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Fall Enrollment Efforts Could Be Pivotal For Federal Health Law

Wed, 10/19/2016 - 8:35pm

Secretary of Health and Human Services Sylvia Burwell at a Senate hearing in 2014. "We expect this to be a transition period for the marketplace," she told reporters Wednesday. "Issuers are adjusting their prices, bringing them in line with actual data on costs."

Alex Wong/Getty Images

Rate hikes are likely on the way for insurance plans issued under the Affordable Care Act, health policy analysts say. Consumers' out-of-pocket costs are expected to climb in 2017 and some major insurers have signaled they are pulling out of the health insurance exchanges in a number of states.

In a meeting Wednesday with reporters and representatives of groups working to increase enrollment in the health plans, Department of Health and Human Services Secretary Sylvia Burwell acknowledged that the Affordable Care Act's fourth enrollment season — scheduled to begin Nov. 1 and run until Jan. 31 — is a pivotal time for the federal health law.

"Building a new market is never easy," she told the group at HHS headquarters. "We expect this to be a transition period for the marketplace. Issuers are adjusting their prices, bringing them in line with actual data on costs."

Burwell's comments foreshadow the higher premiums expected when federal officials release details on the health plans to be offered on for 2017. Those details are likely to come just days before a presidential election that could determine whether the ACA is repealed or revamped.

While the health law hasn't been a central issue in the current election season, it has been at the center of a bitter battle between political parties since it was passed in 2010. The House of Representatives has voted more than 60 times to repeal all or part of the measure. The law has survived some court challenges and faces others.

Burwell noted those fights Wednesday when talking about issues that arose in the law's implementation. "It also hasn't helped," she said, "that at nearly every turn, we've had to overcome partisan attempts to repeal and undermine the law through legislation and litigation."

Enrollment in the state and federal marketplaces is expected to grow by about a million people next year — from about 12.7 million to 13.8 million, according to federal estimates released Wednesday. The number of consumers who actually pay premiums and stay in the market is expected to average about 10.5 million per month in 2016 and about 11.4 million per month in 2017.

Consumers flow in and out of ACA plans because they change jobs, get coverage from other sources and face other factors that affect where and how they enroll in health insurance, including affordability. About 9.2 million of the 13.8 million people who now have ACA coverage are expected to reenroll, according to HHS.

This year, Burwell said, health officials working to increase insurance coverage among the uninsured are intent on making the enrollment process faster and simpler, and will particularly focus on signing up healthier consumers – including people between the ages of 18 and 34, who tend to have fewer ailments. They will also remind consumers of the penalty for not having coverage, which for adults in 2016 is $695 or 2.5 percent of income, whichever is higher. The flat penalty will be adjusted for inflation in 2017.

Federal officials are also focusing enrollment efforts on the 5.1 million Americans who are eligible to purchase health care coverage on the exchanges but buy it elsewhere, according to HHS figures. Of that group, 2.5 million people could be eligible for the law's financial assistance if they sign up for coverage during open enrollment, which ends Jan. 31.

The outcome of the November elections may well determine the future of the ACA. Republican presidential nominee Donald Trump has promised to repeal and replace the law, while Democratic nominee Hillary Clinton has said she wants to fix the law, making it more affordable for consumers who don't qualify for subsidies, yet struggle to afford coverage.

Burwell called on Congress to work with her and the Obama administration to make needed changes to the law. "To make more substantial changes — like a public option to encourage competition — we'll need cooperation from Congress," she said. "And we are hopeful that soon, we'll see more bipartisan efforts to make improvement."

Bipartisan cooperation isn't likely to happen until the next Congress meets, if then. Much will depend on the outcome of the presidential and congressional elections – on who is in power and whether GOP leaders think the ACA is still a potent political issue, as well as on how willing Democrats are to make changes that appeal to Republicans.

Mary Agnes Carey reports for Kaiser Health News, an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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

Emergency Room Use Stays High In Oregon Medicaid Study

Wed, 10/19/2016 - 5:45pm
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October 19, 20165:45 PM ET Heard on All Things Considered


Although expanding Medicaid in Oregon didn't drive down the recipients' overall use of hospital emergency rooms, the state has seen a decline in avoidable use of ERs by 4 percent in the past two years, according to state statistics.

Paul Burns/Getty Images

Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care?

Not yet, suggest the latest findings from a landmark study published online Wednesday in the New England Journal of Medicine.

The study of Medicaid patients in Oregon who got Medicaid in 2008 found their ER use stayed high two years after they gained the health insurance coverage — even as they also increased their visits to doctors' offices.

All eyes have been on Oregon to answer this question about ER use because, eight years ago, the state tried an experiment. It wanted to expand Medicaid, but it didn't have the money to cover every eligible resident.

So it held a lottery to give coverage to as many people as possible, in the fairest way possible. The result was something of a gift to researchers like Bill Wright, director of the Providence Center for Outcomes Research and Education.

Bill Wright, one of the authors of the study, called the results "a surprise to a lot of folks."

Kristian Foden-Vencil/Oregon Public Broadcasting

"You couldn't do this as a researcher," Wright says. You couldn't design a study that randomly gave some people insurance, but not others. It wouldn't be ethical to leave some people without coverage just to have a control group.

"As a researcher," Wright says, "you don't want to put someone in that position, just to study it."

But, since Oregon was already conducting the insurance lottery, that offered an invaluable chance to study the differences between people who have Medicaid insurance and similar people who don't.

It was the first randomized study on the impacts of health insurance, and it's one of the largest, surveying about 25,000 people.

The study's first findings, published a few years ago, showed that Medicaid was beneficial in many ways. It improved people's financial security. They went to the doctor when they were sick. And having the insurance correlated with a drop in rates of depression.

"These are all things that are really important benefits of Medicaid expansion," says Wright.

But the study also found Medicaid enrollees increased their emergency room visits by 40 percent over the first 15 months.

"That was a surprise to a lot of folks," says Wright.

It was widely believed that having insurance would encourage people to get routine medical care in doctors' offices or clinics, instead of waiting until they have more serious symptoms and have to head to the ER, where care is most expensive.

After those early findings were published, health care analysts scrambled to explain why the number of ER visits didn't decline. Some thought it was a reflection of pent-up demand from people who hadn't seen a doctor in years because they didn't have insurance.

Others thought some of these newly insured patients simply hadn't yet had time in that first 15 months to establish a relationship with a primary care doctor. As more time passed, that theory suggested, and more patients had primary care providers, their reliance on emergency rooms would drop.

But Wright, one of the study's authors, says he and his colleagues have now studied two years of data — and that's not what they're finding.

"There was no sign that this [ER] use went down," he says. "So this idea of pent-up demand sort of fading away — at least in the first couple of years, it didn't happen."

Quite the opposite.

"If your hope is that, in the short term — the first couple of years — you're going to see savings that come out of reduced [ER] use from Medicaid expansion alone, I don't think I'd be super optimistic about that," Wright says. "I think that it is going to cost money in the short term."

However, there may be savings in other areas, he says, like an increased use of preventive services that could stave off problems that would become more expensive later.

And, Leslie Clement, with the Oregon Health Authority, says over the past two years, Oregon has seen avoidable use of emergency rooms drop by 4 percent.

That's because the state is now coordinating care better, she says, by doing things like helping people get to their doctors' appointments and take their medication.

"It is not just a 'open up coverage and let people used health care services as they have done historically,' " she says. "It's reforming that system."

The researchers won't be able to tease much more information out of what's come to be known as the Oregon Health Insurance Experiment — the experiment had to stop once the state expanded Medicaid fully under the Affordable Care Act.

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

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

Small Savings For Drugs Made To Mimic Biotech Blockbusters

Wed, 10/19/2016 - 3:48pm

A patient with Crohn's disease receives an IV infusion of Remicade, or infliximab.

Dr P. Marazzi/Science Source

Generic drugs generally cost 80 percent less than brand-name drugs, so hopes were high when a law enacted in 2010 paved the way for competition among the highest-priced drugs of all, known as biologics.

But, as these competing drugs start to appear on the market, consumers aren't reaping a windfall.

On Monday, Pfizer said it would start selling Inflectra, its version of the blockbuster rheumatoid arthritis drug Remicade, in late November. But Inflectra, the second so-called biosimilar set to hit the market, isn't exactly a steal.

Note: Chart shows the highest annual price, according to wholesale acquisition cost, for a vial containing 100 milligrams of powder for preparing an intravenous solution.

Truven Health Analytics

The wholesale acquisition cost (a benchmark price in the drug industry) for Inflectra is $946 a vial, only 15 percent off $1,113 for a comparable vial of Johnson & Johnson's Remicade, according to data from Truven Health Analytics. (The WAC price doesn't reflect rebates drugmakers typically offer.)

Early indications are that the prices for these substitute medications will only lop 15 or 20 percent off the price, said Dr. Mark McClellan, director of the Duke-Margolis Center for Health Policy, at a Tuesday meeting in Washington, D.C.

That discount is a far cry from the one for standard generic drugs, McClellan said at a forum hosted by Duke and Friends of Cancer Research. "On the other hand, 15 to 20 percent of a very big price – a very large number — is still a big number."

Steady price increases for Remicade mean that Inflectra, even at a 15 percent discount, will cost about what Remicade did in 2014.

Pricing this new class of drugs is just one challenge. Drugmakers will also have to persuade consumers and physicians that they are every bit as good as the drugs they would replace. Because these biotech drugs are similar but not identical to the brand-name medicines they mimic, pharmacists generally are restricted from substituting one for the other automatically, unlike most traditional generics.

The case for biosimilars as these new medicines are sometimes called isn't quite as straightforward as it is for standard generics. Typical drugs are simple molecules, so generic versions can be built atom by atom to be identical with the original.

These new "biologic" drugs are complex biological molecules. These drugs are produced in living cells. As a result, even the brand-name drugs vary a bit from batch to batch. The generic versions of these drugs, known as biosimilars, also vary. The Food and Drug Administration considers them essentially the same as the original drug, as long as their variations fall into the same range as the brand-name biologics.

So far, scientists have found no meaningful differences between these drugs and their mimics. Europe, which is a decade ahead of the United States in developing these drugs, has gathered 400 million patient life-years of data (which, for example, would be studies of 40 million people for 10 years), and hasn't identified any safety issues, said Lisa Bell, senior vice president of regulatory affairs for Coherus Biosciences.

The latest reassuring data, announced at a meeting Tuesday in Vienna, Austria, come from a government-funded study in Norway of 481 patients, half of whom switched from brand-name Remicade to another biosimilar called Remsima. After a year of follow-up, there was no meaningful differences between the two groups (though there were nonsignificant findings that provided potential fodder for skeptics).

In Europe, governments have a big hand in deciding which drugs are made available to patients in government-sponsored health systems. The system in the United States is a much more complicated picture, involving patients, doctors, insurance companies, middlemen and government providers such as Medicare. Doctors, in particular, have a big voice and will need to be convinced that the substitutes are just as good as the original drugs.

For example, doctors routinely prescribe Herceptin to treat certain forms of breast cancer. Dr. Richard Schilsky, senior vice president and chief medical officer of the American Society of Clinical Oncology, said a competitive product was shown to be at least as good as the original drug in a study that measured the likelihood that a woman taking the drug would suffer a relapse. But Herceptin has a 25-year-history that looks not only at relapse rates, but at long-term survival and other significant endpoints.

"At what point does the doctor and the patient have the confidence to make that switch" to the substitute brand, Schilsky asked at the meeting in Washington.

A patient may or may not see any savings, given the convoluted system of insurance and medical reimbursement in this country.

And the doctor may have a financial incentive to opt for the more expensive drug, including some cancer drugs. Currently, Medicare bases some payments to doctors on the price of chemotherapy drugs, so doctors make more when they prescribe more expensive drugs, Schilsky noted. (He said his organization is trying to change that payment system).

Time is running short to sort out all these issues. Leah Christl, at the FDA's Center for Drug Evaluation and Research, says that as of Oct. 5, the agency is processing 66 projects involving biosimilar drugs, which are potentially substitutes for 20 existing medications. Four products have already been licensed, though only one, Sandoz's Zarxio, is currently on the market, she said. Inflectra will be the second.

These applications all result from the 2010 law called the Biologics Price Competition and Innovation Act. It remains to be seen whether the hoped-for price competition will make a significant dent in American health care costs.

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

Don't Look Now! How Your Devices Hurt Your Productivity

Wed, 10/19/2016 - 10:32am
Nick Shepherd/Ikon Images/Getty Images

I'll admit it. I even take my phone with me when I head to the restroom, to fire off a few texts. Or I'll scroll through my email when I leave the office for lunch. My eyes are often glued to my phone from the moment I wake up, but I often reach the end of my days wondering what I've accomplished.

My productivity mystery was solved after reading The Distracted Mind: Ancient Brains in a High Tech World, by Dr. Adam Gazzaley, a neuroscientist at the University of California, San Francisco, and Larry Rosen, a research psychologist and professor emeritus at California State University, Dominguez Hills. Their book explains why the brain can't multitask, and why my near-obsessive efforts to keep up with email are likely lowering my productive output.

How the digital age zaps productivity

I visited Gazzaley in his UCSF laboratory to learn more about the science. On a video screen, he pulled up a 3-D image created from an MRI scan of a human brain. He pointed to different sections to explain what's going on when our attention flits between tasks.

How To Boost Productivity

Feeling chronically distracted? Dr. Adam Gazzaley has been there, too, and says these tricks can help you buckle down and think!

• Clear your work space. Remove mobile devices and extraneous papers.
• Use one computer screen. Shut down all unnecessary programs and apps.
• Open one browser, and use only one tab.
• Turn off email.
• Set expectations. Tell your boss you're going offline for a while. Or, set an auto response for texts and emails, explaining that you'll be offline for a set period of time.
• Work in a quiet environment. If you must work in a coffee shop use noise-canceling headphones.
• Display a "no interruption zone" sign at your desk or on your office door.
• Check out helpful apps like SelfControl, Freedom or FocusMe.

"The prefrontal cortex is the area most challenged," Gazzaley said. "And then visual areas, auditory areas, and the hippocampus — these networks are really what's challenged when we are constantly switching between multiple tasks that our technological world might throw at us."

When you engage in one task at a time, the prefrontal cortex works in harmony with other parts of the brain, he explained, but when you toss in another task it forces the left and right sides of the brain to work independently. It's this process of splitting your attention that usually leads to mistakes.

In other words, each time our eyes glance away from our computer monitor to sneak a peek at a text message, the brain takes in new information, which reduces our primary focus. We think the mind can juggle two or three activities successfully at once, but Gazzaley thinks we woefully overestimate that ability.

Skeptical? Try checking your email on a conference call.

"The act of doing that makes it so incredibly obvious how you can't really parallel process two attention-demanding tasks," he said. "You either have to catch up, and ask what happened in the conversation, or you have to read over the email before you send it — if you're wise!"

Answering an email takes much longer than you think

Our tendency to respond immediately to emails and texts gets in the way of high-level thinking, he said. If you're in the middle of a project and stop to answer somebody's note, it could take you nearly a half-hour to get back on task, some studies suggest.

"When a focused stream of thought is interrupted, it needs to be reset," explained Gazzaley. "You can't just press a button and switch back to it. You have to re-engage those thought processes, and re-create all the elements of what you were engaged in. That takes time, and frequently one interruption leads to another."

And that can make you less productive.

Based on his research, when UCSF neuroscientist Adam Gazzaley needs to focus on a big project he now clears his desk, works on one screen and turns off his phone.

Sierra Niblett/Courtesy of UCSF

Plus, mounting evidence shows a heavy diet of multitasking with multiple media could be hurting the brain's ability to think, in important ways — and that's true even for tech-native young people. Stanford researchers in 2009 studied the minds of students and others who regularly engage in several digital communication streams at once and found that, in general, high-tech jugglers struggle to pay attention, recall information or complete one task at a time.

"When they're in situations where there are multiple sources of information coming from the external world or emerging out of memory, they're not able to filter out what's not relevant to their current goal," said Stanford neuroscientist Anthony Wagner. "That failure to filter means they're slowed down by that irrelevant information."

The researchers are still studying what's causing multitaskers to perform poorly on cognitive tests. It could be that they are born with an inability to concentrate, or digital distractions are taking a toll. In any case, the researchers believe the minds of multitaskers are not performing optimally.

Create digital boundaries

But, take heart, Gazzaley said. You don't have to opt out of technology to get some of that brainpower back. In fact, there's a time and place for multitasking. If you're in the midst of a mundane task that just has to get done, for example, it's probably not detrimental to have your phone nearby or a bunch of tabs open. The distractions may reduce boredom and help you stay engaged.

Still, if you're finishing a business plan or a high-level writing project and need to focus, there are some steps you can take that should help. Check out Gazzaley's tips for turning off distractions in the sidebar above.

Then, get back to work!

This story was produced by KQED's health and technology blog, Future of You. The blog's host and editor is Jon Brooks.

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

7 Insurers Alleged To Have Discriminated Against HIV Patients

Tue, 10/18/2016 - 4:20pm

Once-a-day HIV pills that combine multiple medicines, such as Truvada, are easier to take, but they can be more expensive than pills that contain only one active ingredient.

Justin Sullivan/Getty Images

The Affordable Care Act prohibits insurers from discriminating against people with serious illnesses, but some marketplace plans sidestep that taboo by making the drugs that people with HIV need unavailable or unaffordable, complaints filed recently with the Department of Health and Human Services' Office for Civil Rights allege.

The effect may be to discourage people with HIV from buying a particular health plan or getting the treatment they need, according to the complaints.

The complaints – brought by Harvard Law School's Center for Health Law and Policy Innovation – charge that plans offered by seven insurers in eight states are discriminatory because they don't cover drugs that are essential to the treatment of HIV or require high out-of-pocket spending by patients for covered drugs.

The center filed complaints against Humana plans in six states: Alabama, Georgia, Illinois, Louisiana, Tennessee and Texas. Cigna plans were targeted in three states: Georgia, Tennessee and Texas. The group filed complaints against five other insurers: three in Pennsylvania, including Highmark, Independence Blue Cross and UPMC Health Plan; a complaint against Community Health Choice in Texas and a complaint against Anthem Blue Cross Blue Shield in Wisconsin.

"What's most important to us is that there's a robust enforcement mechanism around the promises ... in the [Affordable Care Act] and its regulations, especially the anti-discrimination provisions," said Kevin Costello, director of litigation at the health law center.

Shots - Health News Complaint Says Insurance Plans Discriminate Against HIV Patients

Although the center's focus is on HIV drugs, the complaints may help people with other chronic illnesses who may face similar hurdles on access to drugs, Costello said.

The HHS Office for Civil Rights investigates and enforces violations of civil rights and health information privacy. The Harvard center complaints were filed in September.

Federal rules prohibit marketplace plans from adopting benefit designs — such as coverage rules or reimbursement rates — that discriminate based on age, illness, race, gender or sexual orientation, among other things. But federal regulators have declined to define discriminatory plan design, noting that they will examine the facts on a case-by-case basis.

They've hinted, however, at some specifics in the regulations. They say, for example, that refusing to cover a single-tablet drug regimen, which is often associated with better compliance because a number of different drugs are combined in one pill, or placing most or all of the drugs that treat a specific condition in the highest cost tiers are examples of "potentially discriminatory practices."

Working with local AIDS groups in several states, the Harvard center examined hundreds of silver-level plans sold on the marketplaces to gauge whether their formularies would allow access to six treatment regimens that are the current standard of care for treating people who are newly diagnosed with HIV. In addition, they looked at the plans' cost-sharing requirements, Costello said.

They found, for example, that this year Anthem silver plans in Wisconsin cover only four of the 16 drugs or combination products that are recommended to meet the current standard of care, and they fail to cover any single-tablet regimens. In Illinois, the center charged that Humana's silver plans place 16 of the 24 most commonly prescribed HIV drugs in the highest cost-sharing tier, which requires patients to pay 50 percent of the cost. With estimated monthly costs ranging from $377 to $684 for different drug regimens, enrollees in the Illinois Humana plans would have to pony up between 8 and 14 percent of their average monthly income, according to the complaint.

"All Humana health insurance plans offered through the Health Insurance Marketplace fully comply with state and federal laws and regulations," said Alex Kepnes, Humana's director of corporate communications. He added, "Humana shares the concerns of HIV/AIDS organizations regarding the high cost of HIV/AIDS drugs and we are committed to working with them to lower prescription drug costs."

Similarly, Anthem spokesman Scott Larrivee said, "Anthem Blue Cross and Blue Shield is committed to providing all of our members with access to the care and services they need, including appropriate coverage of medications for the treatment of HIV/AIDS. Anthem Blue Cross and Blue Shield in Wisconsin covers more than a dozen medications for the treatment of HIV/AIDS and all required therapeutic drug categories are included on our formulary/drug list which is compliant with (marketplace) requirements."

Cigna spokesman Mark Slitt said his company doesn't comment on pending legal matters.

The center's work builds on an earlier discrimination complaint filed in 2014 with the Office for Civil Rights by two advocacy groups, the AIDS Institute and the National Health Law Program, against four Florida insurers that were selling marketplace plans. That complaint, against some of the same insurers highlighted by the Harvard center, charged that the insurers placed all the HIV drugs in the highest cost-sharing tier. The Florida insurance commissioner reached agreements with the four plans to move the HIV drugs to generic tiers and reduce cost sharing, and the same arrangement will continue in 2017, said Carl Schmid, deputy executive director of the AIDS Institute.

"We've been talking about these issues for years now," Schmid said. "These things need to be addressed, and it could be through enforcement" by the Office for Civil Rights.

Marketplace coverage of drugs to treat HIV and other serious conditions have improved somewhat in recent years, according to research by Avalere Health, a consulting company. An analysis found that in the case of five classes of drugs that treat cancer, HIV and multiple sclerosis, fewer silver plans in 2016 placed all the drugs in the class in the top tier with the highest cost sharing or charged patients more than 40 percent of the cost for each drug in the class.

Speaking about HIV drugs, Caroline Pearson, a senior vice president at Avalere, said that while access and costs in marketplace plans are improving, they vary widely from plan to plan. Employer plans tend to offer better coverage, she said.

The new complaints may put more pressure on the Office for Civil Rights to address this issue, said Katie Keith, a steering committee member for Out2Enroll, a health insurance advocacy group for the lesbian, gay, bisexual and transgender community.

"It's smart to do this in multiple states," she said. "People are really pushing for more concrete guidance."

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

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

WEBCAST: The Cost And Quality Conundrum Of Child Care

Tue, 10/18/2016 - 10:05am
Harvard T.H. Chan School of Public Health YouTube

There's a major gap between what parents view as quality child care and what developmental psychologists and other specialists define as good care. That's according to a poll released this week by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

Nearly 90 percent of parents say the quality of their child care is very good or excellent. But a major study in the field of child development has suggested that most child care is of only fair quality.

What's a parent to do? Quality care in a child's early years can help that young person develop lasting social, emotional and learning skills and can promote healthful eating and play.

But high-quality care, whether it comes from a nanny, a sitter, a day care or a preschool, can be difficult to find — and to afford.

There are solutions out there. A lively forum discussion at the Harvard Chan School covered the issues. We streamed the webcast, where specialists in child care and health will talk more about the findings, and what they mean for today's kids. (When the archived video becomes available, we'll add it to this post.)

Some of the issues that were discussed: How do parents find and select child care, and how does that care influence the health and well-being of families? How can child care be made accessible, high quality and affordable? How do we even measure quality in a meaningful and accountable way? The forum panelists discussed ways to equip parents with better information about child care and explained policy changes they thought could help children thrive.

Joe Neel, deputy senior supervising editor on NPR's Science Desk, moderated the discussion with:

Susan Hibbard, executive director of the BUILD Initiative

Kristin Schubert, managing director, Robert Wood Johnson Foundation

Rachel Schumacher, director, Office of Child Care, U.S. Department of Health and Human Services

Gillian SteelFisher, senior research scientist and deputy director of the Harvard Opinion Research Program, Harvard T.H. Chan School of Public Health

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

What Makes For Quality Child Care? It Depends Whom You Ask

Tue, 10/18/2016 - 4:44am
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October 18, 20164:44 AM ET Heard on Morning Edition Michelle Kondrich for NPR

When Jolie Ritzo was looking for day care for her son Cannon in Falmouth, Maine, she checked out as many centers as she could.

She was looking for a place with the right feel.

"Most importantly, the people who are providing the care are loving and kind, nurturing and interested in developing these little beings," she says.

There was one center in town that had a great reputation, but it was so pricey, Ritzo says, "It would break the bank."

She enrolled Cannon in a family child care based in a church. It was small and cozy with a sweet name and a nice playground. But after a few months, she started to get a bad feeling about the place.

"Let's just say she wasn't cut out for child care," Ritzo says of the woman who ran the center.

So the hunt was on again. She settled on a place called Little Hands.

Ritzo says it was convenient to get to, had a good reputation and a nice facility. It had good safety measures in place. It cost about $900 a month for four days a week. And it had space for Cannon immediately.

Ritzo is happy with the choice. Cannon just started kindergarten after going to Little Hands for three years, and now his 2-year-old sister is enrolled.

"It gives me peace of mind knowing that when I drop my daughter off for the entire day that someone is going to be loving, sweet and nurturing," Ritzo says

Like most parents, Ritzo says her children's day care is high quality. In fact, a new poll from NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health shows that the overwhelming majority of parents who use child care are happy with it.

The poll shows 88 percent of parents say their child care is very good or excellent.

It's an interesting result, because researchers in early child development say most child care in the U.S. is mediocre to poor.

A 2006 study by the National Institute of Child Health and Human Development showed that only 9 percent of child care arrangements in the U.S. were considered very high quality.

And a report by the New America Foundation says that only 11 percent of child care centers are accredited by one of the two main organizations that certify day care centers and preschools.

The disconnect between parents and researchers may be because the quality benchmarks measured aren't always the same as what parents are looking for, says, Mary Beth Testa, a child care policy consultant to the National Association for Family Child Care, the organization the accredits home-based child care centers.

"People are looking for, 'Do you care about my child? Is my child happy here?' " Testa says. "How do we regulate whether your child is going to be happy here?"

The NAFCC rates home-based child care and the National Association for the Education of Young Children rates centers. Each group evaluates child care providers on dozens of criteria such as curriculum, whether teachers have college degrees, how children interact with each other and the teachers, and the ratio of children to caregivers.

"There's research to back up that those things are important. The science says this is what children need in order to thrive," Testa says. "But parents are still looking for price, location and 'Do you love my kid?' "

The poll shows parents want quality child care, but that's not always the only deciding factor.

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Like Ritzo, parents are also looking for child care they can afford and that they can get to conveniently. Our poll shows that 27 percent of parents say location played a major role in their child care choice, more than any other single factor. And 18 percent point to price.

"The bottom line is, there's still this three-legged stool of quality, access and cost, and to find all three, unless you are upper middle class, it is very difficult to do," says Rhian Allvin, chief executive of the National Association for the Education of Young Children.

"You find something that's affordable, and often it's not the highest quality," Allvin says. "To find an affordable provider that is high quality, you're driving an hour and a half. And to really find affordable high quality care that is convenient for your family and your situation is incredibly challenging."

That's the situation for Jennifer Nuesi, a single mother who responded to our poll and lives in Northport, Fla. Her mother cares for her 4-year-old daughter, Cairo, while she's at work, and she's not happy about it.

"She's not at all the person I would like to watch my child," Nuesi says.

She says her mom, who is from the Dominican Republic, doesn't share her values in terms of how to raise Cairo. They disagree on everything — from rules to schedules to diet.

"My mom just lets her do whatever she wants. Eat whatever you want, do whatever you want, if you want to go to bed at 12 at night, that's totally OK," says Nuesi.

But she had to go with her mother because "unfortunately she's free, and I can't find better than that," she says.

Two years ago Congress updated the Child Care and Development Block Grant Program, which gives money to states to help low-income families get subsidies for child care. The $9 billion program requires child care providers that receive block grant funding to meet strong quality standards.

But Mary Beth Testa, a policy consultant for NAFCC, says Congress didn't actually increase federal funding enough to help child care centers reach the goals, which include requiring states to create training standards for child care providers, provide parents with the ability to compare child care options and spend 7 percent of their federal grant on quality improvement. She estimates a funding shortfall of about $1.2 billion.

"They are good reforms, they are good ideas," Testa says. "We needed to raise this bar."

But if parents are as happy with their child care as our poll shows, Testa worries there won't be much pressure on lawmakers to spend tax money to make it better.

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

How Gaps In Mental Health Care Play Out In Emergency Rooms

Mon, 10/17/2016 - 5:18pm

Too often, pediatricians say, the teen depression that went undiagnosed in the community shows up in the ER as a suicide attempt.

Studio 642/Blend Images/Getty Images

Nearly 1 in 5 children each year suffers a psychiatric illness, according to research estimates. But a national shortage of medical specialists and inpatient facilities means that many still go untreated — despite national efforts to improve mental health care.

New research is driving home the consequences. Scientific abstracts presented Monday in Las Vegas, at the annual meeting of the American College of Emergency Physicians, offer insights into how frequently patients with mental health issues land in the emergency room — often because opportunities to intervene earlier are missed. Pediatricians and child psychiatrists say children are among the hardest hit.

The researchers analyzed data compiled by the National Hospital Ambulatory Medical Care Survey, which tracked mental health visits to hospital emergency departments between 2001 and 2011.

Compared with physically ill patients, people with mental health conditions rely more on the emergency department for treatment and are more often admitted to the hospital from the ER, the scientists found. Also, they tended to be stuck in the ER longer than people who show up in the ER with physical symptoms.

Specifically, the researchers found that about 6 percent of all the emergency department patients — of all ages — had a psychiatric condition. More than 20 percent of these psychiatric patients were admitted to the hospital, compared with just over 13 percent of the medical patients. About 11 percent of these patients with mental health problems required transfer to another facility, compared with 1.4 percent of the patients with physical ailments.

About 23 percent of mental health patients stayed in emergency care for longer than six hours, and about 1.3 percent for more than 24 hours. Only 10 percent of medical patients were under treatment in the ER for more than six hours, and just half a percent were there for more than 24 hours.

The researchers have not yet determined the distribution of ages among the patients in their study who came to the ER because of mental health symptoms. Anecdotally, though, ER patients with psychiatric problems tend to include more children and elderly patients than you'd expect to see based on the age range of the general population, says Suzanne Lippert, a clinical assistant professor in emergency medicine at Stanford University and lead author on the study.

The findings highlight what can happen when patients can't find good outpatient treatment for mental health problems, Lippert says. The evidence also underscores, she says, that when psychiatric patients arrive at the ER in a crisis, there is often no good place where they can continue treatment, once the immediate issue has been addressed.

Patients who come to the ER because of physical ailments can usually be sent home, Lippert says, "because we know they'll be evaluated by [their] doctor in one or two days." But psychiatric patients don't always have that option because of gaps in the mental health care system.

And young patients may be affected the most, says Dr. Steven Schlozman, a research psychiatrist at Harvard Medical School and associate director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital. He was not affiliated with the research.

"It's a numbers game," Schlozman says. "Unless you live in a large urban area, you're very unlikely to find a child psychiatrist."

Lippert's study found that the most severely ill psychiatric patients typically spent more time in the ER. Patients with bipolar disorder, depression or psychosis and those diagnosed with multiple conditions were more likely than others to be held in the ER longer than 24 hours.

A national shortage of inpatient beds for psychiatric patients is part of the problem, Lippert says. She has seen patients have to wait longer than a week to get the inpatient treatment they need.

Such delays in cramped, overused emergency quarters hurt patients, says Dr. Thomas Chun, an associate professor of emergency medicine and pediatrics at Brown University. Doctors often agree a child needs to be transferred, he says, only to find no outside beds available.

"We are the wrong site for these patients," says Chun, who was not involved in Lippert's study. "Our crazy, chaotic environment is not a good place for them."

Meanwhile, the young patients are even less likely to get reliable care after they are discharged from the ER. Whether they need regular follow-up with a psychiatrist, or a transfer to specialized facility, the resources often aren't in place. The American Academy of Child and Adolescent Psychiatry estimates there are only 8,300 such specialists in the U.S., for more than 15 million young patients.

Dr. Lindsay Irvin, a pediatrician in San Antonio, says the dearth of psychiatrists who specialize in treating young people means many young patients simply don't get the mental health treatment they need. By the time they wind up in the ER, she says, undiagnosed depression may have progressed to suicidal intent. And after leaving the ER, many are lost to follow-up.

"They'll land in a pediatric or family practice," Irvin says, where most primary care doctors haven't been trained "to navigate the ins and outs of psychotropic meds."

Lippert and her colleagues also found that the emergency psychiatric patients were more likely to be uninsured than medical patients were. About 22 percent of mental health patients lacked coverage, versus 15 percent of patients treated for physical conditions.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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

A Reboot For Wheelchair That Can Stand Up And Climb Stairs

Mon, 10/17/2016 - 4:16pm
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October 17, 20164:16 PM ET Heard on All Things Considered

Gary Linfoot was paralyzed in a helicopter crash in Iraq. He's one of the few veterans still using an iBOT, which allows him to rise up to eye level using Segway-style balancing technology. The wheelchair was discontinued in 2009, but may soon be reissued.

Quil Lawrence/NPR

Thirteen years ago, just as the United States began what was to become its longest war, a futuristic wheelchair hit the market.

The iBOT allowed paralyzed people, including many veterans of Iraq and Afghanistan, to stand up by rising to eye level. It also did something no wheelchair ever had: climb stairs.

But even though users loved it, the iBOT went out of production in 2009 when Johnson & Johnson discontinued it.

"I was very disappointed," says disabled veteran Gary Linfoot, a former Army helicopter pilot. "I knew my tent was up, I had one, but I knew there were other people out there who could use this device, this technology and it would not be available to them."

Now, however, the iBOT could be coming back.

Toyota announced this year that it's bankrolling a reboot of the iBOT, which the machine's inventor, Dean Kamen, says will allow him to make some improvements.

"With advances in computers, the advances in solid-state gyros and electronics ... we can take a hundred pounds out of it. We can take a lot of cost out of it. We can improve it," he told NPR.

Kamen is widely known as the inventor of the Segway, which was actually a byproduct from development of the iBOT. The first iteration of the wheelchair had a $25,000 price tag — too high even for the department of Veterans Affairs in most cases. Most veterans who had iBOTs got them from veterans charities, and all but a few are now sitting in the garage, with nowhere to service them.

Today, Toyota is interested in some of the machine's balancing technology, possibly to be used in the company's robotic helpers for the aging. And that could mean new parts and new life for existing iBOTs as well as a new version of the chair.

It also helps that the Food and Drug Administration reclassified the iBOT from its strictest regulatory category for medical devices Class 3, alongside replacement heart valves, to Class 2, alongside condoms. That will also lower the expense of the machine, and Kamen says testimony by veterans using the machine was one key to persuading the FDA to make that switch.

For people like Linfoot, it was a game changer.

He lost the use of his legs after a 2008 helicopter crash south of Baghdad. "I wasn't shot down or anything," he says. "It was just a mechanical malfunction. Probably a $25 part failed and we lost all power to the rotor system."

Linfoot and his co-pilot survived, but the impact left Linfoot paralyzed below the chest. The iBOT allows him to navigate street curbs and the hills around his home north of Nashville, Tenn.

"It goes beyond just reaching in the cabinet to get the cookies that my wife might hide up there, or the good booze," he says, sitting on top of what looks like an easy chair balanced on a pair of unicycles.

Plus the ability to stand up is huge.

"When you go out to a social setting, back up at 6 feet, talking to somebody eye to eye, you get this sense of dignity," he says. "The disability just kind of fades into the background."

Kamen said he hopes stories like Linfoot's will help persuade his new backers to return the iBOT to production and make it available to a wider group of people.

"The reason some of these veterans need these things is they've literally given up pieces of their body for this country," he says. "The least we can do is give them back the best technology that is currently available."

The Two-Way Department Of Veterans Affairs To Pay For Robotic Legs

Several other companies have designed chairs that can get people with spinal injuries up to eye level and even off-road. But doctors at the department of Veterans Affairs are more excited about inventions that can actually get veterans walking again. The health effects of immobility for paralyzed people are just like the effects of sitting down all the time for able-bodied people, they say.

"Sitting is the new smoking," says Dr. Will Bauman, director of the Center of Excellence on the Medical Consequences of Spinal Cord Injury at the James J. Peters VA Medical Center in the Bronx. He and Dr. Ann Spungen, associate director of the center, have studied the secondary health effects of paralysis.

"Just like you and I, if we sat around all day, we already know that's the worst thing can do to ourselves," says Spungen.

Immobilized people are prone to weakened bones, higher blood pressure, urinary tract infections and constipation that can be debilitating. At the Bronx VA, veterans have been using an exoskeleton called a ReWalk to get them moving again. It's like a backpack with robotic leg braces that allows patients to walk using crutches.

So far, devices like these aren't that useful outside a safe, flat surface. Regular therapy with these machines can help reduce pain and promote better sleep, Spungen says.

With as little as four to six hours of walking a week, about half of patients lost more than a kilogram of body fat, says Spungen. For many problems, she says, "the best cure is to take a walk."

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

NPR Poll: Are Parents Overrating The Quality Of Child Care?

Mon, 10/17/2016 - 1:03pm

Parents' views of child care are a little like life in Lake Wobegon — the vast majority say it's way above average.

That's just one of the findings in a poll looking at child care and health from NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health, released Monday.

In it, we found that a remarkable 88 percent rated their child care as "very good" or "excellent."

That stands in stark contrast to the most comprehensive and most recent study on child care and child development, which rated the quality of fewer than 10 percent of child care arrangements in the U.S. as "very high." The vast majority of child care was rated as only "fair."

That 15-year-long study by the National Institutes of Health looked at a wide range of quality measures, from basic safety to daily activities and interactions with providers and other children.

That led us to think about how there could be such a big disconnect between parents' perceptions and apparent reality.

It may be that parents' measures of quality are very different from those who study childhood development. Or parents may be reluctant to tell a pollster that they've got their child in anything other than the best child care.

"Our findings suggest that parents value and seek out quality child care and believe it benefits their child and themselves," says Gillian SteelFisher, research scientist and deputy director of the Harvard Opinion Research Program and the poll's academic leader. "However, we also found that parents face challenges related to the limited options they have for child care, the cost, and a lack of information about its quality."

To get a reading on the state of child care and health in America today, we looked for parents of children up to age 5 who were not yet in kindergarten and whose child receives regularly scheduled care at least once a week from someone other than a parent.

We conducted interviews in English or Spanish and on landlines and cellphones. The margin of error is plus or minus 3.4 percentage points.

When it comes to the individual features of the care their child receives, safety of the indoor and outdoor environment was most frequently rated as excellent, followed closely by other measures.

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But just finding child care can be a major challenge, with 1 in 5 parents saying there was only one "realistic" child care option for his or her child.

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It will come as no surprise, but cost was the most common challenge in finding child care, with 27 percent of people saying it's an issue. Four in 10 parents (39 percent) say that the cost of paid child care in their area is not affordable for them.

That could be a major reason why child care is one of the few domestic social issues getting any attention in the current presidential campaign. (We've detailed the candidates' positions below.)

In addition to asking parents about quality and cost in our poll, we wanted to find out how they perceive the impact that child care has on their child and themselves — and whether child care has lasting effects.

The most surprising finding was that parents, particularly mothers, feel child care has benefited their own health and well-being, as well as their relationship with the child.

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Half the mothers said it had a "very positive effect" on their relationship with their spouse and an even larger percentage, 64 percent, saw a very positive effect on their relationship with their child.

We also wanted to find out what happens when a child is sick and can't go to child care. The results: Mothers are more likely to stay home than fathers. And our results suggest that traditional views of gender roles may foster this dynamic. When parents said mothers are most likely to stay home, 16 percent said it was because it was their responsibility to take care of the child, while just 4 percent of parents viewed it as the father's responsibility.

One of the strongest findings in the poll was that 86 percent feel that care in early childhood has a "major impact" on a child's long-term well-being.

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While it is perhaps not terribly surprising that 84 percent said there was a major impact on kindergarten readiness, it's worth noting that 52 percent said there was a major impact on job success later in life.

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Presidential candidates' child care platforms

Hillary Clinton has proposed universal access to preschool for 4-year-olds within 10 years, and she would seek to double funding for the Early Head Start and Early Head Start-Child Care Partnership programs as well as increasing funding for child development and support programs for children under age 3 and pregnant women. She is also calling for 12 weeks of paid family and medical leave for both parents. And she has proposed capping the amount a family spends on child care at 10 percent of income, among several other actions aimed at reducing costs.

Stretched: Working Parents' Juggling Act On Your Mark, Give Birth, Go Back To Work

Donald Trump has proposed allowing all parents to deduct the average cost of child care in their state from their income taxes, limiting it to those who make under $250,000 as a single parent or $500,000 for a couple. He would also allow tax-free contributions of up to $2,000 a year to dependent care savings accounts, with a 50 percent federal government match for low-income parents, up to $1,000. Trump also has proposed a paid maternity leave program.

Libertarian candidate Gary Johnston has not proposed anything specific on child care, while the Green Party's Jill Stein has called for universal child care.

Detailed fact checks of the Clinton and Trump positions are here and here.

The child care and health series

There's a lot more in the full poll report, but one final note: Parents perceive significant differences in quality depending on where they get care — from a relative versus a nonrelative versus a center.

NPR will provide in-depth reporting on the results of this poll in a series of radio and online reports over the coming weeks, including a story on Morning Edition Tuesday that explores the giant disconnect between parents and experts when it comes to quality.

We'll also live stream an expert panel at Harvard discussing these issues, Tuesday at 12:30 p.m. ET on

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

Is 20-Something Too Late For A Guy To Get The HPV Vaccine?

Mon, 10/17/2016 - 4:45am
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October 17, 20164:45 AM ET Heard on Morning Edition

From Side Effects Public Media

WFYI's Jake Harper reports health stories for Side Effects Public Media in Indianapolis. His newest health anxiety stems from the human papillomavirus, or HPV.

Brian Paul/Side Effects Public Media

Sex with someone new has always made me nervous. Now, TV is making it even worse.

I keep seeing scary ads featuring young people asking their parents why they didn't get the vaccine to protect against the human papillomavirus — HPV. If you're unfamiliar with HPV, it's a sexually transmitted infection that has been linked to various cancers, including cervical cancer in women.

I didn't get vaccinated. So lately I've been wondering: Now that I'm 29, is it too late for me to get the vaccine?

I found out about HPV eight years ago when a college girlfriend got immunized. Back then, the Centers for Disease Control and Prevention only recommended the vaccine for girls and young women between the ages of 11 and 26. The earlier the better, they said, to try to reach girls before they become sexually active. The vaccine is also more effective at a younger age.

At the time, I remember thinking that limiting it to females was strange — after all, males still spread HPV, right? But with my partner vaccinated, I let it go. I didn't know HPV could cause health problems for men.

But HPV absolutely affects men. It causes genital warts and is pulling past tobacco and alcohol as a leading cause of cancers in the back of the mouth and throat, the area called the oropharynx. The CDC now estimates about 70 percent of all oropharyngeal cancers may be caused by HPV, including roughly 12,600 cases in men each year.

"There are now more oropharynx cancers in men in the United States each year than there are cervical cancers in women," says Dr. Erich Sturgis, a surgeon and researcher at the University of Texas MD Anderson Cancer Center in Houston.

And there's no way to screen for oropharyngeal cancer, so Sturgis says most people catch it late.

"Typically it's a man, while he's shaving," says Sturgis. "He notices a lump in his neck. That means it's already a cancer that has spread."

HPV also puts men at risk for cancers of the anus and penis. Those are rare, but still make me anxious.

So, for men like me who missed the vaccine, is it still worth it?

The answer is complicated. In 2011, the CDC began recommending the vaccine for males ages 11 through 21 years old (26 for some high-risk groups).

Despite my age, researchers I talked to said that the vaccine could still help — if I haven't already been exposed.

But therein lies a complication. An estimated 80 percent of sexually active people will be exposed to HPV by age 45. In most people, the virus goes away on its own after two years. For men, there's no commercially available test to find out if you have been exposed. Women can be checked for HPV exposure as part of a Pap test.

To have 80 percent of sexually active young adults exposed sounds bleak. But there's a caveat: "There are several dozen types of HPV that infect the genital region," says psychologist Greg Zimet, who co-directs the Center for HPV Research in Indianapolis. Only a fraction of those cause cancer or warts, and the latest version of the vaccine Gardasil protects against nine of those HPV types — the ones responsible for a vast majority of HPV-related problems.

So let's say — hypothetically — you're kind of shy and haven't had that many partners. Is it possible you've been spared?

"The chances you've been exposed to all nine types are actually vanishingly small," says John Schiller, a microbiologist who studies HPV and HPV vaccines at the National Cancer Institute.

Schiller says the vaccine might not be a bad idea for someone outside the CDC's recommended age range. Still, it's not cheap.

"You're past the age where your health insurance is going to pay for it," says Schiller, so getting the vaccine isn't imperative — it's a personal decision.

"Peace of mind for you may be worth more than it is for some other people," he tells me.

So, I got the vaccine. It's costing $130 out of pocket per dose, and the CDC recommends three shots. But it could help me, even if it just calms my anxious inner voice. And it might keep me from spreading the virus to someone else.

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

Copyright 2016 Side Effects Public Media. To see more, visit Side Effects Public Media.
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Skeptics Question The Value Of Hydration Therapy For The Healthy

Mon, 10/17/2016 - 4:45am
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October 17, 20164:45 AM ET Heard on Morning Edition


Yana Shapiro relaxes while taking an intravenous vitamin treatment at RestoreIV in Philadelphia.

Emma Lee/WHYY

Yana Shapiro is a partner at a Philadelphia law firm with an exhausting travel schedule and two boys, ages 9 and 4. When she feels run-down from juggling everything and feels a cold coming on, she books an appointment for an intravenous infusion of water, vitamins and minerals.

"Anything to avoid antibiotics or being out of commission," the 37-year-old says.

After getting a 100-milliliter drip of a liquid the clinic calls immune protection pumped directly into her bloodstream via a needle in her arm, Shapiro says she feels like "a new person." The infusion, which costs $179, takes less than a half-hour. While she waits, she can recline in one of the cushy seats, watch the 64-inch, flat-screen TV or dim the lights in the room.

"I take this time as 'me time' — to relax and kick back and close my eyes for a couple of minutes," she says.

But if you mostly eat your kale and quinoa, why would you need a boost of vitamins delivered straight to a vein? Skeptical physicians say you probably don't need it. A healthy gut absorbs all the nutrients we need from food. And anyone well enough to drink fluid, they say, can get all the rehydration they need by mouth.

Still, clinics that market treatments of intravenous fluid to the stressed out and worried well can now be found nationwide.

Shapiro gets her infusions at RestoreIV in Philadelphia, but there are similar clinics in New York, Las Vegas, New Orleans, Santa Monica and Dallas, with names like The Remedy Room or Hangover Heaven. The first wave of such companies billed their treatments as a remedy for excess alcohol and partying, or too little sleep; you could get the treatment in a mobile van parked at a music festival, say, or in your hotel room.

Newer firms offer a menu of drips that claim to help rid the body of toxins, balance hormones, improve chronic medical conditions or simply give the skin a healthier glow.

Osteopathic medicine physician Jason Hartman, who launched RestoreIV with a partner out of his Philadelphia integrative medicine practice, says people want the experience he offers. Hartman's specialty is using touch to diagnose and treat patients.

He sometimes helps people remedy a hangover, he says, but his business also includes people with more serious illnesses, including chronic fatigue and migraines. For those patients, he says, IV treatment supports healing. Other clients are generally healthy and want to stay that way.

The basic IV therapy cocktail includes vitamin C, zinc and B vitamins. If you have a headache, the doctor might add a little magnesium.

"These are your natural pharmacy," Hartman says, "and in chronic diseases these things can be depleted [by] just a stressful lifestyle. And if they become deficient enough, it alters your internal pharmacology enough to possibly manifest as a symptom or disease."

The promised benefits of this sort of intravenous treatment vary from company to company.

At the bottom of the website for The Hangover Club, you'll find this warning:

"These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. This service is intended only for healthy adults."

Hartman says any intravenous infusion comes with a small risk of infection — or pain, bruising or bleeding if the needle misses the vein. More serious complications of an IV treatment can include a blood clot, or inflammation of the vein.

And people with certain medical conditions — some metabolic diseases, for example, or congestive heart failure — shouldn't get these treatments, Hartman cautions. That's why, he says, his clinic questions every client about their medical history before a treatment begins.

At RestoreIV, the treatments cost from $150 to $200, and there's an initial $35 fee to consult with the doctor. The business doesn't accept health insurance; patients pay Hartman's office directly.

So, with the out-of-pocket expense, and only anecdotal evidence of benefit, why do people sign up for these sessions?

Ather Ali, a doctor of naturopathic medicine and health researcher at the Yale School of Medicine, says that if an IV infusion of this type makes people feel better, it's probably because of the placebo effect. And the placebo effect can be powerful.

Several years ago, Ali and his colleagues tested a popular IV treatment called the Myers' cocktail on a small group of people with fibromyalgia, a syndrome of muscle pain and fatigue that can be hard to ease. Half the 34 participants in his pilot study got Myers' intravenous cocktail of vitamins and minerals in weekly treatments for eight weeks, and the other half got a standard solution without vitamins.

"The interesting finding," Ali says, "was that everyone got better." People in both groups reported less pain, and said they were better able to do the things they need to do every day.

The placebo phenomenon is more complicated than many people understand, Ali explains. Research has shown, for example, that injections, or other invasive procedures, can generate a stronger placebo effect than dummy pills do.

If, as in the case of his study, people feel a fairly innocuous treatment is helping them, and they haven't been able to get relief in other ways, that may be a reason to use it, Ali says — even if the "fix" is 100 percent placebo effect.

"When your child falls down and scrapes their knee, you give them a kiss," he says. "There's value in that, whether or not there's clinical trial data showing that giving a kiss is better than doing nothing."

Still, Ali says he can't ethically recommend the intravenous vitamin treatments for healthy patients.

"If people are just using it to feel good or for an energy boost," he says, "I would just say go exercise for 30 minutes and you'll get more out of that."

This story is part of NPR's reporting partnership with WHYY's The Pulse and Kaiser Health News.

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

West Virginia Grapples With High Drug Costs

Sat, 10/15/2016 - 5:04pm
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October 15, 20165:04 PM ET Heard on All Things Considered


Skyrocketing prices for essential medicines like the EpiPen, are generating public outcry, congressional hearings and political promises for policy fixes. In the meantime, the increases continue to hit pocketbooks — even of people who don't rely on these expensive drugs. In a state like West Virginia, where dire budget shortfalls have been a problem over the last few years, the problem is especially pronounced.

Kimberly Earl, of Charleston, W.Va., is feeling the pinch. She has four children, all of whom need medication.

"I have a 13-year-old who's a pediatric cancer survivor," she says. "I have two children who are allergic to foods, medication and environmental factors, and both of those children both have asthma."

Last year, two of her children needed new EpiPens — which come in a 2-pack. (The dose of epinephrine each pen delivers is designed to be used in an emergency, to stop a severe allergic reaction.) The Earls have private health insurance, but had yet to meet their $10,000 family deductible for 2015. They didn't have enough money for two boxes of EpiPens at the $600 price — even with a $100 discount from the drug's manufacturer. So the family improvised.

"We took the pens and we split the two pens between two kids," Earl explains. "I actually took the pens out and wrote on the top — 'use this one first' on the current pens, and 'use this one second' on the expired pens. So each kid was walking around with one current pen and one expired pen. And we were just hoping that if there was an issue they wouldn't have to use that second pen."

While Earl paid for the drugs out of pocket, about a third of West Virginians are insulated from these direct costs because they are covered by Medicaid. The state expanded Medicaid under the Affordable Care Act, giving lower-income people the government-sponsored insurance. Most Medicaid patients don't have premiums or copays.

But in the end, rising drug prices affect everybody in West Virginia. When lawmakers consider the state's budget, they only have so much revenue to divvy up among priorities that include health care services, roads and schools, says Dr. James Becker, the medical director of Medicaid in West Virginia.

"So when the cost of a drug goes up dramatically," he says, "that impacts our system and we have to step in and make adjustments to regulate the drug appropriately."

The West Virginia Department of Health and Human Resources can regulate the cost of drugs by negotiating lower prices through the federal rebate program. The rebate program is a complex system, but basically comes down to this: The more Medicaid patients enrolled in the program, the more bargaining power the government has to make drug companies lower their prices. Another way Medicaid manages costs is by including older, cheaper, but still effective drugs in its formulary, rather than relying on more costly new brands.

But even with these measures, the overall increase in the price of medications has forced some shifting of funds in other parts of the state budget, says Ron Stollings, a Democrat and state senator from Boone, W.Va.

"Certainly for Medicaid funding in West Virginia, [the hike is drug prices] is a huge cost," says Stollings, a former chairman of the state senate's health committee. "So when we have to put money into funding Medicaid, we have to cut funding for higher education and secondary education; we have to put off paving projects, etc."

Stollings says these rising Medicaid costs — partially due to higher drug costs — fall on the taxpayer, who may end up paying more state taxes to fund the budget.

"If you're a taxpayer, it impacts you," Stollings says. "If you're an insured person it will impact your premiums, and if you are on Medicaid you may get this expensive medication, but they may be ratcheting down coverage for other things."

Medicaid is a large portion of the West Virginia's budget, right behind public education. And it will probably get even bigger next year, as the state picks up more of the Medicaid expansion costs from the federal government.

This story is part of a reporting partnership with NPR, West Virginia Public Broadcasting and Kaiser Health News.

Copyright 2016 West Virginia Public Broadcasting. To see more, visit West Virginia Public Broadcasting.
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You Can Monitor Heart Rhythm With A Smartphone, But Should You?

Sat, 10/15/2016 - 5:00am
Patric Sandri/Ikon Images/Getty Images

Digital gizmos can monitor your heart, whether it's a wrist-worn fitness tracker or a smartphone app to help cardiologists analyze diagnostic tests. The question is whether they're going to do your heart any good. The short answer: It depends.

One thing to consider is whether the device is a consumer fitness monitor for tracking heart rate, or if it's a medical device approved by the Food and Drug Administration for detecting potentially dangerous heart rhythm irregularities.

First, the fitness monitors. Wrist-worn fitness trackers become less accurate with more vigorous exercise, which presumably is when you'd most want to know your heart rate. The study, published Wednesday in JAMA Cardiology, tested the Apple Watch, Fitbit Charge HR, Basis Peak and Mio Alpha wristbands.

"We have patients come in who have different kinds of monitors like these. Many of them are very concerned because they've recorded values that seem way outside of the normal range," says Dr. Marc Gillinov, a cardiac surgeon at the Cleveland Clinic and an author on the study. The study was designed to find out whether those readings are accurate.

Overall, the Apple Watch and Mio Fuse did best, with about 91 percent accuracy. The others fell in the 80 percent accuracy range, both overestimating and underestimating wearers' heart rates.

For most people, errors like these aren't a big deal, says Gillinov. But for elite athletes and cardiac patients who try to keep their heart rates in certain ranges, these devices might not be the best choice.

"For those groups, I'd recommend medical-quality chest-strap monitors," says Gillinov, adding that he doesn't think that inaccurate heart rate monitors are dangerous, just that they might not be useful.

Part of the problem is how they work, he explained.

If you've ever been in a hospital, you might have had a little plastic clip attached to your big toe (or your ear, or your finger). Those are pulse oximeters — they measure heart rate and oxygen content by shining a light through your skin. Different amounts of light bounce back depending on how much blood is flowing. By measuring changes in reflected light, pulse oximeters can track how fast your heart is beating. Hospital pulse oximeters are wrong all the time. "We often have to move the monitors around because we lose the signal," says Gillinov.

The heart rate monitors in Fitbits and Apple Watches work the same way, except they shine the light through your wrist. If you have dark skin, a tattoo or a birthmark where the monitor sits, Gillinov says that can confuse the monitor.

This isn't the first time wrist-born heart rate monitors have been called inaccurate. A class-action lawsuit filed against Fitbit in early 2016 claimed just that.

In a statement provided to NPR, Fitbit says that "Fitbit trackers are not intended to be medical devices" and that internal research shows that their trackers meet "industry standard expectations for optical heart rate on the wrist."

But there are growing numbers of heart-monitoring apps that are intended to be used as medical devices, which unlike fitness trackers have to be approved by the FDA. Some are designed for home use, while others are for health care providers.

Screening for atrial fibrillation has gotten a lot of attention, because this irregular heartbeat can cause blood clots, parts of which can break off and move to the brain, causing stroke. Patients with atrial fibrillation are five times more likely to have strokes, and it affects 9 percent of people over 65.

It's possible to be experiencing atrial fibrillation and not know it. Since this condition can come and go, there's no guarantee that doctors will catch the errant heartbeats. Right now, the only way to detect it is with an electrocardiogram, or EKG, which involves visiting a medical professional and using a machine to monitor the heart's electric signals.

One iPhone app, called Cardiio Rhythm, monitors the heart using a phone's camera. The concept is similar to a pulse oximeter or wrist wearable. Researchers used this phone-based device to detect atrial fibrillation. In a study published in July in the Journal of the American Heart Association, researchers used the app to screen a little over 1,000 patients for atrial fibrillation. They caught the erratic heartbeats in 92.9 percent of patients who had it, and correctly identified 97.7 percent of patients who didn't.

That's not accurate enough to make a diagnosis, but it is accurate enough for widespread at-home screening, says Ben Freedman, deputy director of cardiovascular strategy at the Heart Research Institute in Sydney, in an editorial accompanying the study. The app could tell people if they were at risk, but confirmation would have to come from a doctor's office.

Another device, called AliveCor, scans for atrial fibrillation using a small handheld EKG. The AliveCor EKG can connect to a smartphone and analyze heart rhythm. A study published Wednesday in Heart trained 13,122 participants to use the AliveCor EKG on themselves. Only 0.4 percent of their results could not be interpreted, and they caught 98 percent of atrial fibrillation cases in participants over 60. However, it had a high rate of false positives and only correctly identified 29.2 percent of those without atrial fibrillation.

"Our study found that a significant number of citizens with previously undiagnosed atrial fibrillation were picked up by community screening," says Dr. Ngai-Yin Chan, a cardiologist at Princess Margaret Hospital in Hong Kong and the lead author on the study. People with atrial fibrillation can be prescribed blood thinners to reduce the risk of clots, and beta blockers or other medications to slow heart rate. "Whether this will be translated into people seeking medical help needs to be answered by future studies."

A cardiologist and director of the Ahmanson-UCLA Cardiomyopathy Center, Dr. Gregg Fonarow, hopes that technologies like this will help identify atrial fibrillation early on and reduce the risk of stroke. "These applications can change the way cardiologists treat atrial fibrillation and prescribe better drug protocols," he told NPR via email.

But we're not there yet. Gillinov, the author of the fitness-tracker accuracy study, deals with a lot of atrial fibrillation patients in his work as a cardiac surgeon. He thinks that self-screening could save a lot of lives, but that it's important doctors be included in the process.

Plus, he says, not everyone should be screened for atrial fibrillation. "If young people start screening themselves, we're going to see a lot of false positives, even with very accurate devices."

Shots - Health News Sure You Can Track Your Health Data, But Can Your Doctor Use It?

The American Heart Association plans to release a policy statement on telehealth, including at-home heart monitoring, sometime in the next six months.

Copyright 2016 NPR. To see more, visit NPR.
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Organ Donations Spike In The Wake Of The Opioid Epidemic

Fri, 10/14/2016 - 7:00am
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October 14, 20167:00 AM ET Heard on All Things Considered


At his home in Haverhill, Mass., Colin LePage leafs through newspapers he shows to middle-schoolers to educate them about the dangers of drugs.

Martha Bebinger/WBUR

On the final day of June 2015, Colin LePage rode waves of hope and despair. It started when LePage found his 30-year-old son, Chris, at home after an apparent overdose. Paramedics rushed Chris by helicopter to one of Boston's flagship medical centers.

Doctors revived Chris' heart, but struggled to stabilize his temperature and blood pressure. At some point, a doctor or nurse mentioned to LePage that his son had agreed to be an organ donor.

"There was no urgency or, 'Hey, you need to do this.' I could see genuine concern and sadness." LePage says, his voice quavering.

The next morning, after another round of tests showed no signs of brain activity, LePage said goodbye to the son who'd been revived but wasn't fully alive.

"I sat in a chair with him and held his hand," LePage says. "It wasn't clinical. It didn't feel like someone's gaining something here. I knew that someone was, and that's comforting that someone else has been able to have a little piece of my son and some of their pain is not what it used to be."

Chris' liver is now working in the body of a 62-year-old pastor. His case is one among the nearly 900 percent increase so far in donations across New England since 2010. So far this year, more than 1 in 4, or 27 percent, of donations in New England are from people who died after a drug overdose. Nationally, that rate dips to 12 percent for the same time period.

Shots - Health News As Opioid Epidemic Surges, Medical Schools Try To Keep Pace

"It's remarkable and it's also tragic," says Alexandra Glazier, president and CEO of the New England Organ Bank. "We see this tragedy of the opioid epidemic as having an unexpected life-saving legacy."

That legacy is much more dramatic in New England than across the U.S. as a whole, where organ donations from drug users are up from 341 in 2010 to 790 through Aug. 31 of this year.

Additional Information: Spike In Organs Donated From Overdose Patients Source: The New England Organ Bank

It's not clear why. Overdose death rates are high in New England, but not the highest in the country. Glazier says the 12 transplant centers in that region may be more aggressive about finding a match for patients with failing hearts, livers or kidneys. And she says New Englanders tend to be pragmatic about end-of-life decisions.

Some hospitals in Massachusetts report that they are performing a record number of transplants. At Lahey Hospital and Medical Center in Burlington, the number of patients receiving a liver transplant has roughly doubled in the past three to four years.

Hospitals are required to test organs and warn patients if there is a risk of contracting HIV or hepatitis B or C, which are more common in IV drug users. That risk may be less troubling for patients these days because there are drugs to treat these viruses if patients become infected.

Some patients in need of organs still hesitate at the idea of accepting a liver or kidney donated by a drug user. But not at Lahey, where Dr. Mohamed Akoad chairs the department of transplantation.

"Most of these patients trust the fact that these donors are tested and they understand that their chance of dying while waiting for an organ is high," he says.

Akoad says Lahey has not had any cases of HIV or hepatitis B or C transmission in recent years.

That's the case at Mass General in Boston as well. Dr. Jay Fishman, associate director of the hospital's transplant center, says an organ from someone who used drugs is not necessarily risky and may even be healthier than other options.

Shots - Health News New Source Of Transplant Organs For Patients With HIV: Others With HIV

"You have to remember that as awful as this outbreak is, these are younger people who are dying, often with needles in their arms, and many of them were first-time drug users," Fishman says. "They weren't all addicts."

Despite the increase in available organs, there's no sign that the supply is keeping up with the demand from aging Americans and those with chronic diseases.

"The number of people on the waiting list is increasing faster than the number of donors, even with the increases related to overdoses," says Dr. David Klassen, chief medical officer at the United Network for Organ Sharing, which tracks and manages organ donations in the U.S.

There are likely many more organs available from the victims of drug overdoses than those collected. Some patients addicted to heroin or other opioids don't carry a driver's license, haven't spoken to a family member about their end-of-life wishes, or aren't in touch with family members who could give consent to donate an organ.

"I've never heard anyone talk about organ donation as a possibility. I'm not sure it's on their radar screen," says Dr. Jessie Gaeta, chief medical officer at the Boston Health Care for the Homeless Program.

Gaeta says she isn't sure how she would suggest organ donation, even to her high-risk patients.

"It's really nihilistic to say that to someone in their early 20s," Gaeta says. "I have so much hope for my patients, yet if someone does die and there's a chance for their organs to be helpful, that's one good thing to come of a death like that."

Debbie Deagle holds a photo of her son Stephen and herself.

Martha Bebinger/WBUR

For many mothers and fathers, sisters and brothers who've lost someone to an overdose, organ donation is a nearly taboo topic. It can trigger feelings of guilt, anger and despair, even among people who participate.

Debbie Deagle sat next to her son Stephen's unresponsive body for six days before agreeing to turn off his respirator.

"Before they took him," Deagle says, weeping, "I had my head on his heart, just so I could hear that beat, and they had to peel me off."

More than a year later, Deagle is still haunted by questions: Should she have asked for another opinion about the scans of Stephen's brain?

"Never in a million years do you ever visualize kissing your child whose heart's beating and having to watch them wheel that stretcher away and know they're going to cut him open and take out a beating heart," Deagle says.

The transplant patient who received Stephen's heart did not make it, leaving Deagle with the feeling her son had died again. She has written to the patients who received Stephen's liver and kidneys, but has not heard back.

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

Copyright 2016 WBUR. To see more, visit WBUR.
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Breast Cancer Death Rates Are Down, But Racial Disparities Persist

Thu, 10/13/2016 - 1:57pm

Lack of access to quality medical care remains a major factor in higher breast cancer death rates among African-Americans.

Deborah Jaffe/Getty Images

Women are less likely to die of breast cancer than they were a decade ago, but not all women are benefiting from that trend.

White women saw more of a drop in death rates than black women — 1.9 percent a year from 2010 to 2014, compared to a 1.5 percent decrease for black women, according to a report published Thursday by the Centers for Disease Control and Prevention.

And while the death rates for women under 50 declined regardless of race, older black women are more likely to die of breast cancer than are white women.

That's especially troubling because 40 years ago, black women were less likely to get breast cancer. That's changed. Black women's breast cancer risk is now the same as that of white women's, and black women are 41 percent more likely to die of the disease.

There can be some good reasons for the rise in the number of black women being diagnosed with breast cancer, like more women getting screening mammograms. But there are bad reasons, too.

The CDC report cites calorie-dense foods, lack of exercise and increasing rates of obesity as potential reasons.

And while this report found similar reductions in deaths among younger black and white women, older white women saw their death rates drop by 2 percent a year, compared to 1 percent in black women.

Shots - Health News Black Women's Breast Cancer Risk Rises To Equal White Women's

Access to care is one big reason why, according to Otis Brawley, chief medical and scientific officer for the American Cancer Society.

"Forty to 50 percent of black women get less than optimal care for breast cancer, whether it's mammography or treatment," Brawley says.

They're not alone in that; poor white women are also much less likely to get adequate care, and more likely to die as a result.

"We need to focus on getting good care, high-quality care to everybody," Brawley adds. "We need to realize that in the United States of America in 2016 a substantial proportion of Americans with cancer get absolutely atrocious care."

Copyright 2016 NPR. To see more, visit NPR.
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Brain Implant Restores Sense Of Touch To Paralyzed Man

Thu, 10/13/2016 - 1:19pm
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October 13, 20161:19 PM ET Heard on Morning Edition

Robert Gaunt tests Nathan Copeland's ability to detect touch by tapping fingers on a robotic hand.

UPMC/Pitt Health Sciences

Twelve years ago, a car wreck took away Nathan Copeland's ability to control his hands or sense what his fingers were touching.

A few months ago, researchers at the University of Pittsburgh and the University of Pittsburgh Medical Center gave Copeland a new way to reach out and feel the world around him. It's a mind-controlled robotic arm that has pressure sensors in each fingertip that send signals directly to Copeland's brain.

The scientists published details of their work online Thursday in the journal Science Translational Medicine.

"It's a really weird sensation," Copeland, now 30, says in a video made shortly after he first tried the system. "Sometimes it feels, kind of, like electrical and sometimes it's more of a pressure." But he also describes many of the sensations coming from his robotic hand as "natural."

When Copeland touches an object with the robotic hand, he can tell which finger the sensation is coming from and whether an object feels hard or soft, says Robert Gaunt, a bioengineer and assistant professor in the Department of Physical Medicine & Rehabilitation at the University of Pittsburgh.

"But we're really not at the point where we could, say, get him to feel the difference between silk and burlap," Gaunt says.

The success represents an advance that is "absolutely critical in terms of making prosthetics useful," says Mike McLoughlin, an engineer at the Johns Hopkins University Applied Physics Laboratory.

McLoughlin is part of a team at Hopkins that developed the Modular Prosthetic Limb that Copeland is using. The research at both Hopkins and in Pittsburgh is supported by the government's Defense Advanced Research Projects Agency.

For several years now, people have been able to control robotic arms using thoughts alone. But they have relied entirely on vision to know whether the arm is going in the right direction or grasping an object with the proper amount of force.

That makes it very challenging to perform simple tasks like grasping a foam coffee cup without crushing it, McLoughlin says.

Additional Information: Sensing Touch

Watch a blindfolded Nathan Copeland accurately sense which finger's being touched.

It was several weeks before the team was able to send the first tiny pulse of electricity to Copeland's brain. In this video, Gaunt tests Copeland's ability to perceive touch through the robotic arm.

Credit: UPMC/Pitt Health Sciences

"Without sensory feedback, somebody would have to actually have to look at the prosthetic, look at the cup, start to close the hand, (and) visually see the cup is starting to deform," he says.

Restoring Copeland's sense of touch was a painstaking process, but the Pittsburgh team knew it was possible.

"His hand has been disconnected from his brain because of his spinal cord injury," Gaunt says. "But the brain hasn't lost its ability to feel."

So the team began looking for a way to send touch sensations directly to Copeland's brain. The first step was to monitor his brain activity using a technique called magnetoencephalography.

"We were able to see the parts of his brain that became active when he was watching videos of a hand being touched," Gaunt says.

Next, the researchers placed tiny electrodes in Copeland's brain that could stimulate the areas corresponding to each finger. Then they waited for the brain to heal, as it adjusted to the presence of the electrodes.

It was several weeks before the team was able to send the first tiny pulse of electricity to Copeland's brain. "When it finally happened, he just very calmly said, 'Yep, I felt it on my index finger,' " Gaunt recalls. "But in the background I was breathing a sigh of relief and other people were cheering."

Of course, mind-controlled robots are still years away from consumer applications, McLoughlin says. At the moment, they are still too expensive, too bulky and too finicky to be used outside a laboratory setting. And there's no good way to control them without implanting electrodes in the brain.

Still, the ability to receive touch sensation from a robotic arm has the potential to help not only thousands of people who are paralyzed, but also people with a wide range of physical disabilities, McLoughlin says. For example, robots that provide sensory feedback could eventually help a disabled person cook a meal or clean up things at home.

"We're on the verge of something here that's going to transform lives," he says.

Copyright 2016 NPR. To see more, visit NPR.
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Kratom Gets Reprieve From Drug Enforcement Administration

Wed, 10/12/2016 - 4:02pm

Kratom, seen in capsule form here, has been under review by the Drug Enforcement Administration for possible restriction.

Photo illustration by Joe Raedle/Getty Images

It's been a wild ride for kratom lately.

Since Aug. 31, when the Drug Enforcement Administration announced its intention to classify the plant as a Schedule I substance, a group of kratom vendors filed a lawsuit against the government to block the move, angry advocates took to social media in protest and scientists questioned whether they would be able to continue kratom research.

Now, the DEA is withdrawing its notice of intent to put kratom in the most restrictive category of controlled substances, with drugs like LSD and heroin. The DEA says it will instead open an official public comment period — to last until Dec. 1, 2016 — for people to share their experiences using kratom as a medical treatment. It has also requested that the Food and Drug Administration expedite scientific research.

DEA spokesman Russ Baer says the DEA received more than 2,000 phone calls since August, mostly in opposition to the plan to classify kratom as Schedule I.

"So in a spirit of transparency, and to open this up to public dialogue, we withdrew our notice to temporarily schedule kratom," Baer says. "We will then give full consideration to those comments before we move forward with any action."

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

In the U.S., kratom has become popular among people coping with chronic pain and others trying to wean themselves off opioids or alcohol.

The main active ingredients in kratom are mitragynine and a related chemical that bind to some of the same receptors as opioids, providing some pain relief and feelings of euphoria. But, Kroll says, not the same high. And the chemical isn't known to cause the same, sometimes deadly, side effects as opioids, such as respiratory depression.

Still, the DEA attributed 15 deaths to kratom between 2014 and 2016. Fourteen of the 15 people who died also had other drugs or illegal substances in their systems.

Shots - Health News Kratom Advocates Speak Out Against Proposed Government Ban

Kratom advocates, like Karisa Rowland of Cleburne, Texas, point out that opioid abuse kills tens of thousands of people every year. She's thrilled that the DEA will now take time to gather public comments and more scientific research.

"Now that the DEA is officially withdrawing the proposal, I can continue the crusade for the rights of chronic pain sufferers like myself," Rowland says.

She attributes the change in position to work by activists and to lawmakers who urged the DEA to reconsider its "hasty" ban.

Kendra Jowers, an attorney who works in the substance abuse treatment industry in Florida, says in an email she is heartened that the DEA has reconsidered what she calls a "misguided and improper attempt to schedule kratom without the input of relevant stakeholders."

"This represents a huge sigh of relief for individuals who have come to rely on kratom to overcome addiction or maintain their sobriety," Jowers says. "At least for the time being, it relieves some [of] the terror people felt at once again facing a life of intractable pain or depression. It has been a lot of work to get to this point, and now I encourage people to fully engage in this hard-fought comment period."

Kratom user Seth Long of Kearney, Neb., is also pleased the DEA is listening to the public. "The DEA spokespeople have emphasized their reliance on science rather than anecdote in making scheduling decisions, so given the response not just from the public but from research scientists at Columbia University, among other institutions, they seem willing to admit their mistake in lumping together a coffee plant with synthetic 'designer' drugs," he writes in an email. "I hope the decision signals the DEA's willingness to become a more responsive institution and isn't just squid ink covering the same old drug war policies."

Instructions for submitting a comment by mail or electronically can be found in the DEA's Oct. 12 announcement. After the public comment period ends Dec. 1, the DEA could still decide to temporarily ban kratom, or permanently place the plant in a scheduled category defined by the Controlled Substances Act. The agency could also decide to leave kratom unregulated.

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

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

Reviews Of Medical Studies May Be Tainted By Funders' Influence

Wed, 10/12/2016 - 12:16pm
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October 12, 201612:16 PM ET Heard on All Things Considered Roy Scott/Ikon Images/Getty Images

When doctors want to help untangle confusing and sometimes contradictory findings in the scientific literature, they often turn to specially crafted summary studies. These are considered the gold standard for evidence. But one of the leading advocates for this practice is now raising alarm about them, because they are increasingly being tainted by commercial interests.

For many years, these studies — called meta-analyses and systematic reviews — seemed to solve a big problem. Doctors who had once relied on each other's expert opinions to select the best treatments gradually turned to careful scientific studies instead.

But the number of studies mushroomed and often came to different conclusions. So in the 1990s, doctors and medical advisory committees started relying on studies that combined results from many different research projects to streamline the search for answers.

These kinds of studies are "extremely important," says Dr. John Ioannidis, a professor of medicine health research and policy at Stanford University. He has conducted many of these types of studies over the course of his career. "They're trying to make some sense out of a very convoluted scientific and medical literature."

But Ioannidis says unfortunately things have gotten out of hand. First, "the problem is that there are just too many meta-analyses," Ioannidis says.

In a recent study on the subject, titled "The Mass Production of Redundant, Misleading, and Conflicted Systematic Reviews and Meta-Analyses," he chose as an example studies involving antidepressant drugs. "There are 185 of them published in the literature within seven years, which means about 25 of them published every year for the very same drugs and the very same indication, major depression," Ioannidis said.

What's worse, they're increasingly being generated by scientists who have financial interests in the outcome, Ioannidis found.

"About 80 percent of them have been funded or have some other conflicts of interest with manufacturers of these drugs," he says. "If you look at what their conclusions are, those that have been authored by industry employees, practically all of them, with one exception, have claimed that there are no caveats about antidepressants."

You have to read deep into the studies to find warnings about potential suicide risks, for example — if downsides are mentioned at all.

That's potentially misleading to doctors who turn to this kind of analysis to get a quick take on what works and what doesn't. Ioannidis says the drug industry has started using meta-analysis for commercial purposes, rather than as a disinterested look at the evidence.

"They can get the results or at least the interpretation that fits their needs. So you have the most powerful and most prestigious design in current medical evidence, and it can be easily manipulated as an advertisement, as a marketing tool."

And that defeats one of the main purposes of these studies, which is to make an overflowing scientific literature more manageable.

Peter Kramer, a clinical professor emeritus at Brown University and author of Listening to Prozac, took a deep dive into meta-analyses when he was writing his latest book, Ordinarily Well. He found the situation even worse than Ioannidis suggests.

"In some ways my doubts are stronger than his," Kramer told Shots.

Some analyses he looked at were trying to parse very subtle differences — for example, comparing two very similar antidepressants. You could get any answer you want, depending on how you set up the study, Kramer says.

And the problems he found aren't simply commercial conflicts of interest. For example, he saw biases among academics who were wedded to the notion that placebos are just as good as actual drugs for depression.

"Even on that side of the equation, where there's no adverse sponsorship but just an allegiance to an idea, I thought it wasn't always the case that everybody's hands were on the table," Kramer said.

But financial conflicts are easier to identify. Five years ago, the National Academy's Institute of Medicine (now called the National Academy of Medicine) suggested dozens of standards that should apply to systematic reviews of the research literature.

The influence of funders is a concern, says Dr. Alfred Berg, a professor emeritus of family medicine at the University of Washington who chaired one of the committees.

"If there's obvious sponsorship from an organization that might have a conflict of interest, that's probably not a good idea," he says. It's reasonable to suggest that scientists with clear financial conflicts of interest should not be producing these studies. "Is it going to happen in my lifetime?" Berg says. "Probably not!"

Pfizer, one of the many drug companies that fund meta-analyses involving their own products, declined an interview request. But the company noted in an emailed statement that the drug company "shares data from its clinical trials with outside members of the research community for them to conduct their own independent meta-analyses."

Fortunately, scientific journals are starting to do a better job of making sure researchers disclose their financial interests. It's up to readers now to take heed.

Email Richard Harris at

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

I'm Just Drawn This Way: Teen Finds Gender Identity Through Art

Wed, 10/12/2016 - 7:00am

I was 8 or 9 years old when I moved from a rural town in Oregon to the San Francisco Bay Area. It was one of seven moves my family made during my elementary years. The culture shock of moving from country to city hit me hard. I stuck out at my new school. It was hard to make friends with my new classmates. My parents argued often. So I spent a lot of time doing my own thing, trying not to think too hard about the rapid changes happening to my life.

This is when I started drawing.

Desmond Meagley/Youth Radio

My interest in drawing started as a way to deal with my feelings. To the rest of the world, I was a girl. But even then I knew that didn't quite fit.

I was a young kid with a changing family, moving from city to city, and drawing gave me a distraction. When I felt lonely, homesick or just bored, I drew my imaginary friends and characters from my favorite games. It was hard to make friends when my family moved so much. So I took characters out of computer games, books and movies, and imagined them like they were there hanging out with me.

Even when I did spend time with other kids, I felt out of place. In middle school, it became increasingly difficult to relate to girls from my class. So I mostly hung out with a group of guys who shared my interests in drawing, Internet culture and video games. I thought I fit in with them. But then, one day, I was talking to one of them over lunch and he said, "You know, it's weird that you're a girl and you hang out with us."

Desmond Meagley/Youth Radio

I was surprised. Then confused. Then hurt.

I felt bad in a way I couldn't describe yet. It wasn't fair. It didn't make sense. And it was one of the first moments I realized that my gender mattered to other people — that the way I experienced gender, as something more nuanced than just male or female, masculine or feminine, was not the way that other people thought about it.

Desmond Meagley/Youth Radio

During this time, my drawings were also changing. I found myself drawing a lot of androgynous dudes. I related strongly to one character in particular: He was an artist; short, with long, silver-dyed hair and shaved patches on the sides of his head. He wore nail polish, piercings and black clothing.

Drawing him was like escaping myself for a moment: I could be where he was, do what he was doing, and think his thoughts. I never felt like I was living in the wrong body. But some of the bodies I drew definitely felt "right." My characters were half friends, half alter egos.

Desmond Meagley/Youth Radio

Meanwhile, in real life, I tried to dress the way the girls in my class did, to look more feminine than I felt. I masked myself with smeary lip gloss and eye shadow. It was bittersweet to get compliments on my more feminized appearance. On the one hand, I liked the positive attention. But it felt hollow.

I figured being a girl was an acquired taste: unpleasant at first, but you eventually get used to it and begin to enjoy it.

Only I didn't. Going to school caused me so much anxiety and dysphoria that I'd fake being sick to stay home. And when I did make it to class, putting my head down to sketch was much more attractive than trying to socialize or focus on schoolwork. I could turn off my thoughts and let the pen take over until the day was over — and then I could disappear.

My drawings provided a raft of confidence that let me drift slowly through the turbulent waters of my early teens. I thought that if I couldn't be normal, then I could at least be accepted on the outside. But that phase of denial wasn't meant to last past the last weeks of middle school, when I came out as transgender.

Source: Youth Radio

Credit: Desmond Meagley

At the time, I didn't ascribe much significance to the role drawing has played in my life. But recently I found a box of my old drawings. Lots of them made me cringe, but when I looked at some of my old characters, I noticed familiar features.

Today, I'm 19 and have long hair that's cut short on the sides. I have a few piercings. I wear black, and I like bleaching and dying my hair and occasionally applying nail polish. The person I am today could have walked out of a drawing I did eight years ago.

Drawing isn't just a hobby for me: It's how I process my thoughts and experiences. It's my way of preserving the past, coping with the present and visualizing the future.

But now, I don't need to escape to feel comfortable with myself. When I look at my art, and how much it's evolved, I appreciate how much my struggles, and the skills I've developed, have shaped me.

This story was produced by Youth Radio's outLoud, with illustrations & story by reporter Desmond Meagley. Teresa Chin was lead designer and producer, and Storm White the design associate. Visit them on the Web at Copyright ©Youth Radio, 2016.

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