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Vision Problems Increase The Risk Of Early Death In Older People

Thu, 08/21/2014 - 4:26pm
Vision Problems Increase The Risk Of Early Death In Older People August 21, 2014 4:26 PM ET

Seeing better can mean living longer because it helps people remain independent.

iStockphoto

An eye exam may be the ticket to a longer life, researchers say, because good vision is essential for being able to shop, manage money and live independently. And maintaining independence in turn leads to a longer life.

Researchers have known for years that people who have vision problems as they get older are more likely to die sooner than those who still see well. But they weren't sure why that was so.

To answer that question, scientists looked at data from the Salisbury Eye Evaluation, which tracked the vision and health of people ages 65 to 84 living in Salisbury, Md., from 1993 through 2003.

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People's visual problems at the start of the study or their loss of vision didn't directly predict an increased death risk, the researchers found. Instead, the vision loss made it less likely that people could pay their bills, do housework and otherwise manage their lives.

People who lost visual acuity equivalent to one letter on an eye chart each year had a 16 percent increase in mortality risk over eight years, and that was due to the loss in independent living abilities, the researchers said.

"An individual who's remaining relatively stable in their visual acuity in their older years is not seeing this subsequent difficulty in functionality," says Sharon Christ, an assistant professor of human development and family studies at Purdue University and the lead author of the study. It was published Thursday in JAMA Ophthalmology.

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The researchers did look at whether other factors, including physical illness, race, sex, depression, smoking, alcohol use and obesity, could be causing the increased mortality risk. But they found that the correlation between vision loss and instrumental activities of daily living was the strongest.

Reducing the risk may be as simple as getting an eye exam and new glasses or contact lenses, Christ told Shots. "It's really important to deal with impairment and make sure you're getting the eye care that you need."

People with vision problems that can't be corrected should get help with tasks of everyday life, Christ says, and be encouraged to remain physically active, postponing those functional declines for as long as possible.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Would A Prize Help Speed Development Of Ebola Treatments?

Thu, 08/21/2014 - 3:34pm
Would A Prize Help Speed Development Of Ebola Treatments? August 21, 2014 3:34 PM ET

Dr. Bruce Ribner, medical director of Emory University Hospital's infectious disease unit, embraces Dr. Kent Brantly (left) who was treated with an experimental Ebola medicine and released from the Atlanta hospital Thursday.

John Bazemore/AP

The human toll of the Ebola epidemic in West Africa is becoming clearer by the day. The virus has killed at least 1,350 people, making this the largest outbreak of the disease ever.

There's no Ebola cure, and only a few experimental treatments are in the works.

One called ZMapp, which contains antibodies against the Ebola virus, was used to treat two Americans who fell ill, a Spanish priest and three health care workers in Liberia, despite the fact that the medicine hadn't been safety tested for humans.

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While the World Health Organization has said it's ethical to use unapproved treatments and vaccine in this unprecedented Ebola outbreak, there aren't many options. And supplies of ZMapp "are now exhausted," WHO said Thursday.

The World Health Organization Says Yes To An Experimental Ebola Drug

What would it take to make Ebola drugs a clinical reality? Financial incentives might help.

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Even now, Ebola isn't the most appealing business proposition for drugmakers. While devastating to the people infected, Ebola hasn't, thankfully, been a widespread illness since it was first identified in 1976. Before the current outbreak, fewer than 3,000 people had reportedly died from the disease.

In the U.S., drugs to treat rare diseases have become lucrative, thanks to tax incentives, special regulatory protection and a willingness by insurers and governments to pay for life-saving treatments.

But Ebola, like many other diseases that are mainly a threat in less-developed countries, have been largely neglected by drugmakers.

Dr. Marie-Paule Kieny, WHO's assistant director-general, said last week that the lack of an approved Ebola drug is a "market failure" because the disease typically strikes "poor people in poor countries where there is no market."

Most Ebola drug research has been financed by the U.S. government, she said, with Canada also pitching in.

For Ebola, there may need to be more financial help to get research started and a reward for success. "As an investor, your expectation is that in the future very few people will have this disease and very few will be in rich countries," says Duke health economist David Ridley. "Should you pay money up front for clinical trials, or should you dangle a sufficiently big prize? It's both."

Ridley is one of the architects of an idea to encourage the development of drugs for neglected tropical diseases that has become U.S. law. Companies that get Food and Drug Administration approval for a drug to treat one of 16 neglected diseases disease get a voucher that moves any drug of their choice to the head of the line for agency review. The fast-track voucher can be sold to another drugmaker that's willing to pay for a shortcut.

Earlier this year, Knight Therapeutics, a Canadian firm, won a voucher when FDA approved its leishmaniasis drug, just the sort of medicine WHO's Kieny wants to see more of. Knight is now trying to cash in its leishmaniasis prize by selling the priority voucher to the highest bidder.

Funding by the Defense Department and National Institutes of Health has provide a push for Ebola research, Ridley says. "An extra pull, like the voucher, would be a great move," he says.

Ebola isn't on the list of neglected tropical diseases that automatically qualify for an FDA voucher. But Ridley says that would be easy to fix. The secretary of Health and Human Services can amend the voucher regulation to cover "any other infectious disease for which there is no significant market in developed nations and that disproportionately affects poor and marginalized populations."

That sounds like Ebola, doesn't it?

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Mental Health Meets 'Moneyball' In San Antonio

Thu, 08/21/2014 - 12:05pm
Mental Health Meets 'Moneyball' In San Antonio August 21, 201412:05 PM ET

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Leon Evans, director of the community mental health system for Bexar County and San Antonio, broke through barriers that had hindered care.

Jenny Gold/Kaiser Health News

The jails aren't overflowing in San Antonio anymore. People with serious mental illnesses have a place to go for treatment and the city has saved $10 million a year on. How did it happen?

