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Maine Bill Aims To Make Abuse-Deterrent Painkillers More Affordable

NPR Health Blog - Wed, 05/20/2015 - 4:58pm
Maine Bill Aims To Make Abuse-Deterrent Painkillers More Affordable May 20, 2015 4:58 PM ET


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Sales of prescription opioid painkillers have quadrupled since 1999, according to the Centers for Disease Control and Prevention.

Rich Pedroncelli/AP

The problem of opiate addiction in Maine is one that state Rep. Barry Hobbins knows something about. "One of my family members has been struggling with this dreaded addiction of opiates for six years," he says.

So when pharmaceutical company Pfizer — which makes opioids that have abuse-deterrent properties — asked Hobbins to sponsor a bill that would require insurance companies to cover these more expensive drugs at the same level as other opioids, he agreed.

Shots - Health News As Pain Pills Change, Abusers Move To New Drugs

Abuse-deterrent opioids are designed to be harder to crush, cut, or dissolve. Some transform into a gel when mixed with water, so are harder to inject than versions that readily dissolve. "The bill that I sponsored was, I think, one step to address the problem that we have," Hobbins says.

Last year, Massachusetts became the first in the nation to pass a similar law, which will take effect this October. This year, states from Vermont to California may follow suit.

Some physicians say such legislation is well-meant, but question how much of a dent it will put in the addiction problem. Insurance companies, meanwhile, say that if the bill becomes law, it will only drive up the cost of monthly premiums for all policyholders.

Hobbins' bill initially sought to require insurance companies to cover all abuse-deterrent opioids as "preferred drugs." It's been amended to allow insurance companies to choose whether or not to cover the more expensive opioids. If they do, the co-pay level that patients pay must be the same as for traditional versions of the pain pills.

But there are only three prescription opioids approved as abuse-deterrent by the FDA, and they're all name brands, says Katherine Pelletreau, executive director of the Maine Association of Health Plans, which represents four insurance carriers.

Shots - Health News Brand-Name Medicines Dominate Medicare's $103 Billion Drug Bill

"We have concerns about requiring that a name brand drug — which can be significantly more expensive — be subject to the same cost-shares as a generic," Pelletreau says. Tamper-resistant opioids can cost hundreds of dollars more than versions of opioids that don't have those properties.

Some doctors aren't keen about Maine's bill, either. Dr. Mark Publicker, a psychiatrist and past-president of the Northern New England Society of Addiction Medicine, says the bill has good intentions, but "I'm not sure it's going to have the desired impact."

These new opioids are not abuse-proof, Publicker says. An HIV outbreak in Indiana has been linked to the opioid drug Opana, which, Publicker points out, "is alleged to be tamper-resistant, and people with opiate addiction fairly quickly figured out how to extract the drug." Sales of prescription opioid pain relievers have quadrupled since 1999, according to the Centers for Disease Control and Prevention, and overdose deaths have shot up, too.

Shots - Health News Indiana Struggles To Control HIV Outbreak Linked To Injected Drug Use Shots - Health News Indiana's HIV Spike Prompts New Calls For Needle Exchanges Statewide

If lawmakers really want to put a dent in the addiction problem, Publicker says, they should increase access to treatment.

Dr. Noah Nesin, chief medical officer at Penobscot Community Health Center in Bangor, says the current problem with opioid addiction has largely been driven by misguided prescribing practices. Making abuse-deterrent opioids more available, he says, could lead to more lax prescribing — exacerbating the addiction problem instead of easing it.

"Creating a dynamic in which we think, 'Oh, here's a safer alternative,' is an extremely relative comparison," Nesin says.

The FDA announced in April that it considers the development of opioids that deter abuse "a high public health priority," and says it is committed to supporting their development.

Nesin says he's wary of lawmakers dictating medical care. Rep. Barry Hobbins counters that increasing access to abuse-deterrent opioids may not be a silver bullet, but is one factor that could help prevent opiate addiction in the first place. His bill is expected to reach the floor of Maine's House of Representatives this week.

A version of this story first appeared on, NPR's Maine affiliate.

Copyright 2015 Maine Public Broadcasting Network. To see more, visit
Categories: NPR Blogs

Terminally Ill California Mom Speaks Out Against Assisted Suicide

NPR Health Blog - Wed, 05/20/2015 - 4:40pm
Terminally Ill California Mom Speaks Out Against Assisted Suicide May 20, 2015 4:40 PM ET


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Stephanie and Brian Packer make lunch with their children, Brian, 11, Savannah, 5, Scarlett, 10, and Jacob, 8.

Stephanie O'Neill/KPCC

Stephanie Packer was 29 when she found out she had a terminal lung disease.

Shots - Health News Contemplating Brittany Maynard's Final Choice

That's the same age as Brittany Maynard, who last year was diagnosed with terminal brain cancer. Last fall, Maynard, of Northern California, opted to end her life with the help of a doctor in Oregon, where physician-assisted suicide is legal.

Maynard's story continues to garner support for right-to-die legislation moving through legislatures in California and several other states. Now, Packer, another young California woman, is stepping up to share her story, but she wants people to draw a different conclusion.

On a recent spring afternoon, Packer, 32, is in her kitchen, preparing lunch with her four children.

"Do you want to help?" she asks the eager crowd of siblings gathered tightly around her at the stovetop.

"Yeah!" yells 5-year-old Savannah.

"I do!" says Jacob, who is 8.

Calmly managing four kids as each vies for the chance to help make chicken salad sandwiches can be trying, but Packer cherishes these moments.

Shots - Health News California Faith Groups Divided Over Right-To-Die Bill

In 2012, after suffering a series of debilitating lung infections, she went to a doctor who diagnosed her with scleroderma. The autoimmune disease causes hardening of the skin and (in about one-third of cases) other organs. The doctor told Packer that it had settled in her lungs.

"And I said, 'OK, what does this mean for me?' " she recalls. "And he said, 'Well, with this condition you have about three years left to live.' "

Packer is on oxygen full time and she takes a slew of medications.

She says she has been diagnosed with a series of conditions linked to or associated with scleroderma, including lupus, gastroparesis, Raynaud's phenomenon, interstitial cystitis and trigeminal neuralgia.

The Two-Way As Planned, Right-To-Die Advocate Brittany Maynard Ends Her Life

Packer's various maladies have her in constant, sometimes excruciating pain, she says. She also can't digest food properly and feels extremely fatigued almost all the time.

Some days, Packer says, are good. Others are marked by low energy and pain that only sleep can relieve.

"For my kids, I need to be able to control the pain because that's what concerns them the most," she says.

But Packer says physician-assisted suicide isn't something she is considering.

"Wanting the pain to stop, wanting the humiliating side effects to go away — that's absolutely natural," Packer says. "I absolutely have been there and I still get there some days. But I don't get to that point of wanting to end it all, because I have been given the tools to understand that today is a horrible day, but tomorrow doesn't have to be."

She and husband Brian, 36, are devout Catholics. They agree with their church that doctors should never hasten death.

"We're a faith-based family," he says. "God put us here on earth and only God can take us away. And he has a master plan for us, and if suffering is part of that plan, which it seems to be, then so be it."

Stephanie Packer, 32, is terminally ill with the autoimmune disease scleroderma.

Stephanie O'Neill/KPCC

They also believe if California legislation called SB 128 passes, it would create the potential for abuse. Pressure to end one's life, they fear, could become a dangerous norm, especially in a world defined by high-cost medical care.

Instead of fatal medication, Stephanie says she hopes other terminally ill people consider existing palliative medicine and hospice care.

"Death can be beautiful and peaceful," she says. "It's a natural process that should be allowed to happen on its own." Even, she says, when it poses uncomfortable challenges.

Brian has traded his full-time job at a lumber company for weekend handyman work so he can care for Stephanie and the children. The family downsized, moving into a two-bedroom apartment they share with their dog and two pet geckos.

Brian says life is good.

"I have four beautiful children. I get to spend so much more time with them than most head of households," he says. "I get to spend more time with my wife than most husbands do."

Shots - Health News A Busy ER Doctor Slows Down To Help Patients Cope With Adversity

And it's that kind of support — from family, friends and people in her community — that Stephanie says keeps her living in gratitude, even as she struggles with her terminal illness and the realization that she will not be there to see her children grow up.

"I know eventually that my lungs are going to give out, which will make my heart give out," she says. "And I know that's going to happen sooner than I would like — sooner than my family would like. But I'm not making that my focus. My focus is today."

Stephanie says she is hoping for a double lung transplant, which could give her a few more years. In the meantime, this month marks three years since her doctor gave her three years to live. So every day, she says, is a blessing.

