottom line, and more choices for employees, John Henry Foster is one of relatively few businesses using a private health insurance exchange. According to research by the Kaiser Family Foundation, last year only 3 percent of employers (excluding the federal government) insure their employees this way.

But it's a trend that some experts expect to pick up steam soon. "I would say a majority of the companies will switch to private exchanges," says Dr. Jim Bonnette, with the health care consulting firm The Advisory Board Co.

Shots - Health News Elusive Goal: A Transparent Price List For Health Care

Bonnette thinks that employees under this sort of system are likely to choose high-deductible plans and be much more motivated than in the past to search out the best value for care. That could finally force consumers to pay attention to the price of health care, he says, a goal that has eluded health policymakers for decades.

"We can't afford the trend — that is, the increase in cost per year — that we currently have," Bonnette says. "So how do you get people to think differently about how they receive care and what it costs?"

But shopping wisely for health care is almost impossible says Sara Collins from the Commonwealth Fund, a health policy research organization.

It's often difficult for consumers to find out how much a doctor visit or a particular procedure costs. And, Collins says, studies show that people with high-deductible plans often forgo care to save money; they'll even avoid free preventive care because they don't understand how their health insurance works.

Shots - Health News Some Insured Patients Still Skipping Care Because Of High Costs

"The idea that people who have such low understanding of what is included or excluded in their deductible can actually go out and price-shop for their health services, I think, really stretches the imagination," she says.

Kim Wagner, a benefits consultant, says predictions of a big shift to private exchanges are overblown. Although some employers are adding more health plan choices for workers, she says, giving employees a set amount to buy insurance on an exchange could alienate workers and increase turnover.

The practice of giving employees a limited amount of money to purchase their own insurance has been around for a while, Wagner says, but "hasn't taken off, particularly in the large employer space, because truly it's a cost shift."

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Workers suddenly asked to shoulder more of the cost of their health care may be more likely to look for a job elsewhere — opting for companies that offer better benefits.

Nonetheless, firms that now use generous benefits as a selling point to lure top talent may soon be more motivated to set up these sorts of private insurance exchanges, too. Beginning in 2018, companies that offer health insurance packages the government deems too generous will start having to pay a 40 percent tax on those packages.

It's called the "Cadillac" tax (meant to reduce health spending by discouraging luxurious health plans), but it is not as exclusive as its name implies. Towers Watson, a consulting firm, predicts that 48 percent of employers will have to pay the tax in its first year.

This story is part of NPR's reporting partnership with Minnesota Public Radio and Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Copyright 2015 Minnesota Public Radio. To see more, visit
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5 Things Your Baby Should Avoid In The NICU

NPR Health Blog - Mon, 07/20/2015 - 2:04pm

Babies in the neonatal intensive care unit hospital don't always need the tests and treatments suggested.


If you've got a baby in the neonatal intensive care unit, your first thought is probably not, "Does my child really need that antireflux medication?"

But antireflux meds in for newborns topped the list of five overused tests or treatments released Monday as part of the "Choosing Wisely" program. About one-third of health care spending in the United States is overuse and waste, costing about $2.7 trillion a year.

"With newborns, there's very little evidence that routine use will improve the symptoms," says DeWayne Pursley, chief neonatologist at Beth Israel Deaconess Medical Center and senior author on the paper, which was published in Pediatrics.

In other words, babies spit up. There's evidence that giving newborns antireflux medications doesn't reduce the risk of apnea or low blood oxygen, the two problems it's typically prescribed for in preemies. And it could cause long-term harm, Pursley says.

The other four tests and treatments to avoid doing routinely are:

  • Antibiotics for more than 48 hours in babies who don't have evidence of a bacterial infection.
  • Overnight breathing studies for assessing apnea in premature infants before they go home.
  • Daily chest X-rays for infants who are intubated, unless there's a specific problem that needs to be investigated.
  • Screening brain MRIs when babies reach their term equivalent age, or at discharge from the hospital.

That's not to say that no infant should ever get these, Pursley says. "But our gripe, if you will, is their routine use."

To come up with the list, an expert panel of 51 specialists in neonatal care compared through almost 3,000 tests and treatments recommended by practitioners.

It was hard to narrow the list down to just five low-value items, Pursley says; there were so many that the experts thought were of dubious worth.

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"I think the take-home message isn't that these are five tests and treatments that appear to have low value, but these represent five of probably many that when used routinely don't add value to the care of the baby," Pursley says.

A great example is brain MRIs for extremely preterm babies around the time they should have been born. They're promoted as helping to predict which children will have neurological and developmental problems and will need interventions, Pursley says. But the MRIs have only a 50/50 chance of getting it right.

"Some families will say, 'Gee, if I had known there would be this uncertainty I wouldn't have wanted to have the test,' " Pursley says. "There are other ways of looking at the brain in babies and probably getting just as good information."

Shots - Health News Doctors Think The Other Guy Often Prescribes Unnecessary Care

MRIs cost a lot of money, and it's another stressful test that a fragile baby shouldn't have to undergo if it's not helping.