"You know Brad Pitt in the movie Moneyball?" asks Gilbert Gonzalez, Director for the Bexar County Mental Health Department. "Well, the success in that movie was based on the data and analytics. We needed to do the same thing."

Gonzalez's task was to look at all the money San Antonio was spending on mental health in one way or another.

Just eight years ago, the jails, hospitals, courts, police and mental health department in Bexar County all worked separately.

Each part of the system was encountering the same people with serious illnesses, but the people were just cycling through, not getting better. Gonzalez found that the city was spending enormous sums of money while taking care of people with mental illness poorly.

So Leon Evans, director of the community mental health system for Bexar County and San Antonio, got everyone talking. That turned out to be the most challenging piece of the puzzle.

"If you think law enforcement and mental health workers have anything in common, we don't," says Evans. "We speak a different language. We have different goals. There's not a lot of trust there."

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But once the decision-makers saw what could be done if they pooled their resources, every sector chipped in and the county built a single, integrated system where people with mental illnesses could actually get better.

Among other things, the San Antonio center has a 48-hour inpatient psychiatric unit, outpatient primary care and psychiatric services, help with substance abuse, housing for people with mental illnesses and job training. More than 18,000 people pass through the Restoration Center each year.

"San Antonio is ahead of what's a growing trend across the country to try to build a non-hospital alternative for people who are experiencing a psychiatric emergency, often with co-occurring alcohol or other drug abuse," says Dr. Mark Munetz, a psychiatrist and professor at Northeast Ohio Medical University who toured the Restoration Center last year.

But he says the San Antonio model might not work everywhere. The Restoration Center and homeless shelter, he says, felt like "a psychiatric oasis, removing the people from the most central part of the city. It felt a little like segregating people in that part of the city, especially with the homeless shelter next door. I'm not sure how that would fly in other parts of the country."

Nonetheless, the rest of the country has started to notice. City officials say every state in the country has sent delegates to San Antonio to see if they can model their own mental health systems after this one.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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What Kids' Drawings Say About Their Future Thinking Skills

Wed, 08/20/2014 - 9:23am
What Kids' Drawings Say About Their Future Thinking Skills August 20, 2014 9:23 AM ET

Researchers asked 4-year-olds to draw a child. Here's a sample of their artwork.

Twins Early Development Study/King's College in London

At age 4, many young children are just beginning to explore their artistic style.

The kid I used to babysit in high school preferred self-portraits, undoubtedly inspired by the later works of Joan Miro. My cousin, a prolific young artist, worked almost exclusively on still lifes of 18-wheelers.

These early works may be good for more than decorating your refrigerator and cubicle, researchers say. There appears to be an association, though a modest one, between how a child draws at 4 and her thinking skills at 14, according to a study published in the journal Psychological Science.

The findings don't mean parents should worry if their little ones aren't producing masterpieces early on. But the study suggests that intellectual and artistic skills may be related to each other in a way that reveals something about the influence of our genes.

Researchers from King's College London enlisted 7,700 pairs of 4-year-old identical and fraternal twins in England to draw pictures of a child. The researchers scored each drawing on a scale of 0 to 12, based on how many body parts were included. All of the kids also took verbal and nonverbal intelligence tests at 4 and 14.

Kids with higher drawing scores tended to do better on the intelligence tests, though the two were only moderately linked. And that was expected, says Rosalind Arden, a cognitive geneticist who led the study while at the King's College Institute of Psychiatry. The drawing test researchers used was first developed in the 1920s to measure children's cognition. And studies have shown the test to be useful but not always accurate.

In a surprise to the researchers, the drawings and the test results from identical twins (who share all their genes) were more similar to one another than those from fraternal twins (who share only half their genes). "We had thought any siblings who were raised in the same home would be quite similar," Arden tells Shots. The findings add to the growing body of evidence that suggests genes can play a role in both artistic and cognitive ability, she says.

This doesn't mean that a child's genetic predisposition necessarily hurts his or her chances of succeeding in artistic and intellectual endeavors, Arden says. As previous studies have shown, countless factors affect a person's abilities — and genes are only one of them.

How would Jackson Pollock and Mark Rothko have done on the drawing test when they were kids? Arden says she and her colleagues are trying to figure out whether judging the children's art in some other way (maybe based on creativity instead of accuracy) would reveal something different about their intelligence.

But we shouldn't assume that these abstract masters couldn't draw realistically, Arden says. Picasso was a prodigy, who could draw everything from birds to busts with amazing accuracy at a young age. In fact, the artist famously said he easily learned to draw like Raphael when he was young, but it took him a lifetime to learn to draw like a child.

The most amazing thing about the drawings collected for this study is that they represent such a range of both ability and style, Arden says. "I had a fantastic time looking through them."

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Cardiologist Speaks From The Heart About America's Medical System

Tue, 08/19/2014 - 3:01pm
Cardiologist Speaks From The Heart About America's Medical System August 19, 2014 3:01 PM ET Listen to the Story 27 min 27 sec   Additional Information: Doctored

The Disillusionment of an American Physician

by Sandeep Jauhar

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As a young doctor working at a teaching hospital, Sandeep Jauhar was having trouble making ends meet. So, like other academic physicians, he took a job moonlighting at a private practice, the offices of a cardiologist. He noticed that the offices were quick to order expensive tests for their patients — even when they seemed unnecessary.

It was "made very clear from the beginning" that seeing patients alone was not financially rewarding for the business, he says.

"Spending 20-30 minutes with a patient might be reimbursed $80, $90, but sending the patient for a nuclear stress test was much more profitable," Jauhar tells Fresh Air's Terry Gross. "A nuclear stress test, at the time when I started working, was reimbursed roughly $800 to $900."

Jauhar was supervising the tests that had been ordered by a physician — and some physician assistants.

"So even though I wasn't ordering the tests, I was in the office while these tests were being performed — and I felt really dirty about it," Jauhar says.

Jauhar's new memoir, Doctored: The Disillusionment of an American Physician, is about how doctors are growing increasingly discontent with their profession. And they're facing more pressures: As the number of patients they're expected to see increases, so does the amount of paperwork. While some doctors who perform a lot of procedures may be paid too much, he writes, many doctors, such as primary care physicians, aren't paid enough.

And, he adds, "the growing discontent has serious consequences for patients."

Jauhar, creator and director of the Heart Failure Program at Long Island Jewish Medical Center, talks about not only unnecessary testing but also uncoordinated care by multiple specialists.

"American medicine is the best in the world when it comes to providing high-tech care," he says. "If you have an esoteric disease, you want to be in the United States. God forbid you have Ebola, our academic medical centers are second to none. But if you have run-of-the-mill chronic diseases like congestive heart failure or diabetes, the system is not designed to find you the best possible care. And that's what has to change."

Interview Highlights

On common complaints doctors have

One of the issues with medicine today is that it's just become so complicated. More and more people are surviving with chronic illnesses, so you have folks in every patient panel who have multiple chronic diseases. And they come to the doctor and they have a whole host of issues that have to be dealt with. And [that doesn't even] mention preventative care, which has become a huge time problem for a lot of primary care physicians.

Dr. Sandeep Jauhar is the creator and director of the Heart Failure Program at Long Island Jewish Medical Center, a teaching hospital. He's the author of an earlier memoir called Intern and contributes to The New York Times.

Janine Sandy/FSG

There's no denying that reimbursement[s] for office visits and for procedures have been drastically cut in the last two or three decades. And that was really an attempt to control health costs. And it seemed to make sense, but it resulted in doctors basically running on a treadmill seeing patients every eight to 10 minutes. So the lack of time to spend with any one patient is a big factor.

On "defensive medicine"

There's no question that there's a lot of unnecessary testing in American medicine today and the reasons for it are manyfold. Part of it is ... a lack of time. You have a patient come into your office and you have eight minutes with them and they have lower back pain and you don't want to miss something because one of the major causes of dissatisfaction among doctors today is malpractice liability; there's that fear.

A lot of doctors are practicing defensive medicine. There have been various estimates that defensive medicine costs up to $100 billion a year out of the roughly $3 trillion we spend on health care, so it's a huge, huge waste. ... It takes time to evaluate the patient, get a good history, examine the patient, and it's just so much easier to order a test— especially when the financial incentives of the system are to reward for more and more testing.

On uncoordinated care by multiple specialists

Today if you go to a hospital, it's rare that you won't have multiple specialists on your case. And I'm a specialist [in cardiology], and when I'm called to see someone with a nonspecific symptom like shortness of breath, which could be a whole host of diagnoses, I'm apt to view the problem through my own expertise. And that's true of rheumatologists and hematologists and so on.

One patient who came in with shortness of breath — his primary care physician called 15 specialists onto the case. ... He underwent 12 procedures in the hospital, and when he was sent home he had follow-up visits with seven different specialists. ... We actually never figured it out. This is so common. ...

When you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician. But when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise and these recommendations are frequently not coordinated and so you get a whole host of recommendations and suggestions for care. But no one is really talking and trying to coordinate this care, so it makes it very difficult for the physician who is trying to manage the whole patient and treat the whole patient and getting these multiple inputs to know what to do.

On treating patients near the end of life

“ I've seen patients have their last days prolonged in misery because of the actions of their well-meaning family members who don't want to let go, and sometimes even by physicians and — unfortunately, at least in one case — by me.

I've seen patients have their last days prolonged in misery because of the actions of their well-meaning family members who don't want to let go, and sometimes even by physicians and — unfortunately, at least in one case — by me.

I had a very dear patient of mine who had severe congestive heart failure and had a very leaky heart valve and she became one of my favorite patients. ... She was in her late 80s and one day I was told she was in the intensive care unit and it turns out she had gone to the emergency room with shortness of breath. ... She had gone into kidney failure because of the poor blood flow to her kidneys.

And I took the attending physician aside and said, "So are we going to provide dialysis?" And he said, "No." And I said, "Why not?" And he said, "Because I don't think it's appropriate, it's futile. She's at the end of her life." I couldn't see that because she had been so vibrant despite all the medical problems.

In the end I argued for being aggressive and he wouldn't budge and so I actually went to the chairman of the department and I transferred the patient to my care in the cardiac unit. ... And there I went through a lot of ... very aggressive interventions to try to save her. It wasn't because of financial incentives — I'm on salary — it was because I just didn't want to lose her. ...

About eight or nine days later she died. There's no question that I deceived myself — that I thought somehow I could keep death at bay and that my judgment was clouded by my love for this patient and not wanting to let her go. ...

Now I'm much more circumspect about how I handle these cases. And in recent years, I've created much more of a relationship with the palliative care team and the hospice team in my hospital. And I think it's been much better for my terminally ill patients.

Read an excerpt of Doctored

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How To Make Sense Of Health Insurance Alphabet Soup

Tue, 08/19/2014 - 12:34pm
How To Make Sense Of Health Insurance Alphabet Soup August 19, 201412:34 PM ET

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There must be an HMO in here somewhere.

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What's in a name? When it comes to health plans sold on the individual market, these days it's often less than people think.

The lines that distinguish HMOs, PPOs, EPOs and POS plans from one another have blurred, making it hard to know what you're buying by name alone, assuming you're one of the few people who know what an EPO is in the first place.

Ideally, the plan name provides a shorthand way to determine the sort of access members have to hospitals and doctors, including cost-sharing for such treatment. But since there are no industry-wide definitions of plan types and state standards vary, individual insurers often have leeway to market similar plans under different names.

"Now, there's a lot of gray out there," says Sabrina Corlette, project director at Georgetown University's Center on Health Insurance Reforms.

In general:

Health maintenance organizations cover only care provided by doctors and hospitals inside the HMO's network. HMOs often require people to get a referral from their primary care physician in order to see a specialist.

Preferred provider organizations, or PPOs, cover care provided both inside and outside the plan's network. Patients typically pay a higher percentage of the cost for out-of-network care.

Exclusive provider organizations are a lot like HMOs: They generally don't cover care outside the plan's provider network. People in EPOs, however, may not need a referral to see a specialist.

Point of Service, or POS, plans vary, but they're often a sort of hybrid HMO/PPO. Patients may need a referral to see a specialist, but they may also have coverage for out-of-network care, though with higher cost sharing.

Although insurers identify plans by type in the coverage summaries they're required to provide under the health law, one PPO may offer very different out-of-network coverage than another.

"You have PPOs with really high cost sharing for out-of-network services, which from a consumer perspective seem a lot like HMOs," says Corlette. Some plans labeled as PPOs don't offer out-of-network services at all. On the other hand, some HMOs have an out-of-network option that makes them seem similar to PPOs.

Higher premiums didn't necessarily correlate with better out-of-network coverage, says Caroline Pearson, vice president at Avalere Health, a research and consulting firm.

Since you can't rely on plan type to provide clear guidance on out-of-network coverage, there are three basic questions to investigate when evaluating a plan, says Pearson:

  1. Is there out-of-network coverage?
  2. Does that out-of-network spending accrue toward your out-of-pocket maximum? Legally it doesn't have to, but some plans include it.
  3. Do you need a primary care physician gatekeeper?

That's only the beginning. Once you figure out whether a plan covers out-of-network care, it can be difficult to find out whether your doctor is even in that plan. You can check with you doctor's office, but sometimes they don't know.

You can also look at provider directories to see who is and isn't in a plan's network, however, that information frequently proved inadequate or inaccurate during the last open enrollment period. But understanding the alphabet soup of plan types is an important first step.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
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Pittsburgh Health Care Giants Take Fight To Each Other's Turf

Tue, 08/19/2014 - 3:38am
Pittsburgh Health Care Giants Take Fight To Each Other's Turf August 19, 2014 3:38 AM ET Listen to the Story 5 min 47 sec  

The headquarters for University of Pittsburgh Medical Center and Highmark Blue Cross/Blue Shield dominate the Pittsburgh skyline much as they organizations have dominated health care in the region for decades.

Jeff Brady/NPR

Pittsburgh's dominant health insurance company and its largest healthcare provider are, essentially, getting a divorce.

For decades, Highmark Blue Cross/Blue Shield and University of Pittsburgh Medical Center worked together. But as the line between insurance companies and health care providers across the country blurs, these longtime allies are venturing into each other's business and becoming competitors.

In the process, patients can get caught in the middle. Day-care worker Gail Jameson has Highmark insurance and she's been going to the same UPMC medical office for more than 20 years. "I could go in and just stop in if I needed to because it's close to my work," Jameson says. "I go past it every day."

She's about five years from retirement and was disappointed to learn her Highmark policy will no longer include UPMC providers. She has to find all new doctors through another health system that is unfamiliar to her.

The road to divorce began when insurer Highmark got into the hospital business. It bought the struggling West Penn Allegheny Health System, which was UPMC's main competitor.

"Highmark stepped in in order to ensure that there was competition in the marketplace and there would continue to be consumer choice," says Highmark President and CEO David Holmberg. In a town where UPMC controls more than 60 percent of the market, Holmberg says there needs to be healthier competition among providers.

Additional Information: YouTube

Highmark's TV ad from 2013 encourages UPMC to sign a long-term service contract.

There's another reason an insurance company would decide to become a healthcare provider: the Affordable Care Act. It tells insurance companies what basic services to offer; who they must insure and even what percent of premiums can go to administrative expenses and profits. That takes away a lot of what insurance companies used to do, so they're looking for new reasons to exist.

"Insurers are trying to demonstrate that they bring value to the table and are doing more than just brokering a benefit ... and doing more than paying bills," says Gail Wilensky, senior fellow at Project HOPE.

Wilensky says some insurance companies are responding by building more efficient networks of high-quality providers. Highmark went a step beyond that and became a provider of health care itself.

UPMC responded by expanding its existing insurance business and refusing to sign a new long-term contract with Highmark, saying it could not both compete and work with Highmark.

Additional Information: YouTube

UPMC's TV ad from 2013 explains why it can't sign a new long-term service contract with Highmark.

"We couldn't have a contract with them," says UPMC President and CEO Jeffrey Romoff, "Because they [Highmark] have the burden of keeping their provider side alive. So, for every one of their insurance subscribers they will want to steer them to go to their own providers."

The divorce of Highmark from UPMC is all but final now. An agreement between the two companies will expire on January 1, 2015. The state of Pennsylvania negotiated a transition agreement. It does things like ensure Highmark subscribers already in certain kinds of treatment at UPMC can continue receiving care.

Now the Pittsburgh health care landscape looks very different. "It went from one of the least competitive environments that you can imagine — a dominant insurer and a dominant health system joined at the hips with a long term contract," says Romoff, "To one without a long-term contract with, now, five choices."

In addition to the two new competitors, UPMC invited three large insurance companies into the Pittsburgh market: Cigna, Aetna and United Healthcare. "Competition is good," says Romoff, "It keeps us all on top of our game. It gives us incentive to not be fat and sloppy."

With competition come the marketing campaigns. UPMC is banking on its good reputation. Highmark will appeal to those concerned about price. "For some people their monthly premium and the cost of their health care may be more important than having access to everything," Holmberg says.

In Pittsburgh now people have a lot more choices — and decisions — to make when it comes to their health care. That's supposed to be a good thing. But for Jameson, who was satisfied with her Highmark-UPMC combination, the extra work is a pain. "I just don't like change. I shouldn't have to change," says Jameson.

It's not just patients dealing with change. Employers who buy insurance for their workers face difficult decisions too. With two insurance/provider networks that don't allow access to each other, Pittsburgh employers can be put in the position of, effectively, choosing which doctors treat their workers.

"Employers want to provide benefits that allow them to be competitive and attract and retain a productive work force," says Jessica Brooks, executive director of the Pittsburgh Business Group on Health. "They don't want to be in the business of making personal life decisions around who their employees can see and who they can't see," she says.

The Affordable Care Act aims to increase the quality and affordability of health care. Creating competitive marketplaces is part of the plan. It will be a few years before people in Pittsburgh and around the country know whether the changes happening now make those goals reality.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
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Mental Health Cops Help Reweave Social Safety Net In San Antonio

Tue, 08/19/2014 - 3:34am
Mental Health Cops Help Reweave Social Safety Net In San Antonio August 19, 2014 3:34 AM ET

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Listen to the Story 7 min 1 sec  

Officers Ned Bandoske (left) and Ernest Stevens are part of San Antonio's mental health squad — a six-person unit that answers the frequent emergency calls where mental illness may play a role.

Jenny Gold/Kaiser Health News

It's almost 4 p.m., and police officers Ernest Stevens and Ned Bandoske have been driving around town in their unmarked black SUV since early this morning. The officers are part of San Antonio's mental health squad — a six-person unit that answers the frequent emergency calls where mental illness may be an issue.

The officers spot a call for help on their laptop from a group home across town.

“ We had absolutely no training 20 years ago in the police academy on how to deal with mental health disturbances.

"A male individual put a blanket on fire this morning," Stevens reads from the blotter. "He's arguing ... and is a danger to himself and others. He's off his medications."

A few minutes later, the SUV pulls up in front of the group home. A thin 24-year-old sits on a wooden bench out back, wearing a black hoodie.

Additional Information: Lessons From San Antonio

Jail is an expensive, ineffective way to treat the mental health problems that underlie some low-level crime, police in San Antonio say. In Part Two of her Morning Edition series, reporter Jenny Gold takes us inside an alternative treatment program.

Listen to the story

"You're Mason?" asks Bandoske. "What happened to your blanket?" Eight years ago, the next stop for someone like Mason would have been a hospital emergency room or jail. (Because of his condition, NPR is not using Mason's last name.) But the Bexar County jail, in San Antonio, was so overcrowded — largely with people with serious mental illnesses — that the state was getting ready to levy fines.

This sort of situation is not unusual: Across the country, jails hold 10 times as many people with serious mental illness as state hospitals do, according to a recent report from the Treatment Advocacy Center, a national nonprofit that lobbies for better treatment options for people with mental illness.

To deal with the problem, San Antonio and Bexar County have transformed their mental health system into a program considered a model for the rest of the nation. Today, the jails aren't full, and the city and county have saved $50 million over the past five years.

The effort has focused on an idea called "smart justice" — basically, diverting people with serious mental illness out of jail and into treatment instead.

San Antonio's new approach starts with the kind of interaction Bandoske and Stevens are having with Mason. The troubled young man is hunched over, and his eyes dart back and forth between the two officers. He mumbles answers to the officers' questions, sometimes stopping to stare at a spot in the distance. For outsiders, it's hard to know what's going on, but the officers say they can tell Mason is hallucinating. Bandoske kneels in front of him, trying to maintain eye contact and get Mason's attention.

Officer Stevens responds to an emergency mental health call in regards to Mason, 24, at a group home in San Antonio.

Jenny Gold/Kaiser Health News

"Are you hearing some voices right now?" Bandoske asks. "You are, aren't you? What are the voices telling you?" Mason is silent, but Bandoske persists. "Hey Mason, you're seeing something that I'm not seeing. What is it?"

These officers seem more like social workers than law enforcers. Stevens says that's a huge change from his early days on the police force.

"We had absolutely no training 20 years ago in the police academy on how to deal with mental health disturbances," recalls Stevens.

Back then, the police were repeatedly arresting the same people; many not only had a serious mental illness but were also addicted to drugs or alcohol, and were often homeless. And whether they went to the jail or the ER, it was expensive for everyone — the jails, the hospitals and the police department that had to pay for overtime while cops waited at the hospital.

San Antonio's response was to require all officers to take a 40-hour course called Crisis Intervention Training, to learn how to handle mental health crises.

But even with strong programs, there's only so much that training alone can do; there's still the problem of where to take patients like Mason.

Around the Nation What Is The Role Of Jails In Treating The Mentally Ill?

San Antonio tackled that problem, too.

People who commit a felony still go to jail, regardless of their mental status. And those who need extensive medical care are taken to the hospital.

Shots - Health News A Son's Death Reveals Chasms In Emergency Mental Health Care

But for patients like Mason, San Antonio built another option: the Restoration Center, a separate facility with a full array of mental and physical health services.

The center was the brainchild of Leon Evans, director of San Antonio's mental health department.

When he took over the department 14 years ago, Evans says not one of the county or city agencies and nonprofits that deal with mental illness was talking to another. The jails, hospitals, courts, police and mental health department all worked in separate silos.

"People who fund these services only look at their little, small piece of the pie and whether there is a return on investment," says Evans.

So, with the help of a county judge, Evans worked to get the funders together to talk about the money they were all spending on mental health. Once they stopped looking at mental health as an isolated expense, the groups realized they were spending enormous sums of money and offering poor care. Pooling their resources instead, they found, could offer significant savings.

Everyone contributed funding to create the Restoration Center. It offers a 48-hour inpatient psychiatric unit; outpatient services for psychiatric and primary care; centers for drug or alcohol detox; a 90-day recovery program for substance abuse; plus housing for people with mental illnesses, and even job training.

More than 18,000 people pass through the Restoration Center each year, and officials say the coordinated approach has saved the city more than $10 million annually.

When Mason arrives at the center, nurse Catherine Riojas checks him in immediately. She gives Mason a physical and helps him get settled in an inpatient psychiatric unit that keeps patients for 48 hours.

And then, about 15 minutes after the police officers walked through the door of the center, they're heading out again, ready to get back on the street.

"OK, Mason, good luck," Stevens calls to the young man, and waves. "OK, buddy? Hope you feel better."

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

Medicare Patients Often See Nurses Instead Of Doctors For Skin Problems

Mon, 08/18/2014 - 1:22pm
Medicare Patients Often See Nurses Instead Of Doctors For Skin Problems August 18, 2014 1:22 PM ET

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Nurse practitioners and physician assistants are taking on more and more responsibility for primary care these days. And an analysis of Medicare data finds many of these health care providers are performing procedures you might not have expected.

More than half of the 4 million procedures that office-based nurse practitioners and physician assistants independently billed Medicare for in 2012 were dermatological surgeries.

That's not surprising to Ken Miller, president of the American Association of Nurse Practitioners. He said older patients, such as those on Medicare, often have skin problems, such as "boils, skin tags and warts."

The study, published in JAMA Dermatology, focused on procedures for which these providers billed more than 5,000 times a year.

"I think that's where you're going to see the majority of procedures that are occurring both in primary care and in some of the other specialties like geriatric clinics," he said.

The study's lead author, Dr. Brett Coldiron, a dermatologist and clinical assistant professor at the University of Cincinnati, said while the "intent for midlevel nurse practitioners was to give primary care," the level of surgical billing implies that they may be doing more.

He said those midlevel providers — PAs and NPs — "are doing invasive procedures and surgery. I'm not sure they were trained to do that."

But practitioners who perform specialized procedures often have received additional training, according to Miller. "If they find something that is out of their scope, they will refer," he said. "It's the same thing that primary care physicians do."

The analysis found that a majority of procedures billed by nurse practitioners and physician assistants relate to dermatology, a trend Coldiron said could stem from the frequency of dermatological procedures being performed in offices rather than hospitals, along with the higher rate of skin cancer among the older patients Medicare covers.

The nurse practitioners performing specialized dermatological procedures often have received extra training, Miller said, and they often attend "the same symposiums and conferences dermatologists actually attend."

"If they're in the same subspecialty of dermatology, they may be doing these procedures because that's how they've been trained," he said.

He thinks no more than 3 or 4 percent of nurse practitioners actually end up specializing in a specific area of care. But all nurse practitioners will often see patients with dermatological conditions, and the treatments they require are usually not "extraordinary," he said.

Coldiron said while the midlevel providers may have received extra training within a relevant specialty, many likely lack the expertise of doctors who have done a residency within the field. "If nurses are going to practice surgery, that's not [nursing] — that's medicine," he said.

Nurse practitioners and physician assistants have been suggested as a potential solution to shortages of primary care physicians.

The study cautioned that a boost in midlevel providers performing surgical procedures could lead to more cases of malpractice, a concern Coldiron said suggested a need for greater regulatory oversight of nurse practitioners and physician assistants.

But that kind of argument is a "red herring," Miller argued.

"There have been no real studies out there that show nurse practitioners are less safe than physicians," he said. "What we're all trying to do," he added, is "trying to provide the best care and the best quality of care."

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.
Categories: NPR Blogs

The Power Of The Peer Group In Preventing Campus Rape

Mon, 08/18/2014 - 3:51am
The Power Of The Peer Group In Preventing Campus Rape August 18, 2014 3:51 AM ET Listen to the Story 8 min 14 sec   Maria Fabrizio for NPR

Many forces can drive a male college student to commit sexual assault. But one of the most important may be the company he keeps.

A number of studies, on college campuses and elsewhere, have shown that having friends who support violence against women is a big risk factor for committing sexual assault. Now prevention efforts are exploring the idea that having male friends who object to violence against women can be a powerful antidote to rape on college campuses.

"One of the things that matters most to boys and emerging adult men is the opinion of other men," says John Foubert, a researcher at Oklahoma State University who studies rape prevention among young men.

One of the most well-known studies on perpetrators of campus sexual assault is psychologist David Lisak's 2002 "undetected rapists" study. Because few campus rapes are ever reported, much less prosecuted, Lisak looked for sex offenders hiding in plain sight at University of Massachusetts in Boston.

“ There is a small percentage of college students who are sex offenders. They are behaving like sex offenders. They are sex offenders.

He surveyed about 1,800 men, asking them a wide range of questions about their sexual experiences. To learn about sexual assault, he asked things like, "Have you ever had sex with an adult when they didn't want to because you used physical force?" When the results came back, he was stunned.

All told, 120 men in the sample, or about 6 percent of the total, had raped women they knew. Two-thirds of those men were serial rapists, who had done this, on average, six times. Many of the serial rapists began offending before college, back in high school.

Other studies at colleges and in the military have since found similar numbers — usually somewhere around 10 percent of men admitting to either an attempted rape or a rape, with a significant proportion of them reporting a history of repeated offenses.

"I was forced, really, to accept that these are college students, but there is this small percentage of college students who are sex offenders," says Lisak. "They are behaving like sex offenders. They are sex offenders."

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Together, the 120 men in Lisak's study were responsible for 439 rapes. None was ever reported.

But Lisak had no problem getting details about how the men carefully planned and executed their assaults. They'd often ask a girl to come to a party, saying it was invite-only, a big deal to a nervous freshman. Then they'd get her drunk to the point of incapacitation so they could have sex with her.

In an excerpt from one of Lisak's interview transcripts, a college student using the pseudonym Frank talks about how his friends would help him prep for an assault:

“ This idea that getting somebody intoxicated so you can have sex with them is an idea we just simply have to confront and erode.

"We always had some kind of punch, you know, like our own home brew. We'd make it with a real sweet juice, and just pour in all kinds of alcohol. It was really powerful stuff. The girls wouldn't know what hit them."

Alcohol was the weapon of choice for these men, who typically saw themselves as college guys hooking up. They didn't think what they had done was a crime.

"Most of these men have an image or a myth about rape, that it's some guy in a ski mask wielding a knife," says Lisak. "They don't wear ski masks, they don't wield knives, so they don't see themselves as rapists."

In fact, they'd brag about what they had done afterwards to their friends. That implied endorsement from male friends — or at the very least, a lack of vocal objection — is a powerful force, perpetuating the idea that what these guys are doing is normal rather than criminal.

But in a group of guy friends, Oklahoma State's Foubert says, the opinions that can end up influencing behavior are often just what a guy thinks his friends think.

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"Let's say you have a peer group of 10 guys," says Foubert. "One or two are constantly talking about, 'Oh, I bagged this b- - -h.' Many of the men listening to that are uncomfortable, but they think that the other men support it through their silence."

What if that silence could be broken before college — as early as high school?

At a few high schools in Sioux City, Iowa, students are starting to find out what that might look like.

MVP, or Mentors in Violence Prevention, matches upperclassmen with groups of incoming freshmen. Throughout the school year, the older kids facilitate discussions about relationships, drinking, sexual assault and rape.

Xavier Scarlett, a rising senior and captain of the football, basketball and track teams, says he tries to get inside the heads of the freshmen guys he mentors. They talk through various scenarios. What does it mean to hook up with a drunk girl when you're sober? Would you be letting down your guy friends if you didn't hook up in that situation?

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And they spend a lot of time on that scenario Lisak heard about over and over in his U-Mass Boston study. You're at a big party. You see a guy you know with an extremely drunk girl, and he's trying to leave with her.

Scarlett says he talks through all the options with the freshmen in his group. "Do I let them just leave? Or do I grab him, or do I grab her? Or do I get some friends? If I say something, then will my friend judge me?"

These conversations are tough, often awkward, in high school. A lot of the mentors still haven't confronted this kind of situation in real life by the time they graduate. But once they get to college, says Iowa State University junior Tucker Carrell, a former MVP mentor, the scenarios come to life.

Tucker says that he's not afraid to confront his Delta Tau Delta fraternity brothers when they talk about women in a way that makes him uncomfortable. He'll sit down with them, sometimes even bringing a woman they've hit on into the conversation.

The day we talked, Tucker said he'd used his MVP training to intervene in a situation just the night before.

This was at a going-away party at a bar in Ames, Iowa. Tucker noticed that a friend's female cousin was pretty drunk. She was over by the jukebox with two guys who weren't part of the party. They were strangers. Tucker says he was paying attention to her body language, and something didn't look right. She looked almost cornered.

So Tucker grabbed a buddy, and they went over to the jukebox together.

"We were like, 'Hey, let's pick a song.' So we picked a song. And then we were like, 'Do you want to go to the table and see your cousin?' "

They steered her back toward their group of friends.

And that was it. The night went on as if nothing had happened.

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Lisak says by the time 18-year-olds leave for college, they need to be hearing this kind of challenge from their guy friends.

"This idea that getting somebody intoxicated, plastered, so that you can have sex with them is an idea we just simply are going to have to confront and erode," he says. "Just like we have eroded the idea that it's fine to get drunk and get in your car."

There are only a few dozen high schools around the country that offer the MVP program. It's been used in high schools around Sioux City, Iowa, for over a decade now. Surveys of participating students suggest their attitudes about sexual assault, and intervening in dangerous situations, shift after they go through the program, but researchers have yet to evaluate how effective it is in reducing incidents of sexual violence.

John Foubert, the psychologist in Oklahoma, says it's important to remember that 90 percent of men have never committed a rape. The key is opening their eyes to what's going on with the other 10 percent, so they can see it and intervene.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

When Patients Read What Their Doctors Write

Sun, 08/17/2014 - 5:29am
When Patients Read What Their Doctors Write August 17, 2014 5:29 AM ET Katherine Streeter for NPR

The woman was sitting on a gurney in the emergency room, and I was facing her, typing. I had just written about her abdominal pain when she posed a question I'd never been asked before: "May I take a look at what you're writing?"

At the time, I was a fourth-year medical resident in Boston. In our ER, doctors routinely typed visit notes, placed orders and checked past records while we were in patients' rooms. To maintain at least some eye contact, we faced our patients, with the computer between us.

But there was no reason why we couldn't be on the same side of the computer screen. I sat down next to her and showed her what I was typing. She began pointing out changes. She'd said that her pain had started three weeks ago, not last week. Her chart mentioned alcohol abuse in the past; she admitted that she was under a lot of stress and had returned to heavy drinking a couple of months ago.

As we talked, her diagnosis — inflammation of the pancreas from alcohol use — became clear, and I wondered why I'd never shown patients their records before. In medical school, we learn that medical records exist so that doctors can communicate with other doctors. No one told us about the benefits they could bring when shared with patients.

In fact, before the Health Insurance Portability and Accountability Act, a federal law enacted in 1996, patients generally had to sue to see their records. HIPAA, as that mouthful is abbreviated, affirmed that patients have a right to their medical information. But the process for obtaining records was often so cumbersome that few patients tried to access them.

In 2010, Tom Delbanco, an internist, and Jan Walker, a nurse and researcher, started an experiment called OpenNotes that let patients read what their primary care providers write about them. They hypothesized that giving patients access to notes would allow them to become more engaged in their care.

Many doctors resisted the idea. Wouldn't open medical records inhibit what they wrote about sensitive issues, such as substance abuse? What if patients misunderstood the notes? Would that lead to more lawsuits? And what would patients do with all the information anyway?

After the first year, the results were striking: 80 percent of patients who saw their records reported better understanding of their medical condition and said they were in better control of their health. Two-thirds reported that they were better at sticking with their prescriptions. Ninety-nine percent of the patients wanted OpenNotes to continue, and no doctor withdrew from the pilot. Instead, they shared anecdotes like mine. When patients see their records, there's more trust and more accuracy.

That day in the Boston ER was a turning point for me. Since I started sharing notes with my patients, they have made dozens of valuable corrections and changes, such as adding medication allergies and telling me when a previous medical problem has been resolved. We come up with treatment plans together. And when patients leave, they receive a copy of my detailed instructions. The medical record becomes a collaborative tool for patients, not just a record of what we doctors do to patients.

The OpenNotes experiment has become something of a movement, spreading to hospitals, health systems and doctors' offices across the country. The Mayo Clinic, Geisinger Health System and Veterans Affairs are among the adopters so far. (The OpenNotes project has received funding from the Robert Wood Johnson Foundation, which also provides financial support to NPR.)

But there are new controversies arising. Should patients receiving mental health services obtain full access to therapy records, or should there be limits to open records? What happens if patients want to share their records on social media? Will such "crowdsourcing" harm the doctor-patient relationship? What if patients want to develop their own record and videotape their medical encounter? Are doctors obligated to comply?

Delbanco tells me that he considers OpenNotes to be "like a new medication." Just like any new treatment, it will come with unexpected side effects. In the meantime, patients and doctors don't need to wait for the formal OpenNotes program to come to town. Patients can ask their doctors directly to look at their records. Doctors can try sharing them with patients, in real time, as I do now. It's changed my practice, and fundamentally transformed my understanding of whom the medical record ultimately belongs to: the patient.

Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. She is the author of "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Care," and founder of Who's My Doctor, a project to encourage transparency in medicine. On Twitter: DrLeanaWen

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs

When Patients Read What Their Doctors Write

Sun, 08/17/2014 - 5:29am
When Patients Read What Their Doctors Write August 17, 2014 5:29 AM ET Listen to the Story 3 min 54 sec   Katherine Streeter for NPR

The woman was sitting on a gurney in the emergency room, and I was facing her, typing. I had just written about her abdominal pain when she posed a question I'd never been asked before: "May I take a look at what you're writing?"

At the time, I was a fourth-year medical resident in Boston. In our ER, doctors routinely typed visit notes, placed orders and checked past records while we were in patients' rooms. To maintain at least some eye contact, we faced our patients, with the computer between us.

But there was no reason why we couldn't be on the same side of the computer screen. I sat down next to her and showed her what I was typing. She began pointing out changes. She'd said that her pain had started three weeks ago, not last week. Her chart mentioned alcohol abuse in the past; she admitted that she was under a lot of stress and had returned to heavy drinking a couple of months ago.

As we talked, her diagnosis — inflammation of the pancreas from alcohol use — became clear, and I wondered why I'd never shown patients their records before. In medical school, we learn that medical records exist so that doctors can communicate with other doctors. No one told us about the benefits they could bring when shared with patients.

In fact, before the Health Insurance Portability and Accountability Act, a federal law enacted in 1996, patients generally had to sue to see their records. HIPAA, as that mouthful is abbreviated, affirmed that patients have a right to their medical information. But the process for obtaining records was often so cumbersome that few patients tried to access them.

In 2010, Tom Delbanco, an internist, and Jan Walker, a nurse and researcher, started an experiment called OpenNotes that let patients read what their primary care providers write about them. They hypothesized that giving patients access to notes would allow them to become more engaged in their care.

Many doctors resisted the idea. Wouldn't open medical records inhibit what they wrote about sensitive issues, such as substance abuse? What if patients misunderstood the notes? Would that lead to more lawsuits? And what would patients do with all the information anyway?

After the first year, the results were striking: 80 percent of patients who saw their records reported better understanding of their medical condition and said they were in better control of their health. Two-thirds reported that they were better at sticking with their prescriptions. Ninety-nine percent of the patients wanted OpenNotes to continue, and no doctor withdrew from the pilot. Instead, they shared anecdotes like mine. When patients see their records, there's more trust and more accuracy.

That day in the Boston ER was a turning point for me. Since I started sharing notes with my patients, they have made dozens of valuable corrections and changes, such as adding medication allergies and telling me when a previous medical problem has been resolved. We come up with treatment plans together. And when patients leave, they receive a copy of my detailed instructions. The medical record becomes a collaborative tool for patients, not just a record of what we doctors do to patients.

The OpenNotes experiment has become something of a movement, spreading to hospitals, health systems and doctors' offices across the country. The Mayo Clinic, Geisinger Health System and Veterans Affairs are among the adopters so far. (The OpenNotes project has received funding from the Robert Wood Johnson Foundation, which also provides financial support to NPR.)

But there are new controversies arising. Should patients receiving mental health services obtain full access to therapy records, or should there be limits to open records? What happens if patients want to share their records on social media? Will such "crowdsourcing" harm the doctor-patient relationship? What if patients want to develop their own record and videotape their medical encounter? Are doctors obligated to comply?

Delbanco tells me that he considers OpenNotes to be "like a new medication." Just like any new treatment, it will come with unexpected side effects. In the meantime, patients and doctors don't need to wait for the formal OpenNotes program to come to town. Patients can ask their doctors directly to look at their records. Doctors can try sharing them with patients, in real time, as I do now. It's changed my practice, and fundamentally transformed my understanding of whom the medical record ultimately belongs to: the patient.

Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. She is the author of "When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Care," and founder of Who's My Doctor, a project to encourage transparency in medicine. On Twitter: DrLeanaWen

Copyright 2014 NPR. To see more, visit http://www.npr.org/.
Categories: NPR Blogs