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Supreme Court Upholds Obamacare Subsidies

Thu, 06/25/2015 - 10:52am

Supporters of the Affordable Care Act cheer outside the Supreme Court in Washington, D.C., after a majority on the court ruled that Obamacare tax credits can continue to go to residents of any state.

Mark Wilson/Getty Images

The Affordable Care Act survived its second Supreme Court test in three years, raising odds for its survival but by no means ending the legal and political assaults on it five years after it became law.

Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.

June 25, 2015

The 6-3 ruling stopped a challenge that would have eliminated subsidies in at least 34 states for individuals and families buying insurance through the federal government's online marketplace. Such a result would have made coverage unaffordable for millions and created price spirals for those who kept their policies, many experts predicted.

Chief Justice John Roberts wrote the opinion for the court, joined by frequent swing vote Anthony Kennedy and the liberal justices Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor and Elana Kagen.

"Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them," wrote Roberts. "The combination of no tax credits and an ineffective coverage requirement could well push a State's individual insurance market into a death spiral. It is implausible that Congress meant the Act to operate in this manner."

Consumer advocates were hopeful for this outcome.

"The first thing going on for a huge swath of people is relief that we didn't blow up the system," said Lynn Quincy, a health policy specialist at Consumers Union. "The law was never meant to work without this pillar in there," she said of the subsidies.

But even a victory for the law closely identified with President Barack Obama leaves the health system with incomplete insurance coverage, rising costs and other uncertainties. The ACA itself still faces several lawsuits, although some believe Thursday's decision will discourage judges from advancing the cases.

"It sends a message to the lower courts that they need to take a good, hard look at all the ACA litigation that's out there and probably clean up and get rid of most of it," said Timothy Jost, a law professor at Washington and Lee University and an expert on the health law.

Kaiser Health News interviewed Jost and other authorities before Thursday's decision in a case known as King v. Burwell asking them to explain the implications of upholding the law.

Republicans controlling Congress are likely to advance new legislation amending or repealing the law, although it is even more likely to be vetoed by President Barack Obama if it gets to his desk.

The high court decision sets up the 2016 presidential election as the health law's next big test, although by then it could be difficult to fully uproot even if Republicans take the White House.

"With another year and a half of business as usual under the ACA, if it's a Republican as the next president, it'll be that much more difficult to make changes," said Joseph Antos, a health care economist at the American Enterprise Institute.

The case hinged on tax credits created by Congress to help middle-income consumers buy insurance through online marketplaces, also known as exchanges.

The subsidies are available through an exchange "established by the state," according to the law.

Thirty-four states did not set up their own exchanges and rely instead on healthcare.gov, run by the federal government. Lawyers for the plaintiffs argued that, as a result, millions of consumers in those states should not receive tax credits to pay premiums.

Pulling the subsidies would have undermined the insurance market in those states to the point of likely failure, experts said. Unable to afford the coverage, many consumers would have dropped out. Those remaining would probably have been older and sicker, driving up premiums to unsustainable levels.

Eighty-five percent of those who bought insurance through healthcare.gov qualified for subsidies averaging $272 per month. The Department of Health and Human Services predicted 6.4 million people would have lost subsidies if the court ruled for the plaintiffs.

Those subsidies are effectively revenue for hospitals and health insurers, financing premiums and the cost of care. Both industries are relieved they were upheld.

"Providers will feel better," said Peter Strack, a consultant with the Altarum Institute, which works closely with hospitals. "They don't have to worry about this back and forth of, 'Will I have the appropriate population covered?'"

A loss for the administration would have affected employer-based coverage as well, although not nearly as much, benefits lawyers said.

For large employers not offering health insurance, penalties are triggered when workers obtain subsidies in the marketplaces. No subsidies, no penalties, so employers could have dropped coverage without fearing fines.

Although employers are focused on complicated, health-law reporting requirements that take effect this year, their situation changes little in the wake of the decision, said Edward Fensholt, a benefits lawyer with brokers Lockton Companies.