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

Copyright 2015 Southern California Public Radio. To see more, visit
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Looks Good Enough To Smoke: Marijuana Gets Its Glamour Moment

NPR Health Blog - Wed, 05/20/2015 - 12:52pm
Looks Good Enough To Smoke: Marijuana Gets Its Glamour Moment May 20, 201512:52 PM ET
  • Hide caption GDP (Granddaddy Purple). Smell/taste: grape, creamy, berry. Common effects: euphoria, relaxed, body buzz. Top medicinal uses: appetite and pain. Previous Next Courtesy of Chronicle Books
  • Hide caption Blue Kush. Smell/taste: floral, berry, spicy. Common effects: body buzz, relaxed, alert. Top medicinal uses: pain and muscle tension. Previous Next Courtesy of Chronicle Books
  • Hide caption Black Cherry Soda. Smell/taste: cherry, creamy, berry. Common effects: relaxed, euphoria, lazy. Top medicinal uses: stress and pain. Previous Next Courtesy of Chronicle Books
  • Hide caption Skunk #1. Smell/taste: skunky, pungent, acrid. Common effects: uplifting. Top medicinal uses: stress and anxiety. Previous Next Courtesy of Chronicle Books
  • Hide caption Sour Amnesia. Smell/taste: spicy, fuel, skunky. Common effects: energetic, uplifting, cheerful. Top medicinal uses: fatigue and mood enhancement. Previous Next Courtesy of Chronicle Books
  • Hide caption Strawberry Cough. Smell/taste: strawberry, cedar, earthy. Common effects: sociable, cheerful, focused. Top medicinal uses: fatigue and mood enhancement. Previous Next Courtesy of Chronicle Books
  • Hide caption Sugar Daddy. Smell/taste: peppery, lemon, earthy. Common effects: relaxed, mellow, lazy. Top medicinal uses: stress and nausea. Previous Next Courtesy of Chronicle Books

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When Erik Christiansen started smoking pot, he became fascinated by the look of different marijuana strains. But the photographs of marijuana he saw didn't capture the variety.

So he went to the hardware store and picked up two lights and a cardboard box. "I didn't even have a macro lens — I was shooting through a magnifying glass," he says.

High-Def Views

Christiansen has created high-resolution 360-degree views of some strains of marijuana, including this one of Platinum Bubba.

Credit: Courtesy of Erik Christiansen

The California-based photographer tinkered with his macro technique until he had created a consistent way to capture highly detailed images of marijuana.

Then Dan Michaels, a cannabis aficionado and strategist for the growing legal pot industry, contacted Christiansen about collaborating on a field guide. The result is Green: A Field Guide to Marijuana (Chronicle Books, $30). The high-end coffee table book documents over 170 strains of cannabis, explaining their medicinal and recreational attributes. (Though it's worth noting that the medicinal benefits are based on subjective reports rather than randomized clinical trials.)

The book is meant to appeal to the growing artisanal marijuana industry, describing each bud's tasting notes and effects much like a sommelier would describe a vintage wine.

We asked Christiansen about becoming a professional weed photographer, and what we can tell about a marijuana bud's effects by looking at it. The conversation has been edited for length and clarity.

How did you source all of these buds?

I had a library of probably 300 to 400 strains that we were able to pull from. There's your popular strains that most people who enjoy cannabis have heard of, like your Blue Dreams and your Girl Scout Cookies. But we also wanted to include the rare ones. I searched through hundreds of dispensaries in San Diego, L.A., and the Bay Area to try and track down all of them.

Additional Information:

Seeing the buds close up accentuates the variations — some have these wiry golden threads and others are tightly coiffed, like beehive hairdos. They seem to take on personalities. What does this tell us about the plants?

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A Field Guide to Marijuana

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You can take the same plant and give a clone to six different growers and at the end of that grow cycle each will be unique in its own way, based on the nutrients that the growers us, the CO2 content of the air and the temperature of the room. Being able to get up close and see those differences is important.

If you look at any of the pictures, there are these little balls on the end of each plant— that's where the THC is stored. The more little balls, or trichomes, that are present on the buds, the more potent it can be. The color will also tell you a lot about the effect it will deliver. More amber-color trichomes will deliver a more body effect, where lighter-colored trichomes will be more of a head-y effect.

Do you have any favorites?

My favorite in the book is the strain called the Shire. I've only been able to find it once. The effect was so uplifting. It's the only strain that's ever given me the stereotypical effect where you're just sitting there laughing. I went back to that dispensary trying to get it again and was never able to find it again.

There's a certain legitimacy to field guides, or any reference book that documents variations of a species. Was legitimacy the intention?

Absolutely. It's not this stoner druggie culture anymore; it's becoming a real industry.

It's like the wild, wild West. Or craft beer. It's a bunch of little guys tinkering and creating new strains. Some of them totally take off and blow up and you see them all over the place.

What happens to the buds after you've shot them?

I usually get to sample them. Not all the time, but that's a perk of the job.

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

Grassley To Justice Department: Crack Down On Medicare Advantage Overbilling

NPR Health Blog - Wed, 05/20/2015 - 11:57am
Grassley To Justice Department: Crack Down On Medicare Advantage Overbilling May 20, 201511:57 AM ET Fred Schulte

Sen. Chuck Grassley has questions about what the feds are doing to investigate allegations of Medicare Advantage fraud.

Drew Angerer/Getty Images

Senate Judiciary Committee Chairman Chuck Grassley has asked Attorney General Loretta Lynch to tighten scrutiny of Medicare Advantage health plans suspected of overcharging the government, saying billions of tax dollars are at risk as the popular senior care program grows.

In May 19 letters to Lynch and Andrew M. Slavitt, acting administrator of the Centers for Medicare and Medicaid Services, Grassley wanted to know what both agencies have done, together and apart, to stamp out overcharges that have plagued the privately run insurance program for years.

Shots - Health News How Medicare Advantage Investors Profited From Loose Government Lips

"Safeguards become all the more important as Medicare Advantage adds more patients and billions of dollars of hard-earned taxpayer money is at stake," the Iowa Republican wrote.

Medicare Advantage plans have gained popularity as an alternative to the government-run Medicare program in recent years, and the plans now cover some 16 million people.

Grassley cited the Center for Public Integrity's investigative reporting, which found that CMS made more than $70 billion what the agency itself deemed "improper" payments to Medicare Advantage plans between 2008 and 2013.

The concerns revolve around the accuracy of a billing tool called a "risk score," which is supposed to pay insurers higher rates for taking sicker people and less for those with few medical needs.

But federal officials have struggled for years to track overspending tied to inflated risk scores. A 2009 agency study found that some plans had exaggerated how sick patients were to boost their payments, for instance. CMS also has acknowledged that faulty risk scores remain a costly problem, as the Center for Public Integrity first reported last year.

"With the reported increase in risk score gaming, and the monumental cost that the taxpayer will shoulder for such wrongdoing, it is imperative that CMS implement safeguards to reduce risk score fraud, waste and abuse. Moreover, if the reports of abuse are true, CMS should increase its auditing practices," Grassley wrote.

Neither CMS nor the Justice Department had any immediate comment on the letters.

Shots - Health News Feds Knew About Medicare Advantage Overcharges Years Ago

Grassley also cited a 2015 report by the Government Accountability Office , the watchdog arm of Congress, that found CMS "could save billions of dollars by improving the accuracy of its payments to Medicare Advantage programs." The watchdog noted that CMS had estimated "improper payments" to Medicare Advantage plans at more than $12 billion in 2014 alone.

Grassley additionally referenced Center for Public Integrity reports on "an increasing number" of whistleblower lawsuits targeting Medicare Advantage. The suits argue that some insurance companies that offer Medicare Advantage "are allegedly engaging in billing abuse by altering patient records in order to claim patients are sicker than they actually are ... . News reports indicate that some insurance companies are wrongfully claiming sicker patients, leading to inflated risk scores and reimbursements," Grassley wrote.

Medicare Advantage often resonates with many seniors because of its low out-of-pocket costs. It's also winning favor with some health policy wonks who argue these managed care plans can offer higher quality care than standard Medicare, which pays doctors and hospitals on a fee-for-service basis.

Medicare Advantage plans also have proven to be a formidable lobbying force in Washington able to repeatedly beat back any efforts by the government to cut payment rates, most recently in April.

At the time, Karen Ignagni, chief executive officer of America's Health Insurance Plans, the industry's trade group, noted: "Millions of seniors across the country have made their voices heard in Washington, and more than 340 members of Congress have stood in support of Medicare Advantage."

Shots - Health News More Whistleblowers Say Health Plans Are Gouging Medicare

But the whistleblower cases and government audits suggest that it's far too easy for health plans to gouge the government.

Grassley asked Lynch for a "detailed explanation" of what steps the Justice Department "has taken, and is currently taking, to ensure that insurance companies are not fraudulently altering" risk scores.

Government investigations of Medicare Advantage plans rarely spill out into public view. One exception was a 2009 Justice Department lawsuit against the owners of America's Health Choice Medical Plans Inc. in Vero Beach, Fla. The government accused the health plan of bilking Medicare out of millions of dollars by reporting "as many diagnosis codes as possible without regard to their truthfulness."

The health plan denied the accusations. The case was settled in 2010 when the plan's owners agreed to pay the government $22.6 million. The HMO is defunct.

At least one other Justice Department probe into whether exaggerated risk scores are jacking up costs is believed to be widening.

Humana Inc., based in Louisville, Ky., which counts more than 3 million seniors in its plans, wrote in a March Securities and Exchange Commission filing that "a number of Medicare Advantage plans, providers and vendors" have come under scrutiny.

On April 14, DaVita Healthcare Partners Inc., headquartered in Denver disclosed that Justice Department investigators had subpoenaed Medicare Advantage billing data and other records from January 2008 through the end of 2013.

Grassley asked both Justice and CMS to tell him how many risk-score fraud investigations had been conducted over the past five years and their outcome. He asked for a reply no later than June 3, 2015.

Grassley also wants to know how many risk score audits CMS has conducted, how much money was recovered and how much CMS spends attempting to collect overpayments.