So what are parents to do when they've got a child in the NICU and they're facing dozens of mysterious tests or treatments?

Parents can ask if they can do rounds with the medical team, Pursley says, which is an increasingly common practice in NICUs. That way they'll hear how the care team assesses the child's progress and how they do their planning. "It provides [parents] an opportunity to ask why certain tests and treatments are being done."

Copyright 2015 NPR. To see more, visit
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Sometimes A Little More Minecraft May Be Quite All Right

NPR Health Blog - Mon, 07/20/2015 - 6:54am
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At a Minecraft camp in Shaker Heights, Ohio, kids trade secrets about making their virtual worlds come to life.

Sarah Jane Tribble/WCPN

It's family vacation time, and I've taken the kids back to where I grew up — a small plot of land off a dirt road in Kansas.

For my city kids, this is supposed to be heaven. There are freshly laid chicken eggs to gather, new kittens to play with and miles of pasture to explore.

But we're not outside.

I'm sitting in my childhood bedroom watching my 7-year-old son and his 11-year-old-cousin stare at a screen. The older kid is teaching the younger the secrets of one of the most popular games on Earth: Minecraft.

Planet Money Minecraft's Business Model: A Video Game That Leaves You Alone

"You can't mine ores unless you have a pickax," explains my nephew to my son. "You need a wooden pickax to get stone, and you need a stone pickax to get iron, and you need an iron pickax to get gold," and so on.

Minecraft is the megapopular video game that ranges from simple to complicated. But the basics are that players enter a world that looks sort of like Legos on a screen and build anything they want. Think houses, mountains and farms.

But I'm a health reporter, which means I'm more aware than anybody should be about the many rules of raising a healthy, well-adjusted child.

So I monitor and limit their screen time, taking pains to stick to the American Academy of Pediatrics' recommendations. For kids under 2, that means no screen time. For kids 2 and older — like mine — the doctors recommend "less than one or two hours per day."

But this is Minecraft. My son's addiction is acute, and he's got plenty of company.

Illinois-based graphic novelist Chris Ware was so taken aback by his 10-year-old daughter's interest that it inspired his recent New Yorker cover.

Ware's drawing shows two girls, with their backs facing each other, staring at screens and ignoring the toys littered about them.

"It's pretty amazing how it seems to almost completely usurp the consciousness of the 6- to 14-year-old set," he says. "My daughter made all these series of underground classrooms, which I thought was such a strange idea, you know."

NPR Ed An Update On Screen Time

This is no Grand Theft Auto-like video game with guns and graphic violence. Schools and camps use Minecraft to teach basic spatial reasoning concepts, albeit with some odd characters, such as squid and pigs.

Before taking vacation, I caught up with Mel McGee during a coding camp she runs in Shaker Heights, Ohio. She was explaining to a handful of preteens how to use red stone dust to make an electrical wire.

"We try to drop some engineering stuff, real-world concepts in there and how it relates to what they're building in Minecraft," she says.

So, if you're using it for good, does it count as screen time? I asked Dr. Victor Strasburger, who helped write the American Academy of Pediatrics recommendations 15 years ago.

"We're not a bunch of old fuddy-duddies sitting around trying to figure out how we can poke a hole in kids' entertainment options," he says.

Research has established that kids who sit in front of TV or video for hours have higher rates of obesity and possibly other health problems. But Strasburger says it's more complicated than just setting strict time limits.

The academy has no set recommendations on educational screen time or even the use of different types of screens.

"We don't know about iPads, cellphones, smartphones, new technology because there isn't the research. When there is, believe me, we would be the first to be talking about it. But there ain't!"

His advice to parents is to create their own family policies.

Here in my childhood bedroom, I'm watching my son and trying to figure out what our policy should be.

My boy's virtual person has moved past a pig and is gathering sugar cane, for reasons I am only beginning to understand.

"Dude, you should start a sugar cane farm," says my nephew. My son agrees.

The obvious irony here is, they don't actually have to build a farm. They can just walk outside and be part of a real one.

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

Copyright 2015 90.3 WCPN Ideastream. To see more, visit .
Categories: NPR Blogs

Women Want To Stay In The Game, But Life Intervenes

NPR Health Blog - Mon, 07/20/2015 - 4:29am
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Maria Fabrizio for NPR

The United States is basketball crazy.

For boys and girls who play sports, basketball is the most popular choice.

But as Americans age, a new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health reveals, there's a widening gender gap when it comes to hoops. Why are adult female basketball players giving up the game they once loved?

Certainly not all women are giving up the sport.

On a hot summer evening in Portland, Ore., Tanya Martin is running with the men. The scene is Portland's Hillside Community Center, another Monday night of basketball league games. Martin, a 30-year-old mother who works for Child Protective Services in nearby Vancouver, Wash., is wearing her favorite non-work clothes: white tank top, baggy black shorts, electric blue Nikes. She darts on defense; on offense, she sets solid screens and then pops open, calling for the ball.