"The working assumption has been, 'We need to offer this coverage to our full-time employees or we're going to risk these penalties,'" he said. "And that's not going to change."

ACA supporters said the lack of a reference to tax credits for the federal exchange was a drafting error and that Congress intended for subsidies to be available regardless of the platform. Lawyers for the plaintiffs said the government must follow the letter of the law.

The health law faces other legal cases, including objections from religious institutions to their role in providing birth control coverage and a suit by the House of Representatives contending that Obama's delay in requiring employers to offer coverage was illegal.

But even if legal challenges to the law disappear, health insurers, doctors and hospitals face broad uncertainty.

Signups for 2015 exchange coverage were lackluster. At the end of March, a little more than 10 million people had enrolled and paid for insurance, less than the 13 million the nonpartisan Congressional Budget Office was projecting last year.

Health costs seem to be creeping up again in a system that is already the most expensive in the world.

In recent years large, self-insured employers have seen health-spending increases of 4 or 5 percent a year, said Dale Yamamoto, an independent actuary who works closely with such companies. So far this year those companies are seeing 6 or 8 percent, he said.

"Everyone I'm talking to — it sounds like they've started to go up this year," he said. "If it's going up for them, it's probably going up on the individual side as well."

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Most Dialysis Patients Aren't Receiving The Best Treatment

Thu, 06/25/2015 - 10:03am

When kidneys fail to cleanse the blood, dialysis is often the solution. But the odds for success over the long haul depend in no small measure on the details of how the dialysis machinery is connected to the patient.

Mehau Kulyk/Science Source

For the past 20 years, doctors have recommended that dialysis patients have a simple operation to make it safer and easier to connect to a machine that cleans their blood.

Yet only 20 percent of new dialysis patients are receiving the lifelines known as arteriovenous fistulas, a study published Wednesday in JAMA Surgery finds. With about 100,000 people starting dialysis each year, that means 80,000 patients aren't receiving the preferred standard of care, putting them at a higher risk of infection, blood clots and even death.

"Doctors are usually really good about following standards of care and recommendations, but in this area, we are failing miserably," said Dr. Mahmoud Malas, a surgeon at Johns Hopkins University School of Medicine who led the study. "We have had recommendations for [the best possible care for] 20 years now, but after all this time, only about 20 percent of those starting dialysis are getting it done right."

Kidneys play a vital role in our daily lives. They constantly clean our blood, removing harmful toxins that are eventually disposed through our urine. When someone's kidneys fail, the organs can no longer perform this essential function and weekly dialysis treatment is used in their stead.

Connections called arteriovenous fistulas are the preferred method for patients to connect to hemodialysis machines. Surgeons stitch together an artery and vein, usually in the arm, to create a sturdier vein with greater blood flow. The fistula reduces dialysis treatment time, while increasing the effectiveness of the blood cleaning.

Fistulas are also safer. "Chances of you dying are 30 to 40 percent less if you use a fistula," Malas says.

Despite these clear benefits, only about 1 in 5 new dialysis patients receive fistulas, according to national data analyzed by Malas and his team.

The researchers collected data from the U.S. Renal Data System, which tracks all patients with end-stage renal disease. They looked at 464,547 individuals who began dialysis between January 2006 and December 2010.

Texas, Florida and South Carolina had the lowest number of ESRD patients obtaining fistulas, with only about 1 in 9 patients receiving fistulas. But instead of pointing the finger at the puny performance of those three states, Malas says it's more important to see the bigger problem.

"Even if you look at the region that had the highest incidence of fistulas, which was New England, they only had a 22.2 percent usage," he says. "That's still pathetic."

"This is an opportunity for improvement in general," says nephrologist Joe Vassalotti, who works at Mount Sinai Hospital in New York. "It's a call to action for the whole country. Everyone would agree that more than 20 percent of patients should be starting with fistulas. Everyone would agree we can do better."

So what's stopping new dialysis patients from getting fistulas?