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

Copyright 2015 The Center for Public Integrity. To see more, visit .
Categories: NPR Blogs

Map Reveals The Distinctive Cause Of Death In Each State

NPR Health Blog - Wed, 05/20/2015 - 10:42am
Map Reveals The Distinctive Cause Of Death In Each State May 20, 201510:42 AM ET

There's no getting around the strangeness of a map that shows the most distinctive cause of death in each of our 50 states and the District of Columbia.

In Texas, it's tuberculosis. In Maine, it's the flu. And in Nevada, it's the ominous "legal intervention."

But what does it mean to label a cause of death distinctive?

I asked Francis Boscoe, a researcher with the New York State Cancer Registry, who came up with the analysis and the map published last Thursday by Preventing Chronic Disease, an online journal from the Centers for Disease Control and Prevention. Since then, the map has gone, well, viral.

"To be honest, I was seeing these maps about a year ago," he tells Shots. One he points to is a state-by-state map of distinctive musical artists based on the online listening habits of people across the country. In other words, which artist was listened to far more often in one state than the others.

"I wondered what it would look like if you applied this to something more serious, like mortality data," he says. He took advantage of a standardized list of causes of death — 113 in all — that are used across the country and a national database of the underlying causes of death collected between 2001 to 2010.

Boscoe calculated the mortality rates for all 113 causes of death in each state and compared them with the rates for the same causes nationwide. On the map, each state and Washington, D.C., then got labeled with the local cause that was, essentially, the largest multiple of the corresponding national rate.

If you'd like to try it, here's the formula for standardized mortality rate that he used:

The biggest of the outliers was Oklahoma, where the rather vague death cause "other acute ischemic heart diseases" was used 19.4 times more often than it was nationally.

Boscoe says the most distinctive death cause in about half the states, including Oklahoma, says more about how people there are classifying deaths than the actual health of people. There are "a few different flavors of heart disease," Boscoe says. "Oklahoma, for whatever reason, is putting them in the other, unspecified category. If you're interested in heart attacks vs. chronic heart disease, you're not going to get a good read on that there, whereas in most states you would."

Other top causes are clearly on the money, he says, such as tuberculosis in Texas and black lung disease, or pneumoconiosis, in the coal-mining states of West Virginia and Kentucky. Those causes are straightforward to diagnose and make sense in context.

The map has limitations. "Some states deserve to have more than one color," he says, because there are a couple of causes that rise above the rest. In Nevada, for instance, he says, atherosclerosis and legal intervention (which is a death in the context of a crime scene and could be either someone in law enforcement or a civilian) were both quite high.

In general, he says, the most distinctive cause of death in each state is at least double the corresponding national rate. He plans on looking at that doubling rule of thumb in more detail.

Boscoe says the map has already sparked conversations with public health officials in some states about how to improve the classification of deaths. And he's been deluged with calls from reporters interested in the prime causes where they work.

While he acknowledges a certain cartoonishness to the map, he says that he doesn't think the work was frivolous: "It obviously works better than sending out a 16-page report that no one would open."

Copyright 2015 NPR. To see more, visit
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Dense Breasts Are Just One Part Of The Cancer Risk Calculus

NPR Health Blog - Tue, 05/19/2015 - 1:06pm
Dense Breasts Are Just One Part Of The Cancer Risk Calculus May 19, 2015 1:06 PM ET

Almost half the states now require doctors to tell women if they have dense breasts because they're at higher risk of breast cancer, and those cancers are harder to find. But not all women with dense breasts have the same risks, a study says.

Those differences need to be taken into account when figuring out each woman's risk of breast cancer, the study says, and also weighed against other factors, including family history, age and ethnicity.

The researchers looked at the records of 365,426 women who had a normal mammogram, then looked to see which ones were diagnosed with breast cancer within a year — a cancer that may have been missed by the mammogram.

All told, 47 percent of the women in the study had dense breasts. But just half of those women had a higher cancer risk. The women who got cancer were more likely to be older and white, have a family history of breast cancer, and to have "heterogeneously" or "extremely" dense breasts, the top two categories of breast density.

Shots - Health News Letters About Dense Breasts Can Lead To More Questions Than Answers

The results were published Monday in Annals of Internal Medicine.

Breast cancer advocates have been pushing for state and federal laws requiring that women be told if they have dense breasts, so they can get extra screening with ultrasound or MRI. That screening can find more cancers in dense breasts, but it can also lead to more false positives and needless surgery.

This study makes the point that women need to know not just about breast density, but what kind of breast density, and other risk factors, too.

Sounds complicated. So we called up Dr. Karla Kerlikowske, a professor of medicine at the University of California, San Francisco and lead author of the study, to help us figure this out. The conversation has been edited for length and clarity.

Your study looks at breast cancer risk using not just breast density but also family history, age and ethnicity. Why is that?

About 45 percent of women have dense breasts; that's a large number of women. But the sensitivity of mammograms is such that we're not missing 45 percent of cancers. So can we narrow it down to women who are at higher risk of cancer, and especially women at higher risk of advanced cancer? Then if we did supplemental imaging of women in that group, it might help them.

How would I figure out the other risk factors besides breast density?

Shots - Health News Federal Panel Revisits Contested Recommendation On Mammograms

You can use our Breast Cancer Surveillance Consortium Risk Calculator; it looks at age, race, family history, history of biopsy and breast density. Ours is the only risk calculator that has breast density in it. We actually validated it in another mammography population. And it's an app; just type in "BCSC Risk Calculator" and download.

I looked at the calculator, and even though I've been told I have dense breasts I realize I have no idea if they're heterogenous or extremely dense, which are the higher-risk categories. How do I find that out?

The provider who ordered the test will get that information. You'd have to ask the provider; it's in the mammography report. My understanding from the bills in Congress is that you'd actually be told what your density is; if you're fatty or scattered or heterogenous or extremely dense. All women would be informed, and they would know the category. If I have fatty breasts I'd like to know that, too, because then I'm at really low risk.

Are you telling your patients that?

It sort of depends. If I don't think they're at high risk of an interval cancer I tend not to worry them too much. If they're at high risk then I have a discussion with them. If they have fatty breasts I let them know, wow, you're really at low risk for cancer.

It feels like we're still struggling with who really needs the extra scans. How will we figure that out?

Now that we know who these high-risk groups are, we need to know how supplemental screening works in those high-risk groups. If we add ultrasound, do we miss less cancer? If we add MRI, do we miss less cancer? We have data on both of them, and we're in the process of analyzing them.

When will we find out?

I'm hoping sometime this summer.

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

How Medicare Advantage Investors Profited From Loose Government Lips

NPR Health Blog - Tue, 05/19/2015 - 10:54am
How Medicare Advantage Investors Profited From Loose Government Lips May 19, 201510:54 AM ET Fred Schulte

On Wall Street, Feb. 3, 2011, was mostly a ho-hum day. But not for companies that sell Medicare Advantage plans.

Several of those that offer the privately run Medicare coverage option hit the jackpot, tacking on billions of dollars in new value after federal officials signaled they might go easy on health plans suspected of overcharging the government.

Shots - Health News More Whistleblowers Say Health Plans Are Gouging Medicare

The stocks took off after the federal Centers for Medicare and Medicaid Services advised the plans in a memo that it was rethinking a move to ratchet up audits. Some of these plans are run by publicly traded insurance companies whose fortunes can rise and fall on a whiff of change in Medicare policy.

At the time, health insurers were bracing for tougher audits, fearing they could wind up owing the government millions of dollars as a result.

The memo was sent to Medicare Advantage plans, but wasn't available to the general public.

A CMS spokesman said the two-paragraph memo was routine and that officials did nothing wrong in sending it out. But the advisory appears to contradict CMS regulations that urge officials to wait until after markets close to disclose information that could move stocks. The episode also raises fresh questions about the security and timing of so-called market-sensitive disclosures — and just who gains access to the information.

"When the memo was released by people at the agency, they had to be brain dead if they thought it would not quickly make its way into the hands of those who influence stock prices," said Lynn E. Turner, a former Securities and Exchange Commission official and expert on financial reporting requirements.

Big Jump

CMS said it began sending out the memo on an internal message system at 9:30 a.m. on Feb. 3 and it took "several hours" to reach all of the 6,500 health plan recipients.

By mid-afternoon, a CMS official in Washington noted that shares in three major Medicare Advantage insurers had "shot up" as a result.

"There's also an incredible volume — an atypical number of buyers and sellers," CMS official Misha Segal wrote in an email to several agency higher-ups at 2:37 p.m. (See the email traffic below.)

UnitedHealth Group, the nation's biggest Medicare Advantage company, rose 4 percent, which "is nearly $2 billion in 'newly created equity' for the company," according to Segal. "This is a big jump."

The huge stock rally — and the role CMS played in sparking it — is disclosed in agency emails and other records obtained by the Center for Public Integrity through a Freedom of Information Act lawsuit.

CMS officials, in a statement, said nothing was amiss.

The memo "was routine, appropriate and did not contain sensitive information. This standard memo was simply a reminder that CMS would thoroughly evaluate all the comments received and that we anticipated potential future changes based on the input we received. No non-public information was provided in this message."

Yet even the suggestion of an upcoming Medicare policy shift can trigger a stampede of buying or selling of health care stocks — and raise questions about how closely agency officials followed CMS regulations written to prevent this sort of Wall Street windfall.