When she does, it's probably a good idea for her male teammates to get it to her — Martin averages more than 20 points a game playing with the men in and around Portland. She's really good at volleyball, too. But the basketball court is Martin's place to escape.

"It's kind of like my beach," she says. "It's the one time that my mind can actually just not think about anything else but ... but playing."

Martin gets this mental and physical boost about four days a week, playing games with both men and women. But even if she played only one day, that would put her ahead of many of the women included in the NPR/Robert Wood Johnson Foundation/Harvard poll.

According to the poll, nearly equal proportions of men and women age 30 and over who played sports when they were younger said basketball was the sport they played most often in their youth — 19 percent of these men and 20 percent of these women. But the poll shows that by the time they became adults, there's a big difference. Among adults who played sports in the past year, 14 percent of men, but only 5 percent of women, said basketball is what they played most often.

Basketball is among the top five sports played most often by men in every age group. It only breaks the top five in the youngest age group of women polled (ages 18-29). In all the other age groups of women, basketball drops off the list of top five sports — a list that includes softball, volleyball, golf and tennis.

To find out why the drop in hoops, we asked adult women on NPR's Facebook page to explain their decision to quit after being heavily involved in the game when they were younger.

They say career, parental responsibilities and injuries have made it harder to play.

Numerous scientific studies confirm that female athletes are more likely than men to suffer knee injuries, including ACL tears, and basketball can be ruthless with its jumping, pivoting and pounding. For 36-year-old Jodi Ostlund, that painful reality began after she got a basketball scholarship to Bethel College in Kansas.

"My freshman year I didn't play much," says Ostlund, who lives in McPherson, Kan. "I was anticipating more playing time my sophomore year, but tore my ACL the day before practice started."

Ostlund rehabbed all year long, came back the next year and got hit by more bad luck. "I tore my other ACL, like three days into practice," she says. "So that was kind of the end of competitive sports for me." Oh, and Ostlund tore an ACL for the third time, after college, playing pickup volleyball.

Correen Schall from Columbus, Ohio, avoided major injury while playing basketball in high school and in college at the University of Mount Union in Alliance, Ohio. After college, she played rec basketball. Schall, now 35, stopped playing for other reasons. The main one? She had three kids in four years. And she says even in the most equal of marriages, like hers, mothers still, often, are the default parent.

"Because we're so involved in the day-to-day care when [the kids] are little," she says, adding: "When I was nursing, I couldn't not be home."

Shots - Health News Benefits Of Sports To A Child's Mind And Heart All Part Of The Game

Schall's kids are older now. She'd love to find her way back into basketball. The sport, she says, gave her a real sense of self.

"I like the team, the sense of camaraderie, the sense of working together," Schall says. "I like being able to be full-out aggressive and have it be welcomed instead of criticized to some degree."

That's a feeling shared by Nikia Smith Robert. Aggressiveness was mandatory when she was a kid; she grew up playing street ball with the boys, in Harlem. She played a year in college and then played in lots of tournaments into young adulthood. Smith Robert stopped playing when she was pregnant with her first child, then returned to the game after the baby was born in 2009.

Nikia Smith Robert stopped playing basketball when she was pregnant with her first child, then returned to the game after the baby was born in 2009.

Courtesy of Nikia Smith Robert

She was stunned when she got back onto the court.

"I lost my nerve," Smith Robert says. "There was more at risk, so I didn't want to risk injury if that meant being out of a job or losing a job or not being able to properly care for my child."

And so, Smith Robert says, when she did play, she played "reserved."

"I didn't dive for balls. I didn't jump for rebounds if that meant colliding with other players. To me that was unacceptable, because I saw how that affected and even frustrated my teammates."

Now 36, Smith Robert is a chaplain and Ph.D. theology student living in La Crescenta, Calif. She's out of the game but taking baby steps back through her kids.

"I'm starting to teach my very dainty daughter how to be more comfortable with a basketball," Smith Robert says, laughing. "And I'm playing with my son. Because I want them to still see me as a baller. That's important to me. It's a part of my history and identity."

For many adult women, the key to getting back to basketball is finding the right game, the right group. That can be tough because the opportunity isn't often there.

Courtney Weigand was a scrappy shooting guard growing up and playing ball in rural Missouri. "I always won the hustle award," she laughs. Now 32 and an economist at the Treasury Department in Washington, D.C., Weigand would like to play regularly again. But she isn't having much luck.

"People are just way recreational or very, very competitive," she says. "I really haven't found a league that [matches] my skill level."

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

Are opportunities limited because there aren't enough players? Or are there not enough players because opportunities are limited? Many of the women we contacted said pickup basketball, often dominated by men, isn't an option. Some said it was dangerous, with the men often bigger and more physical. Other women said pickup is an affront to the fundamentally sound basketball they learned as girls.

"The selfishness in a pickup game, the suppressed sexist decisions, and the sloppy fundamentals can borderline ruin it!" says 28-year-old Julia Hartsell Chisholm, from Asheville, N.C.

Lei Hart, in black jersey and blue shorts, boxes out an opponent on a free throw attempt. Hart, 41, plays every Monday night at the Hillside Community Center in Portland, Ore.

Tom Goldman/NPR

The scene at Portland's Hillside Center seems to be an antidote to what ails adult women's basketball. Women of varying abilities are playing a pretty crisp, officiated game. There are working mothers out on the court — like Tanya Martin. And like Lei Hart. She played college basketball at George Washington University in Washington, D.C. Hart is a 41-year-old lawyer who has carved out the time to play, even with two kids.

"I bring one with me," Hart laughs during a break in the action. "And Monday night is just my regular thing [for basketball]. I don't schedule anything else for Monday night, and if I don't have to work, then I'm able to be here."

But Portland is not immune to the national trend. Hart's team, Bonnie's Ballers, is one of roughly 20 women's teams in this city league. That's compared with more than 200 for men. That's not good enough for Mikal Duilio. He started the league 23 years ago.

"Portland, Ore., should be producing 30 to 35 women's teams at least, before I can feel good," Duilio says.

He says home life is the biggest deterrent to more women playing, and he's trying to figure out a solution.

"What product can I create for them?" Duilio asks. "Can they play at 6 [p.m.]? Can there be a league that's only at 6:45?"

Of course the nature of basketball, requiring a high level of fitness, a durable body and specific skills, weeds out women and men as they age. But if the people we talked to are an indication, many more adult women are leaving the game before they're ready.

Which is why Julia Hartsell Chisholm emailed us this call to arms:

Ladies, where have you gone? There are CERTAINLY more than just me — there have to be women who love the sport ... who probably gave significant parts of their lives to the sport that have a desire to keep playing. Can't we all band together and make it happen? Can't we bring women's basketball to a place where it's not only the elite who continue to play? Can't we make room for us on the court, who spent hours sprinting, sliding and lifting? Can't we peel ourselves away from what our futures have brought us — motherhood or careers — to play the sport we once did everything in our power to play?

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

Siren Song Of Tech Lures New Doctors Away From Medicine

NPR Health Blog - Sun, 07/19/2015 - 12:03pm

Amanda Angelotti (left) and Connie Chen, both graduates of University of California, San Francisco's medical school, opted for careers in digital health.

Josh Cassidy/KQED

Even as a young child, Amanda Angelotti dreamed about becoming a doctor.

But by her third year at the University of California, San Francisco medical school. Angelotti couldn't shake the feeling that something was missing.

During a routine shift at the hospital, making rounds with her fellow students, Angelotti said her thoughts kept drifting.

"I was supposed to be focused on the patient's vital signs and presenting a summary, but I was consumed with thoughts about how to improve the process of rounds," she said. Most striking to her was the patient's absence from the discussion. "I kept asking myself, 'How could we change things to involve the patient more?'"

Just a stone's throw from UCSF Medical Center, a small group of entrepreneurs at Rock Health, a business accelerator program that is now a venture firm, were thinking about how to shake up the health care process with technology. These startups were developing new wearable devices and mobile apps to help patients take more control of their own health.

The timing was right to bring new ideas to the sector. By 2012, hospitals around the country were rapidly moving away from paper-based medical records to electronic systems, a first step to moving health care into the digital age.

Angelotti graduated the following year, but she didn't apply for any residency programs. Instead, she went to work at Rock Health as a researcher and writer and later joined the medical review site Iodine, one of an exploding number of digital health startups in San Francisco.

By the end of that year, Rock Health projected that venture funding for digital health funding had exceeded $1.9 billion, a 39 percent jump from the prior year.

Angelotti is far from alone in making the leap from medical school to digital health.

Bay Area-based medical students from Stanford and UCSF have among the very lowest rates of pursuing residency programs after graduation compared to the rest of the country. Stanford ranked 117th among 123 U.S. medical schools with just 65 percent of students going on to residencies in 2011, according to Doximity, a physician-network that generates data for the U.S. News Best Hospitals rankings. UCSF is 98th on the list, with 79 percent of its graduating students going on to residency. (Some students may have opted to apply to residency after taking a few years off. The 2011 figures haven't yet been updated to reflect that.)

"We've seen that many of these Bay Area-based medical students are drawn to startup opportunities," said Jeff Tangney, CEO of Doximity. "It used to be biotech, and now it's more often digital health."

Many of the top digital health companies are eager to hire new grads straight out of medical school, even though they lack years of clinical experience.

As Sean Duffy, the CEO of Omada Health and a Harvard Medical School dropout put it: "I wanted to understand what's in the trenches, so I could redefine the trenches." Omada Health offers an online help for people looking to change their behavior to avoid developing diabetes.

Duffy is part of a private Facebook group called "dropout doctors," which includes some of the biggest names in digital health. It functions as a support group, of sorts, and meets every few months for dinner or drinks. Some members, like Angelotti, said they find solace in the group as it can be difficult and lonely to opt out of clinical medicine for a different path.

The members includes Angelotti, who now works at primary care chain One Medical; Duffy, CEO of Omada Health; Connie Chen, the co-founder of Vida Health; Shaundra Eichstadt, medical director at Grand Rounds; Abhas Gupta, a health-focused venture capitalist with the firm Mohr Davidow; Molly Maloof, a medical advisor to DoctorBase; and Rebecca Coelius, the director of health at Code for America.

'I Never Thought I Would Leave Medicine'

There's both a push and a pull motivating young doctors to seek opportunities in technology.

Many of the students at the top Bay Area medical schools, Stanford and UCSF, are exposed to entrepreneurial thinking during their education, which can be a major draw.

"I never thought I would leave medicine," said Eichstadt, who now works at Grand Rounds Health, a San Francisco-based startup that helps patients access second opinions from top medical experts online. "But there's such a rich opportunity at companies here."

Eichstadt graduated from Stanford and pursued several years of residency, specializing in plastic and reconstructive surgery.

"I realized that the system isn't designed for doctors to make the real change you would like to for the patient." Eichstadt concluded that she could make a bigger impact elsewhere.

Many of the dropout docs say they want to improve the doctor-patient experience. Several said they spent very little time administering care during medical school, and they felt that patients were too often kept out of the loop.

A recent study found that doctors-in-training spend an average of just eight minutes with each patient. This is a drastic decrease from previous generations and is linked to more record-keeping requirements and restricted on-duty hours.

Connie Chen still practices medicine a half-day each week. But shortly after medical school, Chen co-founded an app called Vida, which connects people who have chronic diseases with virtual health coaches, like nutritionists and nurses.

Chen said learned very little about nutrition at medical school. But digital health opened up opportunities for Chen to educate herself about wellness.

"Traditional health care is really oriented to make the life of the provider easier," she said. "Your patients cycle in and out of the hospital, and very often, no one makes enough of an effort to communicate with them."

Lack of Opportunities

Other dropout docs said they felt pushed out of medicine, due to the lack of career opportunities or earning potential. Family practitioners, who serve on the front lines of health care, are paid the least.

"I loved working with patients but I looked around me and realized that I didn't want the jobs of anybody who had 'succeeded' as a clinician," said Rebecca Coelius, who graduated with a medical degree from UCSF.

Coelius now advises a number of health-tech startups, including Doximity and previously worked for HealthLoop, which was founded by Jordan Shlain, another entrepreneurial doctor. She's also worked for the government as a medical innovation officer.

"Tech culture is very appealing when juxtaposed against the hierarchy and myriad hoops to be jumped through in clinical medicine," she said.

Christina Farr is the editor and host of KQED's Future of You blog, which explores the intersection of emerging technologies, medicine and health care. She's on Twitter: @chrissyfarr

Copyright 2015 KQED Public Media. To see more, visit
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Alzheimer's Drugs In The Works Might Treat Other Diseases, Too

NPR Health Blog - Sun, 07/19/2015 - 9:38am
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In this colorized image of a brain cell from a person with Alzheimer's, the red tangle in the yellow cell body is a toxic tangle of misfolded "tau" proteins, adjacent to the cell's green nucleus.

Thomas Deerinck/NCMIR/Science Source

Efforts to find a treatment for Alzheimer's disease have been disappointing so far. But there's a new generation of drugs in the works that researchers think might help not only Alzheimer's patients, but also people with Parkinson's disease and other brain disorders.

Previous efforts to treat Alzheimer's have focused on a single target — usually the protein called beta-amyloid, says Maria Carrillo, chief science officer of the Alzheimer's Association. "The one-target approach is probably not going to be the answer," Carrillo says.

Instead, several teams of scientists reporting their work at the Alzheimer's Association International Conference in Washington, D.C., this week are targeting a process in the brain that leads to toxins involved in several different diseases.

The biotechnology company Treventis is working on one of these potential drugs.

"Our ultimate goal is to discover a pill that can be taken once a day that could either stop or slow Alzheimer's disease," says Marcia Taylor, the company's director of biological research. Treventis hopes to do that with a drug that prevents the build-up of two toxic proteins.

Shots - Health News Toxic Tau Of Alzheimer's May Offer A Path To Treatment

These toxic substances, called beta-amyloid and tau, are the result of a process that begins when a healthy protein inside a brain cell somehow gets folded into the wrong shape.

"Sometimes it gets what I call a kink," Taylor says. Then, when the misfolded protein meets another protein floating around in the cell, "It kind of grabs onto that protein and they both kink up together," she says.

That can trigger a chain reaction that produces clumps of misfolded beta-amyloid and tau proteins that damage brain cells.

"And our compound — because it targets protein misfolding — is actually able to prevent both beta-amyloid and tau from making these clumps," Taylor says. The compound works in a test tube and is currently being tested in animals, she says.

Another potential new treatment could help people with Parkinson's and a disease called Lewy body dementia, as well as those with Alzheimer's.

Previous efforts to treat those diseases have focused on differences in the proteins thought to cause them, says Fernando Goni of New York University. "So what we said is, 'Do they have something in common?' "

Shots - Health News Mad Cow Research Hints At Ways To Halt Alzheimer's, Parkinson's

The common element is proteins that misfold and then form toxic clumps. Goni and his colleagues decided to go after these clumps, without worrying about which protein they contain. The result is a class of monoclonal antibodies that work like guided missiles to find and neutralize protein clumps in brain cells.

Previous experiments showed that the monoclonal antibodies work on the tau and amyloid clumps associated with Alzheimer's. Studies in mice show that the treatment can reverse symptoms of the disease, Goni says.

"We took animals that already had the disease and we infused them with the monoclonals and after a couple of months they were almost as perfect as the normal mice of that age," he says. Goni also presented evidence at the meeting that these targeted antibodies work on clumps associated with Parkinson's disease and Lewy body dementia, too.

Perhaps the most unusual potential new treatment for Alzheimer's comes from Neurophage Pharmaceuticals, a company that owes its existence to an accidental discovery.

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A few years ago, Beka Solomon, a researcher in microbiology and biotechnology at Tel Aviv University in Israel, realized that a virus she was using for another purpose seemed to reverse Alzheimer's in mice. So she continued to study the virus, says Richard Fisher, the chief scientific officer of Neurophage.

"Meanwhile, her son, who had just spent 10 years in Israeli special forces, goes to Harvard Business School," Fisher says. "He needs a project. And he and another colleague at the business school put together a potential company based on [his mother's] discovery."

In 2008, that potential company became Neurophage. "I was the first employee and I thought, 'Wow, this is really crazy,' " Fisher says.

But it wasn't. Scientists were able to figure out how the virus was attacking Alzheimer's plaques and use that information to create a treatment.

And in mice, that treatment appears to work against both Alzheimer's and Parkinson's, Fisher says. The company plans to begin testing its treatment in people in early 2016.

Copyright 2015 NPR. To see more, visit
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When Losing Memory Means Losing Home

NPR Health Blog - Sat, 07/18/2015 - 5:08pm
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Greg O'Brien and his wife are finding it more difficult to drive to and from their family's secluded house on Cape Cod. As they move out and move on, O'Brien has discovered a bittersweet trove of memories.

Sam Broun/Courtesy of Greg O'Brien

In this installment of NPR's series Inside Alzheimer's, we hear from Greg O'Brien about his decision to sell the home where he and his wife raised their three children. O'Brien, a longtime journalist in Cape Cod, Mass., was diagnosed with early onset Alzheimer's disease in 2009.

Greg and Mary Catherine O'Brien have lived in their house on Cape Cod for more than 30 years. It's their dream house. They used to imagine growing old there.

But this winter, as Greg's Alzheimer's disease worsened, it became clear that they couldn't stay in the house, which sits on a couple of acres in a secluded part of the Cape. Greg doesn't drive much anymore, and he'll need more and more medical care in the coming years.

Plus, without Greg working as much, the house costs too much to keep up.

So the O'Brien family is preparing to sell their home. The process began with cleaning out Greg's office, where he has worked as a journalist and writer his entire career. Sifting through all his journals and notes has revealed a precious trove of memories.

Interview Highlights

On deciding to sell the house

We made the decision, over the weekend, to sell the house. That's a tough decision and, you know, as a working journalist I never made enormous amounts of money; but I was always able to take care of my family. And now, I'm wondering how I take care of them in the future.

The good thing is, I know that I have these memories, because they're here and I saved them. I don't know why I did that.

You know it's so cool, when you think you've lost your memory and you know you have, but you have all these notes in front of you, and you have your kids. I couldn't think of a better Father's Day present.

On old letters Greg found while cleaning out his home office

It's Father's Day and the kids have given me a great present. They're helping me clean out a bunch of memories in my office. I have, like, four boxes of notes, not knowing where I'd be today in the weeds of my memory. Notes in here about how the kids ... snuck out [to my office]. Brendan writes, many, many years ago, as a little kid:

Hi Dad, It's Brendan. Have a nice Day. I love you a lot. I bet you're wondering how I did this. Love ya. Bye.

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He figured out how to get on my computer and print.

Here's another one. I remember [my daughter] Colleen had her first rabbit, Cuddles, and the rabbit died. And she writes:

This is the best I could do, Cuddles. I have included a box full of, along with this letter, your favorite song on a CD and a tape of me; your favorite food, celery, your brush and your chew toy.

I feel as though someone has ripped out my heart and stomped all over it.

I love you, Cuddles, and I will miss you. And many nights I will cry myself to sleep. I will visit you from time to time and I hope you visit me in my dreams.

Goodbye and I love you,


I don't know, they're pretty good memories.

Greg O'Brien and his family will share more of their experiences with Alzheimer's in coming installments of Inside Alzheimer's on Weekend All Things Considered, and here on Shots.

Copyright 2015 NPR. To see more, visit
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In Court, Your Face Could Determine Your Fate

NPR Health Blog - Fri, 07/17/2015 - 8:33am
Sally Faulkner/Getty Images/Ikon Images

Your face has a profound effect on the people around you. Its expression can prompt assumptions about how kind, mean or trustworthy you are. And for some people, a study finds, it could help determine their fate in court.

Individuals who are deemed to have untrustworthy faces are significantly more likely to be on death row compared with other people convicted of murder, according to a study published Wednesday in Psychological Science. Inmates thought to have trustworthy faces, however, have a higher chance of receiving the more lenient punishment of life in prison.

"Facial trustworthiness is a significant predictor of the sentence people receive," says John Paul Wilson, who led the study and is a social psychologist at the University of Toronto.

Past research has shown that people make quick judgments about someone's character based on their face. For instance, we tend to place more trust in someone whose lips naturally turn upward when their face is relaxed, Wilson says; it's like they're making a smile. The opposite is felt for people who have lips that curve downward, like a frown.

To learn how these biases affect real-life scenarios with serious implications, the research team collected more than 700 mugshots of white and African-American criminals in Florida. Images of the state's prisoners are freely available to the public online.

Florida is one of the few states that still doles out the death sentence, so the team focused on inmates with murder convictions. Individuals who are convicted of the crime either are placed on death row or receive life without parole.

The photos, which ranged from scowling frowns and blank stares to toothy grins, were then judged by more than 200 people who participated in the study. Each participant viewed about 100 images and rated the individual's trustworthiness on a scale of 1 to 8, where one was very untrustworthy and 8 was extremely trustworthy.

While participants probably knew they were looking at prison inmates — the prison uniforms were visible in the mugshots — they were not given any information about the individuals, including what crime they committed and their sentence.

Afterward, Wilson and his team compared the ratings with the sentence the individuals had received.

They found that the average trustworthiness rating inmates received could predict whether they were on death row; the lower the score, the more likely they had a harsher punishment.

Race did not play a role, Wilson says. It all boiled down to the face.

To investigate a bit more, the team carried out the study again. But this time, they used photos of men who had once been convicted of murder and whose charges were later dismissed. The idea was to test the faces of people who were absolved to see if there was any bias against their faces.

Shots - Health News You Had Me At Hello: The Science Behind First Impressions

The team gathered 37 headshots from the Innocence Project, a national litigation effort that works to exonerate wrongfully convicted individuals. In the past, the men had been on death row or had been sentenced to life in prison.

Like before, the photos were judged by participants. And this time? The results were the same. Even a person who was exonerated is judged based on perceived facial appearance, Wilson says.

"This finding shows that these effects aren't just due to more odious criminals advertising their malice through their faces, but rather suggests that these really are biases that might mislead people independent of any potential kernels of truth," he says.

Psychologist Alexander Todorov, a professor at Princeton University, says in an email to Shots that the study confirms faces can have an effect on extremely consequential legal decisions.

"Trustworthiness judgments matter in all domains of life ... and people cannot help but engage in these evaluative judgments," Todorov writes.

He adds that past research has shown that legal decisions are not immune to psychological biases.

But what can we — and, more importantly, the judicial system — do about these biases?

Wilson says that just knowing that we make these inaccurate judgments is a step in the right direction.

"People should be aware of these biases and their susceptibility to them," he says. "Any one of us could find ourselves on a jury one day, and the more we know about what can bias our judgments, the more we can be equipped to combat them."

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'When Thunder Roars, Go Indoors' To Best Avoid Lightning's Pain

NPR Health Blog - Fri, 07/17/2015 - 5:35am
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You don't have to be outdoors to be hurt or injured by a nearby lightning strike, like this one in New Mexico. The pain for survivors can be lifelong.

Marko Korosec/Barcroft Media/Landov

Lightning strikes have killed at least 20 people in the U.S. so far this year, according to the National Weather Service. That's higher than the average for recent years, the service says.

Most people who are injured or killed by lightning, it turns out, are not struck directly — instead, the bolt lands nearby.

That's what happened to Steve Marshburn in 1969. He was working inside a bank and says lightning somehow made its way through an ungrounded speaker at the drive-through window to the stool where he was sitting.

"I still have the migraines," Marshburn says. "The lightning — when it hit my back, it went up my spine, went to the left side of my brain and scorched it, came down, went out my right hand that was holding a metal teller stamp."

That hand still shakes a lot, he says.

Marshburn has since had 46 surgeries, and he says his back still isn't right. He started a group called Lightning Strike and Electric Shock Survivors International. The pain for those who survive a lightning injury can be so severe, he says, that some consider suicide.

The Protojournalist The Randomness Of Lightning Fatalities: A Map Story

"Just a couple of weeks ago we talked our 27th individual out of taking their life," he says.

In those phone calls, Marshburn tells lightning strike survivors that there's help available from the 1,800 or so members of his group.

Dr. Mary Ann Cooper, an emergency physician who directs the lightning injury research program at University of Illinois, Chicago, says that while most people assume lightning strikes cause burns, brain injuries are more common.

Lightning strikes can damage nerves in a way that causes nerves to misfire, sometimes for the rest of the survivor's life, she says, and the brain reads that misfiring as chronic pain.

Even with the near doubling of lightning strike fatalities this year so far, the total is way down compared with the 1940s. Back then, according to the National Weather Service, a division of the National Oceanic and Atmospheric Administration, 300 to 400 people died each year. John Jensenius, a meteorologist and lightning safety specialist with the agency, says there are a few reasons for that.

"Most homes had corded phones," he explains. "So a corded phone, when people held it right up to their head, was a direct connection with wires outside."

The Two-Way Climate Change To Make Lightning More Common, Study Says

And he says there were a lot more farmers sitting on uncovered tractors decades back.

Today about two-thirds of fatalities happen while people are having fun instead of at work. Jensenius says people who were fishing account for more than 10 percent of the lightning deaths in the last decade.

"We have a very simple saying: 'When thunder roars, go indoors.' Which means," he says, "if you hear thunder you need to be inside right away."

One problem with following that advice is that many lightning injuries happen at beaches, where the loud surf can make it difficult to hear thunder. So Jensenius advises making sure you know the weather forecast before you go.

If you want to know how far lightning is from you, he says, count the seconds between the flash of lightning and clap of thunder, then divide that number by 5. That's how many miles away the strike is.

"In the case of a thunderstorm, lightning can strike up to 10 miles away," Jensenius says. "That would be 50 seconds and really, that's about the distance you can hear thunder. So, even a distant rumble should tell you you're close enough to be struck by lightning."

And when you go inside for cover, he says, know that if lightning strikes your house it can travel along electric lines or plumbing. So don't hold on to plugged-in appliances or their cords, or take a shower until the storm is over.

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Home Health Agencies Get Medicare's Star Treatment

NPR Health Blog - Thu, 07/16/2015 - 3:13pm

Choosing a home health agency can be even more difficult than picking a nursing home.


The federal government released on Thursday a new five-star rating system for home health agencies, an effort to bring clarity to a fast-growing but fragmented corner of the medical industry where it's often difficult to distinguish good from bad.

Medicare applied the new quality measure to more than 9,000 agencies based on how quickly visits began and how often patients improved while under their care. Nearly half received average scores, with the government sparingly doling out top and bottom ratings.

The star ratings come as home health agencies play an increasingly important role in caring for the elderly. Last year 3.4 million Medicare beneficiaries received home health services, with nurses, aides, and physical and occupational therapists treating them in the home. Medicare spends about $18 billion on the home health benefit, which provides skilled services that must be authorized by a doctor. Housekeeping care isn't included, and some elderly pay for it privately.

For both the government and patients, Medicare's home health visits are one of the least expensive ways to provide care, and the system has been especially susceptible to fraud. Assessing quality is often challenging for patients and their doctors, who must authorize the visits, often just as patients are leaving the hospital. The elderly tend to be less familiar with the reputation of home health agencies than they are with hospitals and other institutions. That makes evaluating quality particularly difficult for family members and guardians.

"It's not like a nursing home, where you can go and walk around," said Dr. Cheryl Phillips, an executive at LeadingAge, an association of nonprofit groups focused on the elderly. "You can call the agencies and find out a little bit about them and their philosophy of care, but even for an informed consumer like me, you're kind of stuck with whatever your physician has ordered."

Experts said the ratings could have substantial financial impacts on agencies, even driving some low-rated ones out of business. Hospitals, doctors and nursing homes may be reluctant to refer patients to agencies with fewer than three stars. A total of 2,628 agencies — 28 percent of those Medicare evaluated — received those below average ratings.

"It's a very fragmented, competitive market in a lot of metropolitan areas," said Lilly Hummel, a manager at Avalere, a health care consulting firm in Washington, D.C. "It could get difficult for home health agencies that, for whatever reason, aren't doing well on the star ratings."

Medicare intends eventually to pay bonuses and penalties to agencies based on performance, as it does for hospitals.

More than 12,000 home health agencies take Medicare, including local for-profit shops with just a few employees, nonprofit associations of nurses, hospital affiliates and subsidiaries of publicly traded corporations like Kindred Healthcare and Amedisys. Medicare assigned stars to all but 2,902 agencies that did not have enough patients to evaluate, had only started business recently or did not provide enough data.

Among those Medicare did rate, 46 percent received 3 or 3 1/2 stars. Medicare gave the top rating of five stars to 239 agencies while 195 agencies received 1 1/2 stars. Only six agencies received a single star. "What this indicates to us is a large proportion of home health agencies are performing reasonably well," said Dr. Kate Goodrich, who directs the quality measurement program at the Centers for Medicare & Medicaid Services.

There was a wide variation in scoring among types of providers, a Kaiser Health News analysis found. Visiting nurse associations and agencies with religious affiliations tended to get the most stars. Home health agencies run out of skilled nursing homes and agencies run or paid for by local governments tended to perform poorly.

A third or more of home health agencies that Medicare rated received four or more stars in Alabama, California, Florida, Maryland, New Jersey, Pennsylvania, Rhode Island, South Dakota and Utah, the KHN analysis found. The highest proportion of one or two star agencies were in Alaska, Arkansas, Minnesota, Ohio, Oregon, Texas, Wyoming, and the District of Columbia. In those places, four out of 10 agencies or more received less than three stars.

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