Malas' research documents the heavy dependence on catheters for dialysis. These are small plastic tubes, usually placed in a vein along the neck, chest, leg or groin, that are open to infection. However, the tubes mean patients don't have to be stuck with needles during dialysis.

"Some patients don't want to be poked," Malas says. "They don't want a needle going into their arm three times a week like fistulas require."

But more importantly, he says, primary care doctors may not be vigilant enough for kidney disease in the first place.

"I don't think doctors are failing," he says. "I think they are overwhelmed by seeing so many patients every day, and it's very hard to recognize when kidneys start deteriorating. Kidney failure can be symptomless and silent for a long time. It's easily missed."

And if it's missed, patients can suddenly "crash into dialysis," requiring emergency hospitalization and dialysis. Catheters are the quickest ways to treat emergency kidney failures because they can be used immediately after insertion. Fistulas, on the other hand, cannot be used for six to 12 weeks after the operation.

To avoid dialysis crashes and emergency use of catheters, Malas recommends doctors pay special attention to patients who have a family history of kidney disease, hypertension and diabetes, which are risk factors for kidney failure.

Once kidney failure is recognized, it helps to get a nephrologist — or kidney specialist — involved quickly. Patients assigned to nephrologists are 11 times more likely to receive fistulas than those without one, according to the study.

"I think what's really important about this research is that it emphasizes seeing nephrologists," says Mount Sinai's Vassalotti, who is also the lead clinical consultant for Fistula First Catheter Last, a national initiative to increase the use of fistulas. "People living with kidney disease should prepare in advance and have fistula surgery before they crash and before it's too late."

Receiving a fistula operation takes months of preparation, but nephrologists can get the process going early on, he says.

Malas says that he hopes his study will make patients and doctors more aware of kidney disease and the benefits of dialysis via fistulas.

"Fifteen thousand deaths occur each year because the wrong method of dialysis is being used," he says. "This country could save thousands of lives if we start doing the right thing."

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Are You Flossing Or Just Lying About Flossing? The Dentist Knows

Wed, 06/24/2015 - 3:58pm

I'd rather be sticking needles in my eyes. But that wasn't on the survey.

iStockphoto

There's nothing like jamming a waxed piece of string between your tightest molars and sliding it back and forth. And who doesn't do that once a day, just as the dentist prescribes?

Well, a lot of us. Twenty-seven percent of adults lie to their dentists about how often they floss their teeth, a survey released Tuesday found. Not only that, but more than a third of people surveyed would rather be doing unpleasant chores than flossing their teeth daily. Fourteen percent would rather clean the toilet. Nine percent would rather sit in gridlock traffic for an hour. And 7 percent would rather listen to small children crying on a plane.

Actually, that 27 percent sounds awfully low. When we called up Dr. Joan Otomo-Corgel, a periodontist and president of the American Academy of Periodontology, which conducted the survey, she said: "Is that all?"

American Academy of Periodontology

She's not the only oral health professional who thinks many patients are fibbing when they say they're flossing. "I am shocked," says Dr. Sally Cram, a periodontist and spokesperson for the American Dental Association, via email. "Given my experience with patients in my practice I thought it would be higher!"

Indeed, a similar survey by the dentists' association found that only 4 in 10 Americans floss every day; 20 percent never do. Some people find it so repulsive that they'd rather be doing nearly anything else. "Cleaning the toilet?" Otomo-Corgel laughs. "I don't think so. Maybe ironing."

So what makes us hate flossing so much?

"It's a lot of work," Otomo-Corgel admits. Though the ADA says it should only take an extra couple of minutes a day, it can seem like an eternity. The floss is hard to get between your teeth. It makes your gums bleed. It's slimy. Tiny particles of food are flung onto your bathroom mirror. And there's no immediate payoff, like the fresh-breath feeling you get from brushing your teeth.

The benefits of flossing may be intangible, but they're real.