The rules say officials should "strive to err on the side of caution" by waiting until after markets close at 4 p.m. Eastern Time to make announcements "because it is sometimes difficult" to predict what will roil stock prices.

The wait is to "allow the investment community broad access to the information and time to fully analyze the announced change before reacting to it," according to a September 2010 CMS policy statement. CMS also regularly cautions employees to keep market-sensitive deliberations under wraps. (See the policy statement below.)

Additional Information:

Signaling changes

But the February 2011 memo from Cheri Rice, acting director of the Medicare Plan Payment Group, stated that CMS "anticipates making changes" to the much-feared audit process. The memo arrived at a time when the industry — and stock market analysts — were worried that the audits could hurt the companies' bottom lines.

Indeed, the memo brought a strong reaction. Justin Lake, then an analyst at UBS Investment Bank, flagged the memo as "breaking news from CMS" in a research note sent via email at 1:33 p.m.

"We have been reading CMS notices for 10 years now and don't EVER remember the agency indicating explicitly that there were changes coming in between publishing preliminary and final rules such as this. Very interesting indeed," Lake wrote.

Lake speculated that it could signify a "kinder/gentler CMS" that would be less aggressive about clawing back widespread overpayments to Medicare Advantage plans. Such a stance would be "very bullish" for Medicare Advantage stocks, he said.

It's not clear how the UBS analyst obtained the memo. Lake, who recently joined a hedge fund in Connecticut, declined comment through the firm.

At 2:07 p.m., a second CMS official remarked that Lake's analysis "is generating huge amounts of interest from the markets. Bank of America just called me too," he wrote.

In his 2:37 p.m. email, Segal cited Lake's note as the biggest driver of the market: "The sales team at UBS must have gotten on [the] phones and convinced a bunch of analysts and traders that this was a big deal," Segal wrote.

Much of the other chatter within CMS as the stocks gained ground was redacted from the volley of emails released to the Center for Public Integrity.

Still, it's clear that agency officials were caught off guard. Stock in Humana Inc., the country's second biggest Medicare Advantage plan, rose by 5 percent. HealthSpring, also a Medicare insurer, was up 4 percent. It all happened on a day when the Standard & Poor's 500 index was roughly flat, according to the CMS mid-afternoon analysis.

CMS spokesman Aaron Albright said the memo was a "standard communication" and suggested the markets had overreacted. "We can't control how people react to a memo like this," he said.

While investors may have welcomed CMS easing up on Medicare Advantage audits, taxpayers, both then and now, have much less cause for applause.

The audits that the industry was hoping to scale back assess the accuracy of a billing tool called a "risk score," which is supposed to pay insurers higher rates for taking sicker people and less for those with few medical needs.

By 2011, CMS officials had been struggling for years to track overspending tied to inflated risk scores. A 2009 agency study found that some plans had exaggerated how sick patients were to boost their payments, for instance. And by the agency's own account, "improper" payments to Medicare Advantage plans cost taxpayers billions of dollars annually, as the Center for Public Integrity first reported last year.

Despite growing losses from improper billing, CMS officials have repeatedly caved in to pressure from the industry to scale back the consequences of these audits, which are known as Risk Adjustment Data Validation — or RADV.

CMS posted a draft regulation on Dec. 20, 2010, that outlined how the audits would be conducted and asked for comments. In the Feb. 3 memo, CMS official Rice wrote: "We are thoroughly evaluating all comments and anticipate making changes to our draft, based on input we received."

The amount of money in dispute could be growing along with the Medicare Advantage program, whose annual cost now exceeds $150 billion.

More than four years after the February 2011 memo was sent, CMS still hasn't finished even the first round of the RADV audits. "These audits are underway. CMS is auditing 30 contracts and we do not have a specific timeframe for completion," agency official Albright said.

CMS has come under fire in recent years over how it releases policy information — and to whom. In Dec. 2011, Sen. Chuck Grassley, R-Iowa, criticized the agency for conducting briefings on behalf of hedge funds and so-called "political intelligence brokers" who seek to profit as a result. The SEC also has regulations on disclosure.

CMS also is at the center of an ongoing probe into whether 2013 Medicare Advantage rate information was leaked in advance of the public announcement.

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

Copyright 2015 The Center for Public Integrity. To see more, visit .
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Change To Mammogram Guidelines Could Lead To Coverage Shift

NPR Health Blog - Mon, 05/18/2015 - 2:53pm
Change To Mammogram Guidelines Could Lead To Coverage Shift May 18, 2015 2:53 PM ET

Millions of women could lose access to free mammograms under changes to breast cancer screening guidelines that influence insurers, the consulting firm Avalere estimates.

The Avalere analysis is based on an update to breast cancer screening recommendations proposed by the U.S. Preventive Services Task Force, a group of medical experts whose work guides health care standards and policy. The public comment period on the proposal expires Monday.

Seventeen million "is the absolutely worst-case scenario," says Caroline Pearson, senior vice president of Avalere and one of the study authors. She says the estimate assumes that every single insurer would refuse to pay for free annual mammograms for women ages 40 to 49, which isn't likely.

Still, some insurers could reject the claims or require that women in that age range pay a share of the cost.

Under the Affordable Care Act, insurers must cover the full cost of preventive services that are recommended by the task force on the basis of strong evidence. The task force grades the strength of the evidence it uses. If its recommendation is based on evidence that gets an A or B, then the federal health law requires insurers to go along. If, however, the evidence is weaker and gets a C or worse, then there's no mandate for free coverage.

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In 2009, the panel recommended that most women get a mammogram every other year, beginning at age 50. For women between 40 and 49, the panel said the evidence merited a C and that getting a mammogram should be an individual decision based on a woman's view of the benefits of cancer detection, weighed against the potential harms of false alarms and unnecessary treatments.

Controversy over that 2009 recommendation caused Congress to intervene and led to an amendment to the Affordable Care Act that instructs insurers to follow a 2002 task force recommendation that gave a B rating to the evidence for screening women ages 40 to 49.

Mammograms for women between 40 and 49 can be lifesaving. But the task force's initial recommendation suggests a disproportionate level of harm tied to screening in that age group. If the USPSTF proceeds with the recommendation, it would reset the standards for screening under the law.

The task force proposal is at odds with guidelines from the American Cancer Society, for instance, which suggest women be screened every year, beginning at age 40.

"It's such a volatile issue that insurers will likely decide it's not in their best interest [not to cover it]," says Dr. Otis Brawley, chief medical officer of the American Cancer Society.

Brawley says insurance companies are competing for customers and will want to offer services they value, such as mammograms.

He expects most insurers to continue paying for annual mammograms for women in their 40s. "They'll say we don't want to be the outlier that doesn't cover this," he says.

He also says it's possible that Congress will intervene, as it did in 2009, and require insurers to pay for annual screenings.

The connection between task force guidelines and insurance company coverage is often loose, says Dr. Kenny Lin, a professor of family medicine at Georgetown University and previously a medical officer for the U.S. Preventive Services Task Force program at Agency for Healthcare Research and Quality.

"There are a lot of things that insurers cover that are not supported by USPSTF," Lin says, such as electrocardiograms in adults at low risk of heart disease and Pap test screening in women over 65.

But Lin says, even if Congress doesn't intervene and some insurers refuse to pay for mammograms, that wouldn't necessarily be a bad thing.

"For every woman in her 40s who has her life saved through breast cancer screening and treatment, 1,000 to 1,200 will receive a false positive [result indicating cancer when there is none], and 10 will get treatment for a cancer that was never going to harm them," he says.

"If screening drops off, these harms would drop off correspondingly," he says.

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Does A Foreign Accent Mess Up Our Memory Of What's Said?

NPR Health Blog - Mon, 05/18/2015 - 11:47am
Does A Foreign Accent Mess Up Our Memory Of What's Said? May 18, 201511:47 AM ET

Sometimes I look at my husband and think, "I really don't remember what you just said." Is that because of his charming European accent, or because hey, we're married?

Don't leap to blame the accent, researchers at Washington University in St. Louis say. They are trying to figure out how the brain deals with foreign accents, hearing loss and other speed bumps on the road to understanding.

People who have hearing loss have a harder time recalling lists of words they've been asked to remember. That's probably because their brains are working harder just to hear each word and have less bandwidth left for understanding and remembering.

The researchers in this study thought that would be true for accented speech, too, so they had a colleague with a Korean accent read a list of words to young native English speakers with no hearing issues.

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But the people didn't have any more trouble remembering accented words than they did words read by a native English speaker. That suggests that the brain deals with the challenges of accented speech differently than it does hearing loss, according to Kristen Van Engen, a postdoctoral researcher in linguistics who led the study. She presented the results Monday at the meeting of the Acoustical Society of America in Pittsburgh.

"A foreign language is really different than a noisy native signal," Van Engen says. "With an accent you have full access to the signal, but it doesn't map onto your existing patterns."

Shots - Health News The Forgotten Childhood: Why Early Memories Fade

Van Engen and Jonathan Peelle, a cognitive neuroscientist who studies thinking and hearing loss, are trying to figure out how noise, hearing loss and accents affect critical issues like health care. What happens if you have hearing loss and your doctor has an accent? Or if the aides in the noisy nursing home aren't native speakers?

They've got a long list of experiments on their to-do list that they hope will figure that out. For now, it looks like listening to a non-native speaker could be a plus in some situations, Van Engen says. In one experiment they've conducted, people did a better job on memory tests when listening to accented speech. "There might be some ways that working harder leads to better memory."

I can't say that's true in my case. But I do know that my husband and I have to put a lot of effort into trying to figure out what the other person really means because of our language differences. And that might ultimately lead to better understanding, even if I do forget a few things along the way.

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Deaf Jam: Experiencing Music Through A Cochlear Implant

NPR Health Blog - Mon, 05/18/2015 - 3:52am
Deaf Jam: Experiencing Music Through A Cochlear Implant May 18, 2015 3:52 AM ET Listen to the Story 6:55
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Sam Swiller and his dog, Sully, in their home in Washington, D.C.

Meredith Rizzo/NPR

When Sam Swiller used hearing aids, his musical tastes ran to AC/DC and Nirvana — loud bands with lots of drums and bass. But after Swiller got a cochlear implant in 2005, he found that sort of music less appealing.

"I was getting pushed away from sounds I used to love," he says, "but also being more attracted to sounds that I never appreciated before." So he began listening to folk and alternative music, including the Icelandic singer Bjork.

There are lots of stories like this among people who get cochlear implants. And there's a good reason. A cochlear implant isn't just a fancy hearing aid.

When his cochlear implant was first switched on, the world sounded different.

Meredith Rizzo/NPR

"A hearing aid is really just an amplifier," says Jessica Phillips-Silver, a neuroscience researcher at Georgetown University. "The cochlear implant is actually bypassing the damaged part of the ear and delivering electrical impulses directly to the auditory nerve."

As a result, the experience of listening to music or any other sound through the ear, with or without a hearing aid, can be completely unlike the experience of listening through a cochlear implant. "You're basically remapping the audio world," Swiller says.

A Boy's Audio Life

Swiller is 39 years old and lives in Washington, D.C. He was born with an inherited disorder that caused him to lose much of his hearing by his first birthday. That was in the 1970s, and cochlear implants were still considered experimental devices. So Swiller got hearing aids. They helped, but Swiller still wasn't hearing what other people were.

Additional Information:

To hear what music sounds like through a cochlear implant, listen to these two clips from a well-known song.

'Sunshine Of Your Love' by Cream

A simulation of what the song would sound like through a cochlear implant.

"The earliest memory I have of that awareness is a family picnic around the time I was 4 or 5," he says. He recalls "feeling isolated and separated from everyone, even though it was a picnic filled with family friends."

Even with hearing aids, Swiller was only understanding perhaps one word in three. He relied on lip reading and creativity to get by.

And he took refuge in music, especially grunge rock that cranked up the low-frequency sounds he heard best. "Isolation was a common theme in my childhood and so Nirvana kind of spoke to me," he says.

Swiller didn't know what most of the lyrics were saying until MTV started closed captioning its music videos. But it didn't matter.

"I just love music," he says. "Not just the sound of music, but the whole theory of music, the energy that's created, the connection between a band and the audience and just the whole idea of just rocking out."

Swiller kept rocking out through high school and college. Then, in his late 20s, the hearing he had left pretty much vanished.

By that time, cochlear implants had been greatly improved and had become a common option for people with profound hearing loss or no hearing at all. So Swiller, after giving it a lot of thought, decided to give the new technology a try.

Health Cochlear Implants Redefine What It Means To Be Deaf

That meant surgery to place a receiver under the skin behind his ear and electrodes in the cochlea, a hollow tube in the inner ear containing nerve endings that carry sound information to the brain. Once Swiller healed from the surgery, the receiver was connected to the external parts of the device: a microphone and processor that resemble a traditional hearing aid.

Swiller says when a doctor switched on his device for the first time, he wasn't prepared for the way people would sound. "I remember sitting in a room and thinking everyone was a digital version of themselves," he says.

The voices seemed artificial, high pitched and harsh. And he couldn't figure out what people were saying. "Your brain is understanding, 'OK, this is a language, but I need to figure out how to interpret this language,' " he says.

Over the next few months, Swiller's brain learned to decode words and sentences. And he started listening to music again, which is when he realized that his tastes had changed.

"All of our senses give us the ability to experience very different worlds," Swiller says.

Meredith Rizzo/NPR

Lots Of Beat, Not Much Tune

A cochlear implant is designed to do one thing really well — allow users to understand speech.

"Where it is somewhat lacking is more in relating information about pitch and timbre," says Phillips-Silver. Current implants simply leave out much of the information needed to tell the difference between notes that are close together on a keyboard or instruments that sound similar, she says.

To show how this affects listening to music, Phillips-Silver did an experiment that involved people with cochlear implants listening to "Suavamente," a merengue song with a strong dance beat. "There is a lot going on," she says. "A lot of different instrument sounds, there's a vocal line, there's a great range of frequencies. It's fairly intricate music."

Even so, people with cochlear implants had no trouble moving in time with the music, Phillips-Silver says. They also kept the beat when they heard a version of the song that consisted entirely of drum tones.

But when they heard a version played on a solo piano, participants had no success keeping the beat, Phillips-Silver says, because they couldn't rely on the bass or drums.

Better Implants For Music

It should be possible to make cochlear implants more music-friendly, says Les Atlas, a professor of electrical engineering at the University of Washington. But there's a reason current models are so limited, he says.

"There is no easy way to encode pitch as an electrical stimulation pattern," Atlas says. Also, it takes a lot of computing power to encode something like pitch information in real time.

As a result, even the newest cochlear implants provide very little information about pitch, Atlas says. To make his point, he plays a recording of a few piano notes, followed by a simulation of how those notes might sound through a cochlear implant. The simulated version sounds like the same note being played again and again.

A simple piano tune

A simulation of what the piano tunes sounds like through a cochlear implant

So Atlas and other researchers are working on software that allows an implant to convey more information about pitch and timbre. "It explicitly looks for the tonality in the music and uses it in how things are encoded," he says.

When he plays a simulation of the piano music as encoded by his software, changes in pitch are much more obvious. The result may not replicate music exactly, Atlas says, but it offers implant users a lot more information about musical sounds.

What the piano tune would sound like through software that restores pitch.

"And lo and behold the results we get now on the few people we've tested is that they do get better music cues," he says. "They can hear the difference between musical instruments. The richness of their experience when they listen to music has increased."

The extra information isn't just useful for music, Atlas says. It also should help people with implants who need to understand highly tonal languages like Chinese and Vietnamese. And it could help people with cochlear implants pick out one voice in a room filled with voices.

Even with technical improvements, the experience of hearing the world through a cochlear implant will still be different. But that's a given, says Sam Swiller, who has now spent a decade with his implant.

"All of our senses give us the ability to experience very different worlds," Swiller says. "Even though we're walking side by side we are experiencing a very different street, a very different day, very different colors."

And that's a good thing, Swiller says. Someday we all may be listening to new and different sounds created by musicians with cochlear implants, he says. "When we truly engage each other we get to experience a little bit of each other's world and I think that's where real creativity happens."

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Sex Ed Works Better When It Addresses Power In Relationships

NPR Health Blog - Sun, 05/17/2015 - 7:18am
Sex Ed Works Better When It Addresses Power In Relationships May 17, 2015 7:18 AM ET iStockphoto

At schools that offer comprehensive sex education, students tend to get the biology and the basics — they'll learn about sexually transmitted diseases and pregnancy, how to put a condom on a banana and the like.

But some public health researchers and educators are saying that's not enough. They're making the case that sex ed should include discussion about relationships, gender and power dynamics.

"The idea here is that sex is a relationship issue — you don't get HIV by just sitting there by yourself, nor do you get chlamydia or gonorrhea, nor do you get pregnant," says Ralph DiClemente, a professor of public health at Emory University.

Knowing how to communicate and negotiate with sexual partners, and knowing how to distinguish between healthy and abusive sexual relationships, are as important as knowing how to put on a condom, DiClemente says.

So, over the past decade, researchers have developed "empowerment based" sex ed programs that address the social and biological aspects of puberty and sex.

Youth Radio Puberty Is Coming Earlier, But That Doesn't Mean Sex Ed Is

The programs often start out with broad discussions about gender norms and gender inequality.

For example, SISTA — a sex ed program that DiClemente helped develop for young African-American women — starts off by having students discuss the perks and challenges of being young women.

And then, in addition to learning about contraceptives, they talk about how to discuss safe sex with partners.

"They play out, for example, how do they negotiate with their sex partner, particularly if they're in a disempowered relationship," DiClemente says. "And maybe their boyfriend doesn't want to use a condom and is threatening to leave, to hurt her."

The goal is to help young women feel empowered to ask for what they want from their sexual partners. "And to feel good about themselves, so if they decide they want to be assertive with their partner, they can do that," DiClemente says.

Children's Health It May Be 'Perfectly Normal', But It's Also Frequently Banned

Similar programs geared toward young men emphasize the importance of empathy and kindness toward women and explore what it means to be a good man. And some programs, geared toward mixed groups of men and women, include lessons about harassment, as well as respect toward people with different sexual identities.

Elementary school students in the Los Angles Unified School District learn about gender norms and human rights even before they learn about sex. Through a program called iMatter, fifth- and sixth-graders learn about puberty alongside lessons on body image and harassment. "They also learn about gender norms, and try to break down these barriers between pink and blue," says Tim Kordic, who helps coordinate the program at LA Unified.

The approach seems to work. A recent study published in International Perspectives on Sexual and Reproductive Health reviewed evaluations of 22 sex education programs for adolescents and young adults, comparing how effective they were in reducing pregnancy and sexually transmitted diseases.

NPR Ed A Classic Prep For Parenthood, But Is The Egg All It's Cracked Up To Be?

It found that while 17 percent of the traditional sex education programs lowered rates of pregnancy and sexually transmitted disease, 80 percent of the programs that address gender and power lowered rates. All told, programs that addressed gender or power were five times as likely to be effective as those that did not.

The results aren't all that surprising, says Nicole Haberland, the study's lead author and a researcher at the Population Council, a nonprofit research organization focused on sexual health.

"In the past, study after study has found that young people who adhere to harmful gender norms have worse sexual and reproductive health outcomes," she says.

Young men are bombarded with messages that trivialize violence against women or pressure men to be tough, Haberland says. "And in the media, women are told they shouldn't be sexual, but they should look sexy."

By helping young people sort through these ideas and understand what healthy relationships look like, sex education programs can help them make better decisions about sex and relationships, she says.

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Feds Tell Insurers To Pay For Anesthesia During Screening Colonoscopies

NPR Health Blog - Fri, 05/15/2015 - 10:33am
Feds Tell Insurers To Pay For Anesthesia During Screening Colonoscopies May 15, 201510:33 AM ET

Partner content from

Michelle Andrews

The administration told insurers that they have to pay for anesthesia during screening colonoscopies for cancer.

Don Ryan/AP

Earlier this week the federal government clarified that insurers can't charge people for anesthesia administered during a free colonoscopy to screen for colorectal cancer.

That's welcome news for consumers, some of whom have been charged hundreds of dollars for anesthesia after undergoing what they thought would be a free test. But the government guidance leaves important questions unanswered.

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Under the health law, most health plans have to provide care that's recommended by the U.S. Preventive Services Task Force without charging people anything out of pocket. (The only exception is for plans that have grandfathered status under the law.)

The medical task force, a nonpartisan group, recommends that starting at age 50 people periodically receive either a colonoscopy, sigmoidoscopy or fecal occult blood test to screen for colorectal cancer.

Most people are anesthetized during a colonoscopy, in which a flexible tube with a camera at the end is inserted into the rectum and snaked through the large intestine to look for polyps and other abnormalities.

Although the health law made it clear that the colonoscopy itself must be free for patients, it didn't spell out how anesthesia or other charges should be handled.

That lack of clarity allowed insurers to argue at first that if polyps were identified and removed during the colonoscopy, the procedure was no longer a screening test and patients could be billed. In 2013, regulators clarified that patients couldn't be charged for polyps removed during a screening colonoscopy because it was an integral part of the procedure.

With this week's guidance, the government has made it clear that consumers don't have to pick up the tab for anesthesia during a colonoscopy either.

But other questions remain. Consumers may still find themselves on the hook for facility or pathology charges related to a screening colonoscopy, according to an email from Anna Howard, a policy principal at the American Cancer Society Cancer Action Network, and Mary Doroshenk, director of the National Colorectal Cancer Roundtable.

In addition, cost-sharing rules are unclear for consumers who get a positive result on a blood stool test and need to follow up with a colonoscopy. The federal government hasn't clarified whether that procedure is considered part of the free screening process or whether insurers can charge for it as a diagnostic procedure, Howard and Doroshenk say.

In a 2012 study, researchers found that four insurers imposed patient cost-sharing for colonoscopies after a positive blood stool test and three did not.

As for consumers who paid for anesthesia and now learn that they shouldn't have been charged, it's unclear whether they can get their money back.

"Our expectation is that those who have received a bill for anesthesia this plan year may be able to appeal, but not for previous years," Howard and Doroshenk said.

The Department of Health and Human Services didn't respond to a request for clarification.

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Nurse Visits Help First-Time Moms, Cut Government Costs In Long Run

NPR Health Blog - Thu, 05/14/2015 - 3:23pm
Nurse Visits Help First-Time Moms, Cut Government Costs In Long Run May 14, 2015 3:23 PM ET

Partner content from

Michelle Andrews

Symphonie Dawson and her son, Andrew. A visiting nurse program helped Dawson finish school while she was pregnant.

Courtesy of Symphonie Dawson

While studying to become a paralegal and working as a temp, Symphonie Dawson kept feeling sick. She found out it was because she was pregnant.

Living with her mom and two siblings near Dallas, Dawson, then 23, worried about what to expect during pregnancy and what giving birth would be like. She also didn't know how she would juggle having a baby with being in school.

At a prenatal visit she learned about a group that offers help for first-time mothers-to-be called the Nurse-Family Partnership. A registered nurse named Ashley Bradley began to visit Dawson at home every week to talk with her about her hopes and fears about pregnancy and parenthood.

Bradley helped Dawson sign up for the Women, Infants and Children Program, which provides nutritional assistance to low-income pregnant women and children. They talked about what to expect every month during pregnancy and watched videos about giving birth. After her son Andrew was born in December 2013, Bradley helped Dawson figure out how to manage her time so she wouldn't fall behind at school.

Dawson graduated with a bachelor's degree in early May. She's looking forward to spending time with Andrew and finding a paralegal job. She and Andrew's father recently became engaged.

Ashley Bradley will keep visiting Dawson until Andrew turns 2.

"Ashley's always been such a great help," Dawson says. "Whenever I have a question like what he should be doing at this age, she has the answers."

Home-visiting programs that help low-income, first-time mothers have been around for decades. Lately, however, they're attracting new fans. They appeal to people of all political stripes because the good ones manage to help families improve their lives and reduce government spending at the same time.

In 2010, the Affordable Care Act created the Maternal, Infant and Early Childhood Home Visiting program and provided $1.5 billion in funding for evidence-based home visits. As a result, there are now 17 home visiting models approved by the Department of Health and Human Services, and Congress reauthorized the program in April with $800 million for the next two years.

The Nurse-Family Partnership that helped Dawson is one of the largest and best-studied programs. Decades of research into how families fare after participating in it have documented reductions in the use of social programs such as Medicaid and food stamps, reductions in child abuse and neglect, better pregnancy outcomes for mothers and better language development and academic performance by their children.

"Seeing follow-up studies 15 years out with enduring outcomes, that's what really gave policymakers comfort," says Karen Howard, vice president for early childhood policy at First Focus, an advocacy group.

But others say the requirements for evidence-based programs are too lenient, and that only a handful of the approved models have as strong a track record as that of the Nurse-Family Partnership.

"If the evidence requirement stays as it is, almost any program will be able to qualify," says Jon Baron, vice president for of evidence-based policy at the Laura and John Arnold Foundation, which supports initiatives that encourage policymakers to make decisions based on data and other reliable evidence. "It threatens to derail the program."

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A Fungus Causes More Unexpected Illnesses In Montana

NPR Health Blog - Thu, 05/14/2015 - 12:50pm
A Fungus Causes More Unexpected Illnesses In Montana May 14, 201512:50 PM ET

Cough? Check. Fever? Check. But bet you didn't think that this common fungus, Histoplasma capsulatum, could be making you sick.

Science Source

If you go to the doctor with a cough and fever, odds are you're not thinking you could have an unusual fungal infection — and neither is the doctor.

That's why the Centers for Disease Control and Prevention wants to get the word out that they found more people sick with histoplasmosis in Montana and Idaho.

When we first heard about people out West getting histoplasmosis back in 2013, it was one of those gee-whiz infectious disease stories. The Histoplasma fungus is common in the Mississippi and Ohio River valleys, but infectious disease doctors hadn't seen it causing illness in Montana before. It could have been a fluke, they figured. Maybe people had gotten infected while traveling out of state.

Shots - Health News Dangerous Fungus Makes A Surprise Appearance In Montana

But now they're reporting two more cases, bringing the total to five in Montana and one in Idaho. Three people were sick enough to be hospitalized; one died. The cases were reported Thursday in Emerging Infectious Diseases.

If you happen to be living in the Intermountain West there's no need to freak out, says Dr. Randall Nett, a medical officer for the CDC in Helena, Mont., and lead author of the report. There are medications that work on histoplasmosis, but doctors need to realize it can be the cause of pneumonia-like symptoms. "It's a very difficult disease to diagnose because it kind of mimics many other things," he tells Shots.

Half of these people had been sick for more than six months before they were correctly diagnosed, Nett says. A urine test detects it.

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The Histoplasma fungus likes to hang out in soil, especially with bird or bat droppings. Four of the six people who fell ill had been doing things that increased their risk of infection, including working with potting soil, exploring caves and cleaning pigeon cages.

Most people who breathe in spores never get sick, the CDC says. But having other health issues ups the risk of life-threatening illness. Five of the six people had other health problems, including Type 2 diabetes, hepatitis C and active mononucleosis.

"We would ask folks in the community to be aware if they have a compromised immune system," Nett says. "They should avoid high-risk activities." That includes spelunking, demolishing buildings or other activities that kick up a lot of dust.

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A Database Of All Things Brainy

NPR Health Blog - Thu, 05/14/2015 - 3:34am
A Database Of All Things Brainy May 14, 2015 3:34 AM ET Listen to the Story 2:01
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The Allen Cell Types Database catalogs all sorts of details about each type of brain cell, including its shape and electrical activity. These cells, taken from the visual area of a mouse brain, are colored according to the patterns of electrical activity they produce.

Courtesy of Allen Institute for Brain Science

When the brain needs to remember a phone number or learn a new dance step, it creates a circuit by connecting different types of neurons.

"The fact that you remember very specific things — that first summer day when you kissed your first girl — that is due to the great specificity of your neural circuits. So that's what we have to understand."

Scientists still don't know how many types of neurons there are or exactly what each type does.

"How are we supposed to understand the brain and help doctors figure out what schizophrenia is or what paranoia is when we don't even know the different components?" says Christof Koch, president and chief scientific officer of the Allen Institute for Brain Science, a nonprofit research center in Seattle.

So the institute is creating a freely available online database that eventually will include thousands of nerve cells. For now, the Allen Cell Types Database has detailed information on 240 mouse cells, including their distinctive shapes.

Science Somewhere Over The Brainbow: The Journey To Map the Human Brain Shots - Health News Mining Cell Data To Answer Cancer's Tough Questions

"They look like different trees," Koch says. "Some fan out at the top. Some are like a Christmas tree; they fan out at the bottom. Others are like three-dimensional fuzz balls."

The database also describes each cell by the electrical pattern it generates. And eventually it will include information about which genes are expressed.

Once researchers have a complete inventory of details about the brain's building blocks, they'll need to know which combinations of blocks can be connected, Koch says. After all, he says, it is these connections that make us who we are.

"The fact that you remember very specific things — that first summer day when you kissed your first girl — that is due to the great specificity of your neural circuits," Koch says. "So that's what we have to understand."

The Allen Institute plans to release a database of different types of human brain cells next year.

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Long-Term Depression May Boost Stroke Risk Long After Mood Improves

NPR Health Blog - Thu, 05/14/2015 - 3:32am
Long-Term Depression May Boost Stroke Risk Long After Mood Improves May 14, 2015 3:32 AM ET Listen to the Story 3:45
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Medical researchers have known for several years that there is some sort of link between long-term depression and an increased risk of stroke. But now scientists are finding that even after such depression eases, the risk of stroke can remain high.

"We thought that once people's depressive symptoms got better their stroke risk would go back down to the same as somebody who'd never been depressed," says epidemiologist Maria Glymour, who led the study when she was at Harvard's T.H. Chan School of Public Health. But that's not what her team found.

Even two years after their chronic depression lifted, Glymour says, a person's risk for stroke was 66 percent higher than it was for someone who had not experienced depression.

The study analyzed data across a dozen years for more than 16,000 adults, age 50 or older. Participants were asked to complete a survey every two years from 1998 to 2010 that asked, among other things, about their mood the previous week.

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The questions, Glymour says, included whether "during the past week, they had often felt depressed; felt that everything they did was an effort; whether they had had restless sleep; they felt lonely; whether they couldn't 'get going'; whether they felt sad."

If people answered "yes" to three or more of these questions, the researchers counted them depressed. The scientists also kept track of whether participants had a stroke during the 12-year study period.

Now, Glymour expected people with long-term depression to have a higher risk of stroke. And they did — more than double the risk of those who weren't depressed. But she was not expecting stroke risk to continue as long as two years after the depression lifted.

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Scientists don't yet know the mechanisms involved, she says — why depression would predispose someone to stroke. It could have something to do with the body's physical reaction to the psychological malady, Glymour says.

"Changes in immune function," she says, "[or] inflammatory response, nervous system functioning — all of these might influence blood pressure [or] cortisol levels and thereby increase your risk of stroke."

It's also possible, she says, that depression changes a person's behavior in ways that increase the risk of stroke. People may be more likely to smoke cigarettes or drink excessive amounts of alcohol when depressed, or find it harder to get exercise.

Glymour says the study's findings imply that the negative health effects of depression are likely cumulative over time — people whose diagnosis of depression was very recent were not more likely to have a stroke than people who never had symptoms.

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That's one more reason why it's so very important to treat depression as soon as possible, she says. Dr. Renee Binder with the American Psychiatric Association agrees.

"There is no health without mental health," Binder says, adding that people should be routinely screened for depression and anxiety when they see their primary care provider.

The answers to just a few questions — such as whether patients feel sad many days of the week or get pleasure from everyday activities — can be clear warning signs that more extensive screening is needed, maybe including a referral to a mental health specialist.

The good news, Binder says, is that depression can be "extremely treatable" once it's addressed. A short course of psychotherapy or a short course of medication, she says, can quickly turn things around in many cases.

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Smokers More Likely To Quit If Their Own Cash Is On The Line

NPR Health Blog - Wed, 05/13/2015 - 5:50pm
Smokers More Likely To Quit If Their Own Cash Is On The Line May 13, 2015 5:50 PM ET Listen to the Story 3:55
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A new study finds that employer-based programs to help people stop smoking would work better if they tapped into highly motivating feelings — such as the fear of losing money.

This conclusion flows from a study involving the employees of CVS/Caremark. Some workers got postcards asking them if they wanted a cash reward to quit smoking. One card ended up in the hands of Camelia Escarcega in Rialto, Calif., whose sister works for CVS.

Escarcega says she had smoked for many years and wanted to quit, and figured money would be a good incentive. Her sister told her she was welcome to enroll in the study, so she did.

"People are much more afraid of losing $5 than they are motivated to earn $5. And so people's actions go with their psychology."

Escarcega didn't know it at the time, but the study was comparing different financial incentives to help people quit smoking. Hers was straightforward: Over a span of six months, she'd get up to $800 if she quit and didn't start again.

She did pretty well, she says. "I've been smoke-free for a year and a half now." The program offered her free nicotine patches, but Escarcega says she didn't even need that added help.

Dr. Scott Halpern, a professor of medicine, epidemiology, medical ethics and health policy at the University of Pennsylvania, worked with colleagues to design the study, as a way of exploring the best way to entice people to quit tobacco, using financial incentives.

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"A dollar is not a dollar," Halpern says, "and how you design smoking cessation programs of the same approximate value goes a long way toward determining how effective these programs will be."

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The researchers compared a few approaches. Some people simply got cash for quitting. Others were offered a carrot-and-stick approach. They'd get a similar financial reward if they quit, but they'd also lose $150 of their own money if they started smoking again.

"People are much more afraid of losing $5 than they are motivated to earn $5," Halpern says. "And so people's actions go with their psychology."

It came as no surprise that the researchers found it a lot harder to convince people to put down a deposit of their own money. But when they did, the results were remarkable.

"The deposit programs were twice as effective as rewards, and five times more effective than providing free smoking cessation aids like nicotine replacement therapy," Halpern says.

More than half of the people who had money on the line stopped smoking for at least six months. These results are reported Wednesday in the latest New England Journal of Medicine. And Halpern argues the approach is much more effective than what most companies do now.

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"Many programs are structured such that employees who stop smoking are rewarded by having less money taken out of their paychecks for insurance premiums the following year," Halpern notes. "But by bundling the rewards into paychecks they're relatively invisible to people — and the fact that they occur in the future — makes it less influential than if people were handed the same amount of money more quickly."

Mercer, a benefits consulting company, reports that 21 percent of large employers currently offer financial incentives to workers who quit smoking or don't start — primarily by reducing their health-insurance premiums. (An additional 5 percent of those companies offer other incentives). And more than half of the nation's biggest employers use incentives.

Halpern says insurance premium rebates aren't the best way to go.

"Employers and insurers could do a whole lot more to curb smoking than they currently are," he says. "And doing so, they would reduce costs to themselves and improve public health." Each employee who smokes costs a company more than $5,000 extra a year, due to health care costs and other expenses.

This is potentially tricky ground to navigate, though.

"Companies may have a concern that if they sign people into this kind of a wellness program and [the employees] lose that deposit, they're going to feel really badly," says Oleg Urminsky, at the University of Chicago's Booth School of Business.

The worry is that those bad feelings "may spill into other things," Urminsky says. "Are they going to resent the employer? Are they going to be complaining? It's a powerful tool but it's one that has to be used carefully."

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Why Would A Fish Make Its Own Sunscreen?

NPR Health Blog - Wed, 05/13/2015 - 3:16pm
Why Would A Fish Make Its Own Sunscreen? May 13, 2015 3:16 PM ET

The lowly zebra fish can make its own sunscreen.

Marrabbio2/Wikimedia Commons

Creatures that venture out into the daylight can be damaged by the sun's ultraviolet rays. Humans produce melanin, a dark pigment, to help protect our skin. And now many of us slather on sunscreen, too.

Bacteria, algae and fungi make their own chemicals that sop up UV rays. And there's one called gadusol that's been found in fish and their eggs.

Scientists at Oregon State University say they've found that zebra fish, a popular species for lab work, can produce gadusol on their own. Until now, many thought fish got the stuff by eating bacteria and algae that made it.

But why would fish make gadusol?

"We know that gadusol has anti-UV properties, sunscreen properties," says Taifo Mahmud, a medicinal chemist at Oregon State's pharmacy school. Still, he says it's not entirely clear if animals such as zebra fish would make it for reasons other than UV protection.

It's possible that gadusol, an antioxidant, might have other uses. In zebra fish, gadusol is produced in significant quantities during the development of embryos.

Mahmud's team found that the genes zebra fish use to make gadusol are different from the ones that microbes use.

After searching the genomes of many different animals, Mahmud's team identified gadusol-producing genes like the zebra fish's in amphibians, reptiles and birds. They didn't find them in mammals or coelacanths, the ancient fish that were only known as fossils before they were discovered alive in 1938.

The group's findings, published Tuesday in the journal eLife, suggest that the genes (called EEVS and MT-Ox) were carried by a common animal ancestor hundreds of millions of years ago that some later creatures, such as zebra fish, preserved while others did not.


Where did the genes come from? Well, they look more like those found in algae than bacteria. So the Oregon State group's paper suggest that there may have been a jump of the genes from algae to the common animal ancestor way back when. These so-called horizontal transfers are common in lower organisms and may account for quite a few genes in the human genome, too.

"Overall, this work illuminates a novel pathway that constructs an important biological sunscreen, but it also raises a number of questions," two Harvard chemists wrote in an accompanying analysis of the gadusol paper. How exactly did the cluster of genes evolve in animals and why did some lose them? And what biological purpose does the sunscreen chemical actually serve?

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Here's A Radical Approach To Big Hospital Bills: Set Your Own Price

NPR Health Blog - Wed, 05/13/2015 - 10:09am
Here's A Radical Approach To Big Hospital Bills: Set Your Own Price May 13, 201510:09 AM ET

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In the late 1990s you could have taken what hospitals charged to administer inpatient chemotherapy and bought a Ford Escort econobox. Today, average charges for chemo, not even counting the price of the anti-cancer drugs, are enough to pay for a Lexus GX sport-utility vehicle.

Hospital prices have risen nearly three times as much as overall inflation since Ronald Reagan was president. Health payers have tried HMOs, accountable care organizations and other innovations in efforts to control them, with little effect.

A small benefits consulting firm called ELAP Services is causing a commotion by suggesting an alternative: Refuse to pay.

When hospitals send invoices with charges that seem to bear no relationship to their costs, the Pennsylvania firm tells its clients, generally medium-sized employers, to just say no.

Instead, employers pay hospitals a much lower amount for their services, based on ELAP's analysis of what is reasonable after analyzing the hospitals' own financial filings.

"This is the best form of true health care reform that I've come across."

For facilities on the receiving end of ELAP's unusual strategy, this is a disruption of business as usual, to say the least. Hospitals are unhappy, but have failed to make headway against it in court.

"It was a leap of faith" when Huffines Auto Dealerships signed on to the ELAP plan a few years ago, says Eric Hartter, chief financial officer for the Texas firm. Now he says: "This is the best form of true health care reform that I've come across."

Huffines, which provides coverage to 300 employees and their families, first worked with ELAP on charges for an employee's back surgery. The worker had spent three days in a Dallas hospital. The bill was $600,000, Hartter said.

Like many businesses, the dealership pays worker health costs directly. At the time it was working with a claims administrator that set up a traditional "preferred provider" network with agreed-upon hospital discounts.

The administrator looked at the bill and said, "'Don't worry. By the time we apply the discounts and everything else it'll be down to about $300,000,' " Hartter recalled. "I said, 'What's the difference? That doesn't make me feel any better.' "

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So he had ELAP analyze the bill. The firm estimated costs for the treatment based on the hospital's financial reports filed with Medicare. Then it added a cushion so the hospital could make a modest profit.

"We wrote a check to the hospital for $28,900 and we never heard from them again," Hartter says.

Now Huffines and ELAP, which launched this service in 2007, treat every big hospital bill the same way. It has saved so much money for the dealership that the amount that the company and its workers pay for health costs has stayed unchanged for six years, Hartter says. And benefits remained the same.

More than 200 employers that provide health coverage to about 115,000 workers and dependents have hired ELAP, the company says. Company CEO Steve Kelly says he is aware of only one other smaller benefits consultant with the same approach.

Normally customers who don't pay bills get hassled or sued. This sometimes happens to ELAP clients and their workers. Hospitals send patients huge invoices for what the employer refused to pay. They hire collection agents and threaten credit scores.

"We wrote a check to the hospital for $28,900 and we never heard from them again."

ELAP fights back with lawyers and several arguments: How can hospitals justifiably charge employers and their workers so much more than they accept from Medicare, the government program for seniors? How can hospitals bill $30 for a gauze pad? How can patients consent to prices they will never see until after they've been discharged?

The American Hospital Association and the Federation of American Hospitals did not respond to requests for comment about ELAP.

ELAP is not merely a medical-bill auditor, like many other companies that comb hospital statements for errors. It sets the reimbursement, telling hospitals what clients will pay.

"Overwhelmingly, the providers just accept the payment" and leave patients alone, Kelly said. A federal district judge in Georgia decided a 2012 case against a hospital and in favor of ELAP and its furniture chain client.

Most patients being dunned by hospitals are unlikely to meet with the same success on their own, lacking backup from ELAP and its legal firepower.

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Under ELAP's main model, neither employers nor their claims administrators sign contracts with hospitals. Employers detail the reimbursement process in documents establishing how the plan covers workers. That gives it legal weight, ELAP has argued in court. ELAP agrees to handle all hospital bills for an employer and to defend workers from collections in return for a percentage fee tied to total hospital charges.

There is no hospital network. Employees may use almost any facility. Payments are made later based on ELAP's analysis.

That may change, Kelly says. Often it makes sense even for medium-sized employers to contract directly with hospitals to treat their workers, he said. That way prices are clear.

But for now, ELAP clients such as Huffines and IBT Industrial Solutions are giving hospitals a different dose of medicine.

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At IBT, a Kansas distributor of bearings and motors, "runaway health costs were starting to threaten the long-term viability of our company," says chief financial officer Greg Drown. After reading "Bitter Pill," a Time magazine piece critical of health-care costs, IBT executives decided to try something else.

They hired ELAP, which was "not a simple or risk-free move," cautions Drown.

About one IBT worker in five using a hospital gets "balance billed" for amounts the employer refuses to pay, Drown says. That can take months to resolve even with ELAP's legal support. But ELAP's program cut health costs by about one quarter, he says.

Recently managers at a big medical system in metro Kansas City "finally figured out we were doing something a little bit different," sent "a nasty letter" and followed up with a call, he said.

The hospital executive on the phone "was very condescending and thought I was stupid and had been duped by a predatory consultant and had been sold a, quote, crappy plan," Drown said.

Drown listened. He told the man he would consult with his colleagues and reply.

"I called him back a week or two later and left him a rather detailed voicemail that said, 'We're not changing anything. We're staying where we are.' And the guy never called me back."

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Seasons May Tweak Genes That Trigger Some Chronic Diseases

NPR Health Blog - Tue, 05/12/2015 - 1:10pm
Seasons May Tweak Genes That Trigger Some Chronic Diseases May 12, 2015 1:10 PM ET Listen to the Story 4:13
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The seasons appear to influence when certain genes are active, with those associated with inflammation being more active in the winter, according to new research released Tuesday.

A study involving more than 16,000 people found that the activity of about 4,000 of those genes appears to be affected by the season, researchers reported in the journal Nature Communications. The findings could help explain why certain diseases are more likely than others to strike for the first time during certain seasons, the researchers say.

"One of the standout results was that genes promoting inflammation were increased in winter, whereas genes suppressing inflammation were decreased in the winter."

"Certain chronic diseases are very seasonal — like seasonal affective disorder or cardiovascular disease or Type 1 diabetes or multiple sclerosis or rheumatoid arthritis," says John Todd, a geneticist at the University of Cambridge who led the research. "But people have been wondering for decades what the explanation for that is."

Todd and his colleagues decided to try to find out. They analyzed the genes in cells from more than 16,000 people in five countries, including the United States and European countries in the Northern Hemisphere, and Australia in the Southern Hemisphere. And they spotted the same trend — in both hemispheres, and among men as well as women.

"It's one of those observations where ... the first time you see it, you go, 'Wow, somebody must have seen this before,' " Todd says.

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When the researchers looked more closely at which genes were more or less active during some seasons than others, one big thing jumped out.

"One of the standout results was that genes promoting inflammation were increased in winter, whereas genes suppressing inflammation were decreased in the winter. So overall it looked as if this gene activity pattern really goes with increased inflammation in the winter," he says.

Inflammation, which is caused by the immune system becoming overactive, Todd says, has long been associated with a lot of the health problems that spike in the winter.

No one knows how the seasons affect our genes. But there are some obvious possibilities, Todd thinks.

"As the seasons come on it gets colder, the days get shorter," he says. "So daylight and temperature could be factors."

Other researchers say the findings could have far-reaching implications.

"The fact that they find so many genes that go up and down over the seasons is very interesting because we just didn't know that our bodies go through this type of seasonal change before," says Akhilesh Reddy, who studies circadian rhythms at the University of Cambridge but was not involved in the new research. "And if you look at the actual genetic evidence for the first time, it's pretty profound really."

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Reddy thinks the findings will prompt other scientists to look into how the seasons may have power over our genes.

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"People might have a variation in their responses to all sorts of things that we haven't really thought about yet," Reddy says.

For example, the seasons may affect how people metabolize drugs.

"Even your cognitive performance ... might be influenced subtly by the time of year at which you're assessed," he says. "There's never been a marker before that you can look at in the blood, or whatever, to say, 'You're looking like you're a winter person now versus a summer person.' "

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