Flossing helps by removing plaque, a sticky film of bacteria and saliva. This goop collects below your gum line and can eventually harden into tartar. If the bacteria cause inflammation, well, that's periodontal disease. Untreated it can lead to receding gums, tooth decay and tooth loss. Periodontal disease is extremely common; one in two people have it, Otomo-Corgel says.

But it's preventable with proper oral hygiene. Which means brushing twice a day, flossing once a day and seeing a dentist or periodontist regularly. Flossing correctly, Otomo-Corgel stresses. Bleeding is normal, because it means you're cleaning out infection; pain means you're doing it wrong. The ADA has a step-by-step guide, and even a video on how to floss right.

What about alternatives to flossing, for those of us who would rather be in gridlock traffic? Proxabrushes are skinny brushes that fit between teeth. Stim-U-Dent picks or even regular toothpicks may work to remove plaque. But, Otomo-Corgel warns, if your teeth are close together, you'll need to use dental floss.

"Flossing is simple once you've learned how," she says. And it's the best way to prevent gum disease, along with regular visits to the dentist.

Who, by the way, can tell if you're lying.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

When Does Workplace Wellness Become Coercive?

Wed, 06/24/2015 - 11:19am

Christine White pays $300 a year more for her health care because she refused to join her former employer's wellness program, which would have required that she fill out a health questionnaire and join activities like Weight Watchers.

"If I didn't have the money ... I'd have to" participate, says White, 63, a retired groundskeeper from a Portland, Ore., community college.

Like many Americans, White gets her health coverage through an employer that uses financial rewards and penalties to get workers to sign up for wellness programs. A small but growing number tie those financial incentives to losing weight, exercising or lowering cholesterol or blood-sugar levels. The incentives, meanwhile, can add up to hundreds, or even thousands, of dollars a year.

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Employers say wellness programs boost workers' health and productivity while helping companies curb rising health care costs. President Obama's signature health law allows employers to increase those financial incentives. But asking workers to undergo medical exams or give personal medical information is sharply limited by another law, the 1990 Americans With Disabilities Act, which prohibits such questioning — except under limited circumstances, such as by voluntary wellness programs.

So when is a wellness program voluntary, and when do employer incentives cross the line and become coercive?

A proposed rule published this spring by the Equal Employment Opportunity Commission attempts to strike a balance between employers who want to use incentives to drive worker participation and consumer advocates who see penalties as de facto coercion. The plan drew about 300 comments from employers and consumer groups by a June 19 deadline, with plenty of criticism.

The equation tilts too far against workers, said Samuel Bagenstos, a University of Michigan Law School professor. "When ... employers can charge you a couple thousand dollars more for refusing to give private medical information, [that] doesn't sound very voluntary to me."

Many employers say the proposed rule doesn't clear up the conflicts between the health law and the ADA. In addition, it restricts their ability to offer rewards, which are needed to "engage employees and their families to be aware of their ... lifestyle risks," said Steve Wojcik, vice president of public policy for the National Business Group on Health.

The EEOC hasn't set a timetable for issuing a final rule.

Under the proposal, wellness programs would be considered voluntary so long as the employer rewards or penalizes an employee no more than 30 percent of the cost of health insurance for a single worker. Since the average cost for such coverage is $6,025 a year, the 30 percent limit would be about $1,800.

Employers can't fire workers for declining to participate, nor can they deny them coverage, the proposal says. They also must give workers a notice explaining what medical information will be obtained by the wellness administrator — often a private contractor — and how that might be used.

Some employers say the rule could force them to cut the size of wellness programs' financial incentives or penalties, particularly for families and smokers. Such limits could mean "advancements in workplace health improvement may come to an end," wrote the Northeast Business Group on Health, a coalition of large employers, insurers and benefit consultants.

Consumer groups are also unhappy, saying the proposal strips workers of important protections against health or disability-related discrimination by loosening earlier government definitions of what constitutes a voluntary program.

"It walks back people's rights," said Jennifer Mathis, director of programs for the nonprofit Bazelon Center for Mental Health Law, a legal advocacy organization for people with mental disabilities.

The health law permits employers to offer incentives or penalties of up to 30 percent of the cost of a health insurance plan — up from 20 percent under a previous regulation — if they set specific health goals for workers, such as quitting smoking or achieving certain results on medical tests. Most employers' incentives are still well below those levels.

Still, how does that square with the ADA's restrictions on employers asking for personal medical information? That's where it gets complicated. The EEOC long defined voluntary wellness programs under the ADA as those where "an employer neither requires participation, nor penalizes employees who do not participate."

But what constitutes a penalty? Prior to the proposed rule, employers who tried to charge workers the full cost of their insurance, or who barred them from coverage for refusing to participate, could run into trouble, said Sarah Millar, a partner at law firm Drinker Biddle in Chicago.

"What was not clear was at what point between zero and 100 percent [of the cost of employee health coverage], does a program not become voluntary?" she said. "Now, as long as it's below 30 percent and meets certain disclosure requirements, then a program is still considered voluntary."

Many employers also asked the administration to allow them to impose penalties of up to 50 percent of insurance costs for tobacco users, which the federal health law allows.

Additionally, employers want to be able to charge workers 30 percent of the cost of more expensive family coverage, if the family is also eligible to participate in the wellness program. That could dramatically increase the dollar amount of the financial incentive or penalty.

But some consumer advocates say the proposed level of financial incentives or penalties is already too punitive.

"Medical questions that an employee may only decline to answer if he or she agrees to pay thousands of dollars more for health insurance can hardly be called 'voluntary'," the Bazelon center wrote. The group wants the government to prohibit penalties for those who decline to answer such questions.

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

That's Not Fair! Crime And Punishment In A Preschooler's Mind

Wed, 06/24/2015 - 8:54am

By age 3, kids already have a burgeoning sense of empathy, ownership and justice.

iStockphoto

Toddlers can throw their fair share of tantrums, especially when you don't yield to their will. But by age 3, it turns out, the little rug rats actually have a burgeoning sense of fairness and are inclined to right a wrong.

When they see someone being mistreated, children as young as 3 years old will intervene on behalf of others nearly as often as for themselves, a study published this month in Current Biology suggests. Just don't ask them to punish the perpetrator.

Researchers in the U.K. and Germany morphed into puppeteers to learn when children develop their sense of justice and interest in punishment. The study included 137 children who were either 3 or 5 years old, and involve each, one at a time, in several different scenarios.

In some of the experiments, a puppet would "steal" a cookie from another puppet or the child by moving the turntable to place the treat in front of herself.

The University of Manchester

In one experiment, a devious puppet stole cookies that were originally intended for the child. In another, an innocent puppet cried out in distress when its marbles were snatched by a troublemaker puppet.

The researchers watched the kids' reactions.

It turned out that the children weren't just concerned about their own precious cookies or toys; they would jump in to assist the wronged puppets, too. Given the opportunity, 3-year-olds would intervene to return items a puppet had stolen to the original owner nearly 60 percent of the time. They would take back their own stolen items almost 80 percent of the time.

"The children were almost as concerned for the puppets as they were for themselves," says Keith Jensen, a psychologist at the University of Manchester who led the study.

The researchers also observed that the 3-year-olds did not seem eager to punish the bad puppets. When given only two options — to leave a stolen toy with a thief, or move it to a place where no one could have it — more than half the tots opted to leave the toy with the thief. Several of the kids were so uncomfortable with the idea of taking the toy away from the thief that they became distressed, and had to be removed from the study.

"It was so distressing that they just started crying," Jensen says. "They didn't seem to want to make [the puppets] suffer."

The 5-year-olds, on the other hand, weren't as hesitant to punish the bad guys. They opted to take the stolen cookies or marbles away from the thieves 70 percent of the time, even if that meant no one could enjoy them.

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In that way, 5-year-olds are more like adults in their sensibility about punishment, Jensen says. Younger children, however, are more concerned about comforting the distraught victims than they are about disciplining the culprits.

And that's pretty surprising, says Peter Blake, a developmental psychologist at Boston University who was not involved in the study.

"They don't really punish." he says. "It seems like they really want to reset everything back to the way it was. It's really neat because no one has looked for that behavior in children before."

Jensen and his team believe the kids' reactions suggest that by age 3, they understand the concept of ownership — and feel empathy for those in distress. And because doling out punishment and taking away toys could cause distress and suffering, the toddlers may have tried to avoid it.

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"On top of that," Jensen says, "children are taught to not take things from others. So they have to work against this rule." And that's not easy.

The notion that justice should sometimes be punitive, he says, comes at a later age, possibly out of the need to maintain fairness in society.

As an adult, when you see someone break a rule, you're more likely to punish them, Jensen says. "Because if cooperation was only used and not punishment, free riders would make fools of all of us."

But Jensen thinks his findings might be useful to parents and teachers of the very young. Since the youngest preschoolers tend to react against punishment and harm to others, he says, maybe we'd do well to teach them about justice by focusing on the victims rather than the culprits.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Medical Marijuana Is Often Less Potent Than Advertised

Tue, 06/23/2015 - 12:05pm

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

David McNew/Getty Images

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Disputes Made Prevention Panel Stronger, Says Former Leader

Tue, 06/23/2015 - 11:21am

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

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

In 2010, everything changed.

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

Courtesy of Michael LeFevre

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

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

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

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

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

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

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

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

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

How do you decide which preventive services to review?

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

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

What other task force recommendations have been publicly controversial?

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

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

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

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

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

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

Take A Hike To Do Your Heart And Spirit Good

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Fraud Still Plagues Medicare's Prescription Drug Program

Tue, 06/23/2015 - 12:03am
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Fraud and abuse continue to dog Medicare's popular prescription drug program, despite a bevy of initiatives launched to prevent them, according to two new reports by the inspector general of Health and Human Services.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Painfully Skinny Jeans Land A Woman In The Hospital

Mon, 06/22/2015 - 6:33pm

Skinny jeans: fashion statement or health threat?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

California's Medicaid Program Fails To Ensure Access To Doctors

Mon, 06/22/2015 - 1:25pm

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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To Ease Pain, Reach For Your Playlist

Mon, 06/22/2015 - 4:44am
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Maria Fabrizio for NPR

We all know that listening to music can soothe emotional pain, but Taylor Swift, Jay-Z and Alicia Keys can also ease physical pain, according to a study of children and teenagers who had major surgery.

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
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Fitness App Aims To Deliver Live Feedback From A Personal Trainer 24/7

Sun, 06/21/2015 - 7:03am

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

Courtesy of FitNet

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

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

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

All Tech Considered Live Video Apps Like Periscope Make Life Even Less Private

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

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

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

Ryan Kellman and Adam Cole/NPR's Skunk Bear

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

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

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

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

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

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

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

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

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

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

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

Adam Cole and Ryan Kellman/NPR's Skunk Bear

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Hunting Ways To Keep Synthetic Estrogens Out Of Rivers And Seas

Fri, 06/19/2015 - 12:09pm

Removing micropollutants from wastewater isn't cheap or easy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

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

Fri, 06/19/2015 - 7:03am

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

Meredith Rizzo/NPR

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

DNA Confirms Kennewick Man's Genetic Ties To Native Americans

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

Brittney Tatchell/Smithsonian Institution

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

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

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

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

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

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

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

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

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

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

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

These results were published Thursday in the scientific journal Nature.

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

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

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

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

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

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

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

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

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

Clearly, Kennewick Man isn't dead yet.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

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

Thu, 06/18/2015 - 11:51am

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

When Should Surgeons Stop Operating?

Thu, 06/18/2015 - 7:03am

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

Why Some Teen Brains May Be Hardwired To Make Risky Choices

Wed, 06/17/2015 - 1:55pm

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2015 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs