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More Evidence That Music Eases Pain, Anxiety After Surgery

Thu, 08/13/2015 - 3:52am
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We all get by better with a little help from our tunes.


Hospitals have a free and powerful tool that they could use more often to help reduce the pain that surgery patients experience: music.

Scores of studies over the years have looked at the power of music to ease this kind of pain; an analysis published Wednesday in The Lancet that pulls all those findings together builds a strong case.

When researchers in London started combing the medical literature for studies about music's soothing power, they found hundreds of small studies suggesting some benefit. The idea goes back to the days of Florence Nightingale, and music was used to ease surgical pain as early as 1914. (My colleague Patricia Neighmond reported on one of these studies just a few months ago.)

Dr. Catherine Meads at Brunel University focused her attention on 73 rigorous, randomized clinical trials about the role of music among surgery patients.

Shots - Health News To Ease Pain, Reach For Your Playlist

"As the studies themselves were small, they really didn't find all that much," Meads says. "But once we put them all together, we had much more power to find whether music worked or not."

She and her colleagues now report that, yes indeed, surgery patients who listened to music, either before, during or after surgery, were better off — in terms of reduced pain, less anxiety and more patient satisfaction.

Maybe most notably, patients listening to music used significantly less pain medication. Meads says, on average, music helped the patients drop two notches on the 10-point pain scale. That's the same relief typically reported with a dose of painkilling medicine.

Some hospitals do encourage patients to listen to music, but Meads says the practice should be more widely adopted, given the evidence of its effectiveness.

In many of these studies, she notes, the patients chose the music they listened to. "It could be anything from Spanish guitar to Chinese classical music."

And, unlike drugs, she says, music "doesn't seem to have any side effects."

Well, there may be one side effect. A few studies (such as this one) have noted that operating rooms are very noisy places, and music played in the room can make it harder for the surgical staff to hear what's going on. Doctors sometimes have to repeat their commands, creating opportunities for misunderstanding or error.

"If surgeons are listening to music, it can be a bit of a distraction," Meads says. "So it may be it's not such a wise idea to have it during the operation itself."

That was not, however, something Meads analyzed in her study of music and medicine. Many surgeons listen to music during a procedure; discouraging that habit could be a tough sell.

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'Defunding' Planned Parenthood Is Easier Promised Than Done

Wed, 08/12/2015 - 4:22pm

The undercover videos purporting to show officials of Planned Parenthood bargaining over the sale of fetal tissue have made the promise to defund the organization one of the most popular refrains of Republicans running for president.

It's actually a much easier promise to make than to fulfill. But that's not slowing down the candidates.

"There is no reason in the world to have Planned Parenthood other than abortion," Sen. Rand Paul, R-Ky., has said. "We should stop all funding for Planned Parenthood."

Carly Fiorina, former CEO of Hewlett-Packard, echoed many of her fellow candidates by vowing that "we should shut down the government" rather than allow further funding of the organization. Many Republicans — though far from all — have been advocating for a fight this fall over the funding of Planned Parenthood, when it comes time to keep the federal government operating.

It's All Politics Fact Check: How Does Planned Parenthood Spend That Government Money?

Candidates that are or were governors have gone even further — saying they have already eliminated funding for the organization in their states.

"I defunded Planned Parenthood more than four years ago, long before any of these videos came out," said Gov. Scott Walker, R-Wis., in the recent Fox News debate.

"As governor of Florida I defunded Planned Parenthood," said Jeb Bush at the same debate; he served as governor from 1999 to 2007. "I created a culture of life in our state."

But did they really? That depends on how you define the word "defund."

Both Walker and Bush (along with Gov. Chris Christie in New Jersey and former Gov. Rick Perry in Texas) did reduce state funding for the organization, mostly by cutting off long-standing grants earmarked for family planning programs. (With few exceptions, funds for family planning may not be used for abortion.)

But while the cuts forced the closure of some Planned Parenthood clinics, all four states still have a number of Planned Parenthood clinics operating within their borders — in some cases still collecting state funds as well as federal money.

That's largely because of a requirement in the Medicaid program, from which Planned Parenthood gets most of its government funding. Medicaid funding is shared between the federal government and the states, although the federal government pays 90 percent of the cost of family planning services.

"There's a requirement in the [Medicaid] statute for free choice of providers," said Cindy Mann, who recently stepped down as head of the federal Medicaid program and is now with the law firm Manatt, Phelps & Phillips. "The only way you can limit the provider is to establish that they're not, in fact, qualified as a Medicaid provider."

Federal courts have agreed. In 2011, when Planned Parenthood was also in the headlines, Indiana passed a law barring Medicaid funding to any entity that also performed abortions, even if those abortions were performed with nonpublic funds. A federal appeals court ultimately blocked that part of the law because it interfered with the Medicaid law's "freedom of choice" requirements.

"Although Indiana has broad authority to exclude unqualified providers from its Medicaid program, the state does not have plenary authority to exclude a class of providers for any reason — more particularly for a reason unrelated to provider qualifications," wrote Appeals Court Judge Diane Sykes in the majority opinion. Sykes was appointed by President George W. Bush.

Congress, of course, could defund Planned Parenthood by changing that requirement in Medicaid law.

But Medicaid experts say recent announcements by the Republican governors of Louisiana and Alabama that they are also attempting to evict Planned Parenthood from the Medicaid program in their states are unlikely to become reality.

Louisiana Gov. Bobby Jindal, who is running for president, said in the debate for the second tier of candidates last week that "we just, earlier this week, kicked them out of Medicaid in Louisiana." None of the Planned Parenthood clinics in the state perform abortions.

In Alabama, Gov. Robert Bentley notified Planned Parenthood last week that he would be ending their contract with the state to serve Medicaid patients. "I respect human life and do not want Alabama to be associated with an organization that does not," he said.

Neither of those actions is likely to succeed, said Sara Rosenbaum, a law professor and Medicaid specialist at George Washington University.

"This is a right for beneficiaries going back to the original statute," she said, referring to the ability of patients to choose their health care provider. She added, however, that governors wishing to take such steps for political gain "have nothing to lose," because it is now up to the providers to sue.

Planned Parenthood has not said yet whether it will challenge the Alabama or Louisiana actions in court.

One way GOP governors have managed to cut Planned Parenthood funding is by dropping out of an optional Medicaid program that provides federal funding to pay for family planning services for women who don't otherwise qualify for Medicaid but who still have low incomes (usually under twice the federal poverty level, or about $23,500).

That's how Texas partly defunded Planned Parenthood in 2011. When Medicaid officials said the state's new law barring funding of organizations that also do abortions violated the federal free-choice-of-provider requirement, Texas was actually expelled from the expanded family planning program — and lost its federal funding. The state instead created its own program with (substantially less) state-only money. Planned Parenthood had been providing just under half of the services for the entire program, so excluding the organization meant women in Texas had trouble getting family planning services.

According to the Texas Policy Evaluation Project, which is studying the impact of the changes, by 2013 the reductions caused 82 clinics (not all of them run by Planned Parenthood) to close or stop providing family planning services. Plus, the cuts prompted other clinics to limit the types of services they provide, and forced women seeking care to pay a bigger share of the cost.

Copyright 2015 Kaiser Health News. To see more, visit
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Not Everybody Likes Kissing

Wed, 08/12/2015 - 1:50pm

The music swells. On-screen, the two main characters' eyes meet. They lean in, and — slowly! — their lips gently press in a romantic kiss. All the teenage girls in the audience exhale audibly.

Such on-screen behavior seems romantic if you were raised in a culture that practices romantic kissing. But that type of culture may not be the majority. In a study published this month in American Anthropologist, researchers propose that romantic kissing isn't something everybody does; in fact, not even half the cultures surveyed lock lips in romance.

Scientists have at least a couple of ideas about why we kiss people we are attracted to. We might be doing it to evaluate a potential mate, evolutionary biologists say, or to maintain a bond, or to arouse the other person. Kissing behaviors have been observed in chimpanzees and bonobos, though how romantic the animals were feeling at the time is unknown.

For a long time it was assumed that, whatever the reason, kissing was something people everywhere did. But according to study author William Jankowiak, an anthropologist at the University of Nevada, Las Vegas, few people have looked across cultures at romantic kissing.

Jankowiak and his colleagues looked at data compiled from decades of ethnographic studies of all sorts in more than 168 cultures. He and his team searched for mentions or observations of a romantic-sexual kiss, which they defined as "lip-to-lip contact that may or may not be prolonged." The researchers found that in 54 percent of the cultures studied, there was no record of romantic-sexual kissing.

"It does seem to be a human universal that adults kiss babies or small children," Jankowiak says. But kissing a partner on the lips? Some cultures find that repulsive.

The team's analysis also showed that simpler, foraging societies were least likely to practice romantic kissing. But why wouldn't couples everywhere kiss?

"Some of these people never go to the dentist," Jankowiak says. "They never brush their teeth." Maybe, he suggests, in some cultures people who don't swap spit survive better because they're less likely to get sick.

Brushing teeth is variable within every culture, of course, and no panacea. Research published last fall suggests that about 80 million bacteria can be exchanged in a passionate kiss that lasts more than 10 seconds.

Jankowiak cites a famous quote from an anthropologist studying the Thonga in Africa. The first time the Thonga people saw Europeans kissing, they were disgusted. "They eat each other's saliva and dirt!" the locals reportedly said.

Still, Robin Dunbar, a professor of evolutionary psychology at the University of Oxford, says he suspects many more cultures engage in passionate kissing than Jankowiak's analysis suggests.

"To be a fair test of the hypothesis," he tells Shots via email, "we have to assume that the ethnographers who compiled the [data] always recorded kissing when it happened." But there are a couple of reasons why they may not have done so. To record romantic kissing, Dunbar says, the researchers would have had to either see people kissing, or hear them talk about it. He questions whether a private act such as kissing would be performed in public view.

In addition, Dunbar says, "most sociocultural anthropologists simply haven't been interested in kissing, period." So they wouldn't have recorded its presence or noted its absence.

Jankowiak says he sees Dunbar's point, but doesn't agree. Since sexuality in humans is something that's done in secret, it's indeed tough to know conclusively that kissing wasn't happening behind closed doors. But, he says, this study wasn't based solely on historical data. His team gathered additional information through interviews with living ethnographers.

"If we did not have the live interviews," he says, "I think the finding would be much more vulnerable."

Some of the researchers interviewed for his analysis, Jankowiak says, have explicitly asked the people they studied about sex. One ethnographer told Jankowiak that "people told him the position they were in when they had sex and that they would nibble each other's eyebrows." But when asked about kissing, they said the equivalent of, "Gross!"

Maybe an appreciation for a kiss as passionate communication is more widespread than his analysis suggests, Jankowiak says. But it's pretty clear that not everyone finds kissing romantic.

Copyright 2015 NPR. To see more, visit
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Whistleblower Says Medicare Advantage Plans Padded Charges In Home Visits

Wed, 08/12/2015 - 5:03am

A whistleblower case in Texas accuses a medical consulting firm and more than two dozen health plans for the elderly of ripping off Medicare by conducting in-home patient exams that allegedly overstated how much the plans should be paid.

The Texas litigation, whose details were unsealed by the court in June, is just the latest of at least a half dozen whistleblower cases that have been filed in the past five years alleging billing fraud and lax government oversight of privately run Medicare Advantage plans, which have proven increasingly popular with the elderly.

The latest lawsuit was filed in federal court in Dallas in 2014 by Becky Ramsey-Ledesma, a medical billing coder, against her former employer, CenseoHealth LLC. The Dallas-based firm has contracted with thousands of doctors who visit elderly people in their homes and evaluate their health on behalf of Medicare Advantage plans.

But the health assessments exaggerated how ill patients were, which in turn inflated Medicare payments to the health plans, according to the allegations in the suit. The suit names 30 Medicare Advantage plans in 15 states, including several Blue Cross plans and other industry stalwarts, such as Humana Inc. Humana has more than 3 million Medicare members.

The private insurance plans offer seniors an alternative to standard Medicare, which pays doctors for each service they render. Medicare Advantage plans receive a set fee monthly for each patient, based on a risk score that pays higher rates for sicker people and less for those in good health. Medicare essentially trusts health plans to report these risk scores accurately. The Medicare Advantage plans have grown rapidly in recent years, and now cover almost 17 million people.

The Texas suit was filed last year, but stayed under court seal until mid-June. It is the second whistleblower action to target Medicare Advantage home visits, which account for billions of dollars in annual revenues for health plans.

A 2014 Center for Public Integrity investigation found that home visits skyrocketed, even as federal officials struggled to prevent health plans from overcharging Medicare by tens of billions of dollars every year. Federal officials as early as 2013 were concerned the home visits could be a factor in jacking up risk scores improperly and wasting tax dollars. But when the industry objected, the officials backed off a proposal to limit the use of home visits, the investigation found.

CenseoHealth's home visits collect data on the health status of patients, which the private health plans then use to bill Medicare. The company had no comment on the lawsuit.

The Centers for Medicare and Medicaid Services press office declined to answer written questions seeking comment on its home visit policy. The agency instead issued a statement that said the home exams can have "significant value." That opinion is shared by the health insurance industry trade group, America's Health Insurance Plans. A spokesperson for AHIP called the visits "an important component of disease management activities."

Medicare Advantage is enjoying robust growth and firm political support in Congress. The industry has beaten back several attempts by the Obama administration to cut its rates as enrollment has grown to include about one in three people on Medicare. In June, the House passed a bill — sponsored by Rep. Vern Buchanan, a Republican from Florida — that appears to prevent federal officials from halting the home health assessments.

At the same time, the Centers for Medicare & Medicaid Services is drawing scrutiny over top manager Andy Slavitt's former ties to UnitedHealth Group, which runs the nation's biggest Medicare Advantage plan. Senate Finance Chairman Orrin Hatch criticized Slavitt's "conflicted history" in a statement issued after President Obama nominated him for the top CMS job in July.

Bringing Back House Calls

CenseoHealth has emerged as a leader in a growing market for in-home health assessments.

Formed in 2009 by two Texans, CenseoHealth grew from four employees to 325 workers by 2013, according to its website. It has built a network of nearly 5,000 doctors who it says are "uniquely qualified to identify and diagnose health conditions." Doctors affiliated with the company have done more than a million home visits, and in 2013 forecast that revenue would reach $120 million, according to the CenseoHealth website.

CenseoHealth's investors include private equity firm Health Evolution Partners, headed by David Brailer, a physician and former health information technology czar under President George W. Bush. In March, Brailer was named chairman of CenseoHealth's board of directors.

Brailer and other leaders at CenseoHealth had no comment on the case.

According to the suit, CenseoHealth used an algorithm to identify patients who might have undetected medical conditions that could raise their risk scores. The company uses marketers to contact patients and schedule doctor visits to their homes.

The lawsuit alleges that the doctors don't provide any medical treatment. Other than taking vital signs and weight, listening to heart and lungs and checking reflexes, no physical exam in involved and no lab tests are performed, according to the suit. The doctors ask the patient a series of questions on a checklist during the visit, which takes about an hour.

"In other words, the conditions reflected on the evaluation forms are not medical diagnoses derived from a medical examination, but instead, are self-reported conditions captured from the medical history and verbally confirmed" by the patient, according to the suit.

Some of the doctors lacked medical licenses, according to the lawsuit, and others were assigned as many as ten visits a day for a flat fee of $100 each. Some faked results, according to the suit. The suit cited a test for Alzheimer's disease in which each patient was asked to draw hands on a clock to indicate the correct time of day. "In some cases it was obvious that the same person had drawn the clock on multiple forms," according to the suit.

Some of the diagnoses could not be made reliably through a home visit, according to the suit. Others were based on medications patients took, even when those medications could be taken for more than one condition, according to the suit.

These practices inflated risk scores, according to the suit, triggering "substantial overpayments" to the health plans.

Ramsey-Ledesma claims she was fired in August 2013, the day after she objected to the practices. According to the lawsuit, her manager told her, "we can no longer trust you."

The other whistleblower case that targeted home visits was unsealed in 2014. It was filed by Anita Silingo, a former compliance officer for Mobile Medical Examination Services Inc., or MedXM. The company, based in Santa Ana, Calif., has denied the allegations. That case is pending.

The Department of Justice declined to join either case, which may make it more difficult for the whistleblowers to proceed with their cases and collect a large award. However, lawyers who handle these cases say more of them are moving ahead without the government.

Other whistleblower cases involving Medicare Advantage have been filed in the past five years in California, Florida and South Carolina, among other locales. These cases also allege that Medicare Advantage plans inflated risk scores and as a result were overpaid by Medicare.

Friends In High Places

As early as 2013, CMS officials said they suspected home visits improperly raise risk scores and waste tax dollars. But as the visits became standard procedure for more and more health plans, CMS apparently lost its appetite for tightening oversight.

CMS officials wrote in February 2013 that they were concerned that the primary objective of the visits was to raise risk scores and revenues "without follow up care or treatment being provided."

In April 2013 though, facing industry pressure the officials backed off their proposal to collect data on the home visits with an eye to excluding their use in setting rates.

The following year, CMS again backed down from a proposal to exclude the visits after meeting with the industry. That decision came even though CMS said "there appears to be little evidence" that the visits led to any improvement in patient care. The insurance industry estimated that cutting out the visits would have cost Medicare Advantage plans nearly $3 billion a year.

Earlier this year, CMS handed the industry a major victory when it ruled out excluding the home visits. Instead, CMS urged the industry to adopt a set of "best practices" for the visits. The new policy "enhances the value of in-home assessments so they are used to support care planning and care coordination and improve enrollee health outcomes."

The press release quoted then-CMS deputy administrator Slavitt saying the proposals "would reward providers of high quality, consumer-friendly care" for Medicare Advantage.

Slavitt is a former executive of Optum, a subsidiary of UnitedHealth Group. In July, President Obama nominated him to take over CMS permanently.

CMS officials declined to answer questions about Slavitt's role in the decision making process for home assessments, but said:

"CMS believes that in-home assessments can have significant value as care planning and care coordination tools. In the home setting, the provider has access to more information than is available in a clinical setting."

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

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I'm An Obstetrician And I Failed At Breast-Feeding

Tue, 08/11/2015 - 12:57pm
Maria Fabrizio for NPR

As an obstetrician, I have counseled countless patients on the benefits of breast-feeding to both mother and baby. But I breast-fed my daughter, Safiya, for only one month, and my son, Haider, for only one week. I was a breast-feeding failure.

My struggle with breast-feeding began immediately. After as easy a pregnancy and labor as I could ask for as a first-time mom, I was excited to begin bonding with my daughter. Safiya wasn't able to get a successful latch, but I knew she would soon figure it out. I put her to my breast every two hours until she would give up and fall asleep.

But when we went home two days after Safiya's birth, she was still not nursing well, requiring me to pump breast milk and supplement with formula early on. I was a fourth-year medical student, and I had one month to study for the second of three exams required to obtain my medical license. So I decided to pump exclusively and feed my pumped milk from a bottle. I pumped every hour to help increase my supply, storing the milk pumped on the odd hours, and feeding the milk pumped on the even hours. After each feeding, I supplemented with formula. In the hours from 10 p.m. to 6 a.m., I studied between feedings, when the rest of my family was asleep. At 6 a.m., my mother-in-law, who had moved in with us to help with the baby, took Safiya and fed her stored milk and formula while I slept. At 10 a.m. I woke up and continued the cycle of pumping and feeding.

If you decide to stop breast-feeding, let me give you permission to do so. You are no less a mother, and your child will be just fine.

By the time I took my exam, I was exhausted and frustrated. Every minute the pump was attached to my body, Safiya was not. I could not enjoy the bonding that breast-feeding was supposed to offer and even began to resent Safiya for not being able to latch on better. I decided to stop pumping, and exclusively feed formula. While I felt relieved to live a more normal life, I continued to mourn the fact that I never experienced what it felt like to breast-feed my child.

When I became pregnant again, I was determined to succeed where I had failed before. I was a fourth-year resident in obstetrics and gynecology, and I knew so much more about breast-feeding. I was due in July, right after graduation, and would not start work until November. For four full months, my only job would be to breast-feed. I would not fall into the trap of supplementing with formula too early.

My enthusiasm crumpled soon after delivery, however, when Haider had the same difficulty as Safiya. For every hour he spent at my breast, he latched for about one to two minutes. At 3 days old, he began to show signs of dehydration, with dry lips, weight loss and no wet diapers.

I called Haider's pediatrician, who listened thoughtfully. She gently advised me that she was worried that Haider was becoming dangerously dehydrated, and that at this point, I should consider formula to be a medicine for him. We decided I would breast-feed for 20 to 30 minutes at each breast, then pump for 20 minutes at each breast and feed the pumped milk, then supplement with formula. I was to repeat this process every two hours. Sleeping did not fit into this equation. Haider did start showing signs of improvement, but feeding him occupied every moment of the day. My husband and I had to send Safiya to my mother's house because we could not manage to look after her while trying to succeed at feeding Haider. We banned visitors, mostly because I could not manage to get through an entire hour without crying.

The following day, I met with a lactation consultant. After working with us for an hour, she listed our diagnoses: retracting nipples, poor milk supply, tight frenulum, poor latch, excessive infant weight loss. I left feeling defeated. The mountain I had to climb to breast-feed seemed to get steeper and steeper. I began to despise every celebrity who posted a gorgeous picture of herself breast-feeding her child, every celebrity who called breast-feeding the most beautiful and natural thing in the world. I'm talking about you Olivia Wilde, Giselle and Angelina Jolie! Sometimes breast-feeding is neither natural nor beautiful! Sometimes it is a heartbreaking and a painful struggle.

As an obstetrician, I had recommended exclusive breast-feeding to all my patients. Yet here I was, a complete failure. Not only did I feel like a bad mother, I also felt like a bad doctor; I could not even follow my own recommendation. I was resenting Haider, just as I had resented Safiya, for not being able to breast-feed. I was angry that my body was failing me, and I was failing my child. I missed Safiya.

My pediatrician told me she would fully support me if I wanted to continue to breast-feed. Finally, she said, "I also want you to know that if you want to stop breast-feeding, it's OK."

One thing I had heard for my entire pregnancy, and my entire training as an obstetrician for that matter, was how important breast-feeding was. I almost felt like I had been brainwashed into thinking breast-feeding was absolutely the only healthful way to feed my child. This was the first time I had ever heard that it was OK not to breast-feed. So on Haider's 1-week birthday, I decided to stop.

I do still sometimes mourn not having been able to breast-feed. But formula feeding allowed me to keep my family together, nourish my children and keep my sanity. It was the right choice for my family.

I recently saw a patient who was having trouble breast-feeding. I shared my own struggles and advised strategies that might help. Finally, I told her: If you decide to stop breast-feeding, let me give you permission to do so. You are no less a mother, and your child will be just fine.

I saw this patient again several months later. She told me how much my support meant to her and how it helped her come to terms with not being able to breast-feed. I hope that as health care providers, we can find a way to create encouraging and supportive environments for breast-feeding, while also supporting women who cannot.

Maliha Sayla is an obstetrician-gynecologist at DuPage Health Specialists in Lisle, Ill.

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Women In Combat Zones Can Have Trouble Getting Contraceptives

Tue, 08/11/2015 - 5:33am

Rates of unintended pregnancy among young women in the military are about 50 percent higher than among young women in the general population, research suggests.


Next year, the military will officially lift restrictions on women in combat, the end of a process that, according to the Government Accountability Office, may open up as many as 245,000 jobs that have been off-limits to women. But those who deploy overseas may continue to face obstacles in another area that can have a critical impact on their military experience: contraception.

It's not a minor issue. Rates of unintended pregnancy among women in the military are about 50 percent higher than those of women in the general population. And because of strict federal rules, their health insurance does not generally cover abortion.

Tricare, the health care plan for more than 9 million active and retired members of the military, covers most contraceptive methods approved by the Food and Drug Administration. Active-duty service members pay nothing out of pocket. Spouses and dependents of members of the service may face copayments in some instances. But all methods aren't necessarily available at every military hospital and clinic; and overseas, for example, women may have difficulty getting refills of their specific type of birth control pill.

Fifteen percent of active-duty service members are women, and 97 percent of them are of childbearing age.

In a 2013 study, based on more than 28,000 responses to the 2008 Department of Defense survey on health-related behaviors, researchers found that after adjusting for the larger concentration of young women in the military, the rate of unintended pregnancy among military women was 7.8 percent. That's compared with 5.2 percent among women in the general population.

It can be challenging to use contraceptives while deployed overseas for many reasons. There is the problem of trying to schedule a daily birth control pill when traveling across time zones; and desert conditions may make a contraceptive patch fall off. Although women are allowed a 180-day supply of contraceptives before deploying, obtaining refills of the same pill can be difficult, some servicewomen reported in a 2012 survey.

"It is unfortunate," says Nancy Duff Campbell, co-president of the National Women's Law Center, "that here we have the military — [with] one of the best health care systems in the country — and, where we still have a gap is in contraception."

Copyright 2015 Kaiser Health News. To see more, visit
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San Diego Installed Public Loos, But Now They're Flush With Problems

Mon, 08/10/2015 - 1:58pm
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A Portland Loo in Portland, Ore. San Diego installed two of the public toilets earlier this year, but they cost more than $500,000 to install, and now residents are raising a stink.

Jonathan J. Cooper/AP

On a steamy San Diego afternoon, baseball fans are headed toward the Padres' downtown stadium. As they approach the park, they pass a large steel stall on the sidewalk. Darlene Collins stops to look at it.

"I did not know that was a bathroom," Collins observes. "I thought it was some kind of electrical equipment or something."

Then the stall emits a familiar sound.

"Well, now that I hear it flush, ..." she says. "I did not know that was a bathroom."

Portland Loos are designed to deter vandalism and misuse.

Jonathan J. Cooper/AP

Collins was mystified by a Portland Loo, a prefabricated public restroom that's been popping up from Seattle to Cincinnati to Montreal. The loos have real toilets and running water, and are better ventilated than port-a-potties.

But they're controversial. The toilets turned out to be much pricier than expected, and some people complain that they could attract illict activity – prostitution or drug use.

Collins isn't keen to try one out. If she had to go, she says, "I would hold it and go in the ballpark."

Portland Loos are designed to ease the daunting task of keeping a public restroom safe and clean. They can be power-washed and have slits along the bottom to make it clear if there's somebody inside. They cost about $100,000 each, but that doesn't include the connection to sewer lines, which is where some cities stumble.

Shots - Health News Bill Gates Crowns Toilet Innovators At Sanitation Fair Goats and Soda Me, Myself And The Loo: A Woman's Future Can Rest On A Toilet

San Diego spent more than half a million dollars installing its two loos — double the initial price tag. Now, due to more costs and residents' complaints, it's planning to remove one and put it in storage. A nearby homeless shelter will open its bathrooms around the clock instead.

Advocates point out that the need to provide clean toilets is a public health problem shared by all cities; solving the problem benefits residents and visitors of all economic levels.

Ronald Bennett, homeless for 22 years, says San Diego's push to open more public restrooms has improved his life.

"A lot of us don't have a restroom to go to, so we can use that one and it helps," he says. "It gives me a chance to not have to go all the way across town to use the restroom."

Not everyone is a loo fan.

"The homeless population is up in this area since the Portland Loo was installed," says Jon Wantz, who runs a restaurant a few blocks away from one. "The increased activity, whether it be criminal or drug-related, or just transient-related in general, it's not good for business."

"Affording individuals the ability to use a private and safe space to utilize the restroom is basic dignity," counters Heather Pollock, executive director of Girls Think Tank, a San Diego homeless advocacy nonprofit. A restroom isn't truly public, she says, unless everyone can use it — and many people aren't allowed in the restrooms inside stores and restaurants.

Around the Nation Health Problems Compound For Aging Homeless

"If I walked in and was holding all of my belongings, or I hadn't showered in a few days, there's a very high likelihood that I would not be able to utilize that," she says.

Pollock points out San Diego provides free dog poop bags from dispensers across the city, but there are only a few places where a homeless person can use a toilet.

"I just wonder what kind of message we're sending as a community," she says, "when we're basically saying we value dog owners more than we value human beings and their basic dignity."

Copyright 2015 KPBS-FM. To see more, visit
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Will Doctors Soon Be Prescribing Video Games For Mental Health?

Mon, 08/10/2015 - 4:51am
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Lorenzo Gritti for NPR

Developers of a new video game for your brain say theirs is more than just another get-smarter-quick scheme.

Akili, a Northern California startup, insists on taking the game through a full battery of clinical trials so it can get approval from the Food and Drug Administration — a process that will take lots of money and several years.

So why would a game designer go to all that trouble when there's already a robust market of consumers ready to buy games that claim to make you smarter and improve your memory?

Think about all the ads you've heard for brain games. Maybe you've even passed a store selling them. There's one at the mall in downtown San Francisco — just past the cream puff stand and across from Jamba Juice — staffed on my visit by a guy named Dominic Firpo.

"I'm a brain coach here at Marbles: The Brain Store," he says.

Brain coach?

"Sounds better than salesperson," Firpo explains. "We have to learn all 200 games in here and become great salespeople so we can help enrich peoples' minds."

He heads to the "Word and Memory" section of the store and points to one product that says it will improve your focus and reduce stress in just three minutes a day.

"We sold out of it within the first month of when we got it," Firpo says.

The market for these "brain fitness" games is worth about $1 billion and is expected to grow to $6 billion in the next five years. Game makers appeal to both the young and the older with the common claim that if you exercise your memory, you'll be able to think faster and be less forgetful. Maybe bump up your IQ a few points.

Marbles, a store in San Francisco, Calif., offers lots of options for shoppers interested in brain games.

April Dembosky/KQED

"That's absurd," says psychology professor Randall Engle from the Georgia Institute of Technology.

Engle says intelligence is largely a function of neurotransmitters — the dopamine system specifically.

"We're really talking about a biological system," Engle says. "The idea that you can do some little computer game for half an hour a day for 10 days and change that system is ludicrous on the face of it."

Engle is one of many skeptics who say the only thing these games make you better at is the game itself.

"There's very little research that's done right that suggests that these things work," he says. Studies done by the companies that sell the games tend to be really small or have no real control group — two key clues that the research may not be reliable.

Engle has done numerous tests himself to see if the games improve cognitive performance.

"Over and over and over again, we just don't see any substantial benefit for these games," he says.

Engle is one of 75 scientists who signed a letter addressed to the brain training industry, criticizing companies for exaggerating claims and preying on the anxieties of elderly customers trying to stave off memory decline.

Engle says the commercialization of these games has harmed brain research.

"Unfortunately, an awful lot of people are more interested in business than in finding the science," he says.

Neuroscientist Adam Gazzaley is interested in both. In his lab at the University of California, San Francisco, he's working on something much more complicated than a brain exercise. It's a fully immersive video game focused on multitasking. While you guide a horse through the Aztec desert, you have to tap green carrots that flash at the top of the screen, but not tap the yellow carrots or the radishes. Gazzaley thinks this kind of challenge will have a positive effect on executive brain function.

The notion, he says, is "if we created this — what we call a high-interference environment, with multitasking going on and lots of distraction ... if we put pressure in that environment, we would see benefits in other aspects of cognitive control."

Think of how a race car works. To get around the track, you've got the accelerator, the gearshift and the steering wheel. If one of them isn't working right, you'll never win the race.

It's like that with the brain, Gazzaley says. The networks that control the three classes of cognitive ability — working memory, attention and goal management — all overlap.

"If you have a problem with any of them, it's going to propagate," he says. "You'll have a problem with memory; you'll have a problem with school or work or relationships or safety in driving."

On the flip side, Gazzaley believes, if you can improve one of those cognitive skills, you might be able to improve all of them.

"If you can apply selective pressure to one of them, using the video game mechanics, you will be able to see benefits across domains," he says.

Gazzaley is well aware of the skeptics.

Remember that letter from Randall Engle of Georgia Tech and other critics? The one urging caution around the weak scientific claims of brain games?

Adam Gazzaley was one of the people who signed it.

And he's the first to admit that his hypothesis needs to be thoroughly tested.

"I am cautiously optimistic about this," he says.

He decided the best proof he could get would come from taking one of his games, called Neuroracer, through the FDA approval process for medical devices.

"Can we go then through a very rigorous validation clinical trial, just like people would expect from a drug," he says, "to then show how it works, how it doesn't work, how it could work better — all those things?"

Gazzaley sees great potential to use these games for a range of psychiatric disorders: post-traumatic stress disorder, traumatic brain injury, attention deficit hyperactivity disorder, autism, Alzheimer's disease.

He's hoping there will come a day when, instead of a pill, a video game might be prescribed to treat a kid with ADHD.

"Most of our drugs are pretty blunt instruments," Gazzaley says, whereas the game, if it works, could be used to target the affected brain networks more precisely. By monitoring the data of each patient playing the game, doctors or psychologists could tailor the treatment on an individual basis.

"Instead of having a patient come in, receiving a therapeutic, like a pill, going home, and having them subjectively monitor the impact and come back months later and report that," he says, "here we have the ability to track in real time what the impact of this therapeutic is."

That is a pretty appealing prospect to psychiatrist Dr. Petra Steinbuchel. She works with kids and adolescents with ADHD at the UCSF Benioff Children's Hospital in Oakland. Parents are always asking her if there's something she can do for their children other than prescribe drugs.

"Nobody wants to give their child a medication, and many people have a lot of hangups about that," she says.

Existing drugs treat only symptoms, and usually wear off before the end of the day. Some children suffer side effects like low appetite, weight loss or sleep problems.

"If we can avoid that," Steinbuchel says, "and avoid anything that you put into your body, and just make use of something that you're using as a tool — to help improve for the long term — that would be great."

Still, medications for ADHD are 75 to 90 percent effective. Until a game matches that standard, Steinbuchel says, it could be just one part of treatment.

"I think it's part of a bigger picture of looking at sleep, diet, exercise, home environment and school systems, as a part of a comprehensive treatment plan," she says.

Adam Gazzaley is betting on his vision of the future. If his first game is approved by the FDA, he has another four in development that he hopes are good candidates for approval, too.

Copyright 2015 KQED Public Media. To see more, visit
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Could Sexting Help Your Relationship?

Sat, 08/08/2015 - 8:03am

It's not just teens who engage in sexy texting. About 82 percent of adults recently surveyed say they've sexted, too.


Sexting is scandalous, dangerous and downright dirty behavior.

Or, at least, that seems to be its reputation, maybe because most studies of the behavior have focused on teens. Among young adults, exchanging explicit messages and photos by phone has been linked to higher rates of early sex, sexually transmitted diseases and drug and alcohol use.

But some psychologists think the negative connotations of sexy texting aren't entirely fair. The behavior may have benefits, too, they suggest, at least for consenting adults.

"If [sexting] was only a bad thing, people wouldn't do it as much as they do," says Emily Stasko, a doctoral student in clinical psychology at Drexel University.

To investigate the benefits and downside among adults, Stasko and some colleagues asked 870 people between the ages of 18 and 82 to fill out a survey about sexting. Participants answered questions like, "Have you ever sexted, and with whom?" and "Do you consent to sexting even if you don't want to?"

The researchers, who described their findings Saturday in Toronto at the annual meeting of the American Psychological Association, report that many of the adults — 82 percent — admitted to sexting within the last year.

The psychologists also found higher frequencies of sexting to be associated with greater levels of sexual and relationship satisfaction — when it's wanted.

"Context mattered and not all sexting is equal," Stasko says. "Unwanted sexting is bad for relationships, but when it's wanted, it's good."

What surprised her, she says, was that the frequency of the behavior, and reports of benefits, didn't differ by gender. Men and women reported similar levels of sexting, and the positive association was the same when it was desired.

Psychologist Susan Lipkins, who has studied sexting in the past, says she can see how the form of communication could be a good thing for relationships. But the experience of sexting, she says, is most likely different for men and women.

"Men are more visually oriented so they're probably more interested in getting sexually explicit pictures," Lipkins says. "Women respond, too, but we don't look at private parts in the same way men do. Women want to read words that are positively reinforcing the male's desire to be with her; words that make her feel sexually special and desired."

Still, Lipkins thinks this study doesn't prove sexting leads to a better sex life or happier relationships.

And Stasko agrees.

"We don't know if sexting promotes intimacy," Stasko says, "or if people who are in satisfied relationships feel more intimate and that leads to sexting."

But she says she's hopeful that if more studies show sexting promotes intimacy and satisfaction, it might be be used in couple's therapy as another form of enhancing communication.

What we can say, Stasko says, is "sexting can be good."

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Crime Interrupts A Baltimore Doctor's Reform Efforts

Fri, 08/07/2015 - 3:25pm
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Workers for the Safe Streets violence interruption project including Gardnel Carter, center, talk with Baltimore residents in 2010.

Kenneth K. Lam/MCT via Getty Images

On a hot, sunny Monday in mid-July, Dr. Leana Wen stood on a sidewalk in West Baltimore flanked by city leaders: Mayor Stephanie Rawlings-Blake, interim police commissioner Kevin Davis, Rep. Elijah Cummings. Under a huge billboard with the web address, she proudly unveiled a 10-point plan for tackling the city's heroin epidemic.

Wen, the city's health commissioner, said she aims to create a 24/7 treatment center, an emergency room of sorts for substance abuse and mental health. She spoke of targeting those most in need, starting with those in jail.

What Wen did not know was that, across town in East Baltimore, police had hours earlier arrested two workers with Safe Streets, the health department's flagship anti-violence initiative.

The project, first launched by the health department in 2007, hires ex-offenders to go into the streets and mediate conflict before it erupts into violence. They're called violence interrupters. It's based on the Cure Violence model out of Chicago.

The workers have credibility in their communities because they are from those communities. Some have histories in the drug trade, and many of them have served time in prison.

What had happened was that in the wee hours of the morning, police responded to a call about an armed robbery. They chased the suspects to an address which turned out to be a Safe Streets neighborhood office. Inside, police found guns, drugs, and paraphernalia related to the manufacture and sale of drugs, including sifters, cutting agents and scales. Nine people were arrested, including Two Safe Streets employees who face gun and drug charges.

It wasn't the first time Safe Streets workers had gotten into trouble. And Wen says she knows there are risks in hiring ex-offenders.

"But everything has risks," she says "In my work as an ER doctor, there's no procedure that I can recommend, no medication I can recommend that doesn't come with a risk."

Research shows Safe Streets does deliver. Last year, the health department says the program mediated 880 conflicts in Baltimore. Until recently, a couple of the neighborhoods they operate in had gone a year without a fatal shooting.

At the time of the arrests, Wen and the health department were preparing to announce the opening of a fifth neighborhood site for Safe Streets. There was talk of it opening in Sandtown-Winchester, Freddie Gray's neighborhood.

Instead, Wen appeared at a press conference at police headquarters, this time flanked by the police commissioner and federal agents. She reported that the raided Safe Streets site had been suspended and that two employees had been fired. She strongly defended Safe Streets as a program, and spoke of standing united with the police and partners in reducing violence in Baltimore.

Her words had been chosen carefully. But there were problems.

She soon learned from her deputy Olivia Farrow that the Safe Streets staff was not happy.

Part of the problem was the image.

"People were upset to see me standing with the police in the first place," Wen told us. "Because the entire point of Safe Streets is that they're separate from the police, and in the mediation for conflicts, there has to be total trust. And we had potentially interfered with that relationship."

So she sets about trying to fix things. She calls a meeting with the Safe Streets site directors. She brings in Brent Decker from Chicago's Cure Violence, who trained many of the Baltimore staff, as well as violence expert Daniel Webster from Johns Hopkins University.

They talk about what could be done differently to keep staff from falling back into their old patterns and getting involved with drugs and crime. They discuss providing more counseling for the staff, who themselves have been perpetrators and victims of violence.

Wen then turns the conversation to a topic she'd heard about in one of her early visits to the program.

"Initially when I was meeting with Safe Streets, I said, 'What is the one type of support we can help you with?' And I thought they were going to say trauma debriefing, mental health support. And they said child support."

That puzzles her. She wonders why she would be helping with child support in the first place, and also just how that would be done.

Dante Barksdale, Safe Streets' outreach coordinator, explains that most of the guys coming to work for the program are over 30, which means they're likely to have children. Many owe upwards of $50,000 in child support. The Safe Streets jobs pay about $28,000 a year.

A couple months after they start working, the state starts deducting child support from their paychecks, leaving them with very little. Most of these men have never held jobs before and don't have the skills to find other work. All of these factors make for a very stressful transition to legal employment.

"We see that a lot," Barksdale says. "That translates through all the sites."

Dedra Layne, who oversees Safe Streets at the Health Department, proposes talking with the bureau of child support enforcement.

"If they don't know that we're faced with this issue, they can't do anything," Layne says. "We should at least be having the conversation about are there any options to consider. Are there any things that we can put in place that would support the staff as they move through their first employment opportunities and still have families to manage."

What started as a conversation about preventing violence has now wandered into the realm of child support law, further and further away from what many might think of as public health. But Dr. Wen pushes on.

Leana Wen talks with Safe Streets outreach workers Dante Barksdale and Gardnel Carter in Druid Hill Park in Baltimore.

Meredith Rizzo/NPR

"Have there been, around the country, efforts to do different types of salary arrangements to bypass the child support problem?" she asks. "An example might be instead of paying child support directly, have there been experiments to see what happens if we pay for housing?"

Heads nod around the table. They don't know if it will work, but the sense is it's worth looking into.

No one here would argue that child support isn't important. In a different story, we might be using the term "deadbeat dads" to describe this problem. But what do you do when your deadbeat dad is someone who voluntarily puts himself in dangerous situations for the good of the community, wedging himself between people who literally want to kill each other? What do you do when your deadbeat dad represents your hope for the city, if only he can stay on track?

These are the questions that Leana Wen is wrestling with. And like so many other questions in Baltimore — there are no easy answers.

NPR and All Things Considered will continue reporting from Baltimore in the coming months, checking in with Leana Wen and her team periodically. Stay tuned for future stories.

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Eye Shapes Of The Animal World Hint At Differences In Our Lifestyles

Fri, 08/07/2015 - 2:11pm
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Can you guess which eyes belong to what animal? Top row, from left: cuttlefish, lion, goat. Bottom row, from left: domestic cat, horse, gecko.

Top row: iStockphoto; bottom row: Flickr

Take a close look at a house cat's eyes and you'll see pupils that look like vertical slits. But a tiger has round pupils — like humans do. And the eyes of other animals, like goats and horses, have slits that are horizontal.

Scientists have now done the first comprehensive study of these three kinds of pupils. The shape of the animal's pupil, it turns out, is closely related to the animal's size and whether it's a predator or prey.

The pupil is the hole that lets light in, and it comes in lots of different shapes. "There are some weird ones out there," says Martin Banks, a vision scientist at the University of California, Berkeley.

Cuttlefish have pupils that look like the letter "W," and dolphins have pupils shaped like crescents. Some frogs have heart-shaped pupils, while geckos have pupils that look like pinholes arranged in a vertical line.

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Needless to say, scientists want to know why all these different shapes evolved. "It's been an active point of debate for quite some time," says Banks, "because it's something you obviously observe. It's the first thing you see about an animal — where their eye is located and what the pupil shape is."

For their recent study, Banks and his colleagues decided to keep things simple. They looked at just land animals, and just three kinds of pupils. "We restricted ourselves to just pupils that are elongated or not," Banks explains. "So they're either vertical, horizontal or round."

The researchers gathered information on 214 species. They noted the pupil shape and the location of the eyes on the head, plus the animal's lifestyle. For example, was it predator or prey, and active during the day or night?

One of the researchers, Bill Sprague, also at the University of California, Berkeley, says some animals have such dark eyes, it's hard to even see the pupil.

An Akhal-Teke horse, from Turkmenistan, has horizontal slits for pupils, while the Mediterranean house gecko has vertical slits that look like a series of pinholes.


"I remember one in particular was the hyena," says Sprague. "It actually has a vertical pupil but it's very difficult to judge unless you work with them."

When they pulled everything together, a clear pattern emerged. In the journal Science Advances, the scientists report that there's a strong link between the shape of an animal's pupil and its way of life.

"If you have a vertical slit, you're very likely to be an ambush predator," says Banks. That's the kind of animal who lies in wait and then leaps out to kill. He says these predators need to accurately judge the distance to their prey, and the vertical slit has optical features that make it ideal for that.

But that rule only holds if the animal is short, so its eyes aren't too high off the ground, Sprague says.

"So for example foxes, in the dog lineage, have vertical pupils, but wolves have round pupils," he says.

And while a small pet cat has vertical slits, Sprague says, "the larger predators, like lions and tigers, have round pupils."

In general, round pupils seem to be common in taller hunters that actively chase down their prey, says Banks.

Meanwhile, he says, if you're the kind of animal that gets hunted, "you're very likely to have a horizontal pupil" and to have your eyes on the side of your head. That makes sense, he says, because it gives prey animals a panoramic view, so they can best scan all directions for danger.

But then the scientists began to wonder. This trick would only work if the animal's pupils were parallel with the horizon. And creatures like horses and sheep are constantly pitching their heads down to graze. When the researchers went to watch the animals in action, they discovered something unexpected.

"When they pitch their head down, their eyes rotate in the head to maintain parallelism with the ground," says Banks. "And that's kind of remarkable, because the eyes have to spin in opposite directions in the head."

"I've spent a lot of time handling horses, and having them put their head down to eat, and up to look around, and so on, and I had never noticed this," says Jenny Read, a vision scientist at Newcastle University in the United Kingdom. "It's just an ordinary observation that anyone could make, and yet apparently it wasn't known to science."

Read wasn't on the research team, but she says its conclusions seem right to her. "I think they're the first people to come up with a convincing explanation," she says, "for why the orientation should be chosen differently depending on your ecological niche."

Now, all of this isn't just important to scientists. Novelists and movie-makers constantly have to imagine the pupil shape of fictional creatures like Lord Voldemort in Harry Potter, or the dinosaur Indominus Rex in Jurassic World.

Giving their eyes vertical slits may make them look nice and evil, but Read says "I think their paper suggests that's unrealistic, because both of those creatures are sufficiently high off the ground that they probably should have round pupils."

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Men Looking To Get Ripped Are At Risk Of Abusing Legal Supplements

Fri, 08/07/2015 - 1:37pm

Turning to over-the-counter supplements to get ripped can contribute to physical and psychological issues.


Men who work out may be using legal over-the-counter supplements to the point that it's harming their emotional or physiological health, according to a recent study.

The preliminary study, presented Thursday at the American Psychological Association's annual convention, recruited 195 men ages 18 to 65 who went to the gym at least twice a week and regularly consumed legal appearance- or performance-enhancing supplements — things like whey protein, creatine and L-carnitine.

Participants answered questions about their supplement use as well as their self-esteem, body image, eating habits and gender roles.

"The heyday for illicit supplements for the average man is over," says Richard Achiro, lead author of the study and a registered psychological assistant at a private practice in Los Angeles. "The bulky Arnold Schwarzenegger and Sylvester Stallone are not what most men are seeking to achieve now. They want to be both muscular and lean, and it makes sense that [legal supplements] are what they're using or abusing."

Forty percent of participants, who were all men, increased their supplement use over time, while 22 percent were replacing regular meals with dietary supplements. Eight percent of participants were told by their physician to cut back on supplement use because of health side effects, and 3 percent were hospitalized for related kidney or liver problems, which can be caused by excessive use of protein powders and other supplements.

Men who used dietary supplements inappropriately also were more likely to have behaviors associated with eating disorders.

Achiro is no stranger to the culture of workout supplements. His interest was piqued when he noticed throughout college and graduate school how common it was for his male friends to use supplements before or after workouts.

"It became more and more ubiquitous," Achiro says. "Guys around my age who I knew — I'd go to their apartment and see a tub of some kind of [protein] powder."

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Not to mention that this has become a multibillion-dollar industry that's grown exponentially in the recent decade or so, he adds.

Achiro was surprised to find that most studies focused on illicit supplements such as hormones and steroids and gave little thought to the role of legal supplements, which are readily available at supermarkets and college bookstores.

One big factor behind supplement use is body dissatisfaction, the study found. The men internalize a particular set of cultural standards of attractiveness usually depicted by the media: healthy, muscular and lean, "like Zac Efron," says Achiro. And they're unhappy that their own bodies don't meet that ideal.

But the study also found that the men using supplements were more likely to feel gender role conflict, which Achiro explained as underlying insecurity about one's masculinity.

"This isn't just about the body," Achiro says, "What this is really about is what the body represents for these men. It seems that the findings in part [show] this is a way of compensating for their insecurity or low self-esteem."

Abusing whey protein and the like can also put gymgoers at risk for other health problems such as body dysmorphic disorder, also known as muscle dysmorphia, and related body image disorders.

"Body dysmorphic disorder used to be referred to as reverse anorexia," Leigh Cohn, a spokesman for the National Eating Disorder Association, says.

"Someone with anorexia will feel they need to continue to get thinner and lose weight. With bodybuilders, they act in the same kind of manner. They acknowledge that they're ripped, but are obsessed with certain body parts that they find inadequate. This drive for muscularity preoccupies them. Supplements serve them the same way diet products serve someone with an eating disorder," Cohn says.

For people affected by body dysmorphic disorders, this constant and compulsive behavior takes over their lives — they are constantly body-checking and can be unhappy, dissatisfied, or have low self-esteem.

"Think about competitive athletics on the high school and college level. Lots of these guys are encouraged by coaches and trainers to take these supplements," says Cohn. "This isn't thought of as a negative behavior but can have negative consequences."

The silver lining, Achiro points out, is that 29 percent of study participants knew that they had a problem of overusing supplements. But they might not be aware of possible underlying psychological factors.

"Guys think taking supplements is healthy, [they're] convinced it's good for them, [it's] giving them all kinds of nutrients they wouldn't be getting otherwise," says Cohn. "[This is] ignorance about what proper nutrition is."

It's also not unusual for people diagnosed with body dysmorphic disorder or its characteristics to also have a high incidence of depression, anxiety and alcoholism, Cohn adds.

Although the research is preliminary and has yet to be peer-reviewed, Achiro hopes his research puts the issue on the map and encourages researchers to replicate his work.

"This is just the very beginning. There're still tons to look at," he says.

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Hospitals Turn To Toyota To Make Care Safer And Swifter

Fri, 08/07/2015 - 8:29am

Nursing attendant Tracie Bell helps manage patients at the ophthalmology clinic at Los Angeles County Harbor-UCLA Medical Center. The clinic created a color-coded system to reduce wait times for patients.

Anna Gorman/Kaiser Health News

Until recently, nurses at Los Angeles County Harbor-UCLA Hospital had to maneuver through a maze of wheelchairs, beds, boxes and lights to find surgical supplies in the equipment closet for the operating rooms.

But as public hospitals like Harbor-UCLA try to cut costs and make patients happier, administrators have turned to an unlikely ally: Toyota.

They are adapting the carmaker's production system to health care — changing longstanding practices such as how to store equipment, schedule surgeries and discharge patients. The philosophy, known as lean, depends on a continuous team effort to pare inefficiency and improve quality.

By using Toyota's methods as inspiration, the operating room staff at Harbor-UCLA was able to reorganize the closet — giving everything an assigned location and affixing easy-to-read labels — meaning nurses and doctors can now find what they need when they need it. This allows the team to mobilize more quickly.

"It saves time because they don't go looking for things — they know where they are," says Dawna Willsey, a clinical director at the hospital.

Private hospitals in places like Seattle and Wisconsin started using Toyota's system a decade or more ago. But the idea is newer to safety net hospitals — medical centers that historically have served large numbers of poor people. With the Affordable Care Act, these patients are gaining insurance coverage, and safety net hospitals are facing pressure to keep them from going elsewhere for care.

In California and elsewhere, some medical professionals have expressed skepticism that a process used to build cars can be translated into treating patients. Others are put off by the use of Japanese vocabulary in the hospitals' hallways, such as muda (waste) and jidoka (automation with a human touch). Still others doubt whether the changes are sustainable.

DeAnn McEwen, a health and safety specialist with National Nurses United, says lean management reduces nursing to a series of standardized tasks, as if nurses were robots applying nuts and bolts to identical patients.

"The problem with that is patients, of course, are not widgets and nurses are not robots," she says. "And nursing care is not a commodity but a service. It's a process that requires critical thinking and the application of judgment."

Research and experience from around the country, however, has shown that using Toyota's techniques in hospitals has can improve quality and safety for patients, says Kelly Pfeifer, director of high-value care at the California HealthCare Foundation. The foundation helped fund the project at Harbor-UCLA and four San Francisco Bay Area hospitals — San Francisco General Hospital, Contra Costa Regional Medical Center, San Mateo Medical Center and the Alameda Health System.

Changes inspired by the Toyota process have had direct, positive results, such as reducing the time patients spend at the hospital and decreasing medication errors, according to the foundation. They also have saved money. For example, reducing surgery cancellations at the San Mateo hospital saved nearly half million dollars, the foundation says.

Harbor-UCLA happens to be just a few miles from Toyota's U.S. sales headquarters in Torrance. After approaching the car maker for help, Harbor opened an office in 2013 dedicated to kaizen, the Japanese word for continuous improvement and a main tenet of the auto company's philosophy. Now, the hospital has a chief kaizen promotion officer, Susan Black, whose team is working closely with administrators, doctors, nurses, clerks and janitors to streamline and standardize everything it can.

Susan Black, chief kaizen promotion officer at Los Angeles County Harbor-UCLA Medical Center, reviews the quality and safety board in the ophthalmology clinic.

Anna Gorman/Kaiser Health News

"This is not a flavor of the month," Black says. "We have a real need to do better, to do more, improve our access and do it for less. That is part of our survival."

Toyota's strategy is based on making small changes that have a big impact, says Jamie Bonini, vice president of the Toyota Production System Support Center. Hospitals typically want to improve certain elements, such as medication error rates or appointment wait times.

Toshi Kitamura, a Toyota advisor, says he sees natural parallels between auto production and patient care. Organizing the equipment rooms and supply cabinets is the perfect example, he says.

"There was a clear translation," he says. "Just as in the hospital environment, in our environment ... we need to make sure we have all the tools and materials we need and we need to be able to find them quickly."

Unlike in a car plant, however, Kitamura says saving time can spare people pain and even save their lives.

Toyota officials say their philosophy has been honed over decades of quickly producing high-quality cars. The company's nonprofit arm, Toyota Production System Support Center, now provides consulting services to dozens of manufacturers, which pay a fee, and nonprofits, which don't.

At Harbor-UCLA, the effort started with an overhaul of the outpatient eye clinic. Administrators there say some patients were going blind while waiting for surgeries to be scheduled. And during clinic visits, some had to have their eyes dilated twice because they waited so long to see a doctor.

Working with Toyota, staff members picked up the pace: They created a system of color-coded folders so it became clear what patients were there for and who they needed to see. They stopped sending patients back and forth to the waiting room during their visits. They put a locked box in each exam room with prescription pads and other medications so doctors could spend more time with patients and less fetching what they needed to treat them.

"Before, it was total chaos," says Tracie Bell, a nursing attendant. "We had piles and piles of paper. With this new color-coded system ... it makes it a whole lot easier for us to do our jobs."

Within several months, staffers doubled the average number of new patients seen each day. In addition, the time patients spent at the clinic dropped from 4 1/2 hours to just over two. Surgeries also got scheduled more quickly.

Now, doctors and nurses at the primary care clinic downstairs are in the early stages of adopting Toyota's strategies.

This story is part of a reporting partnership between NPR and Kaiser Health News.

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Can A 32-Year-Old Doctor Cure Baltimore's Ills?

Thu, 08/06/2015 - 3:26pm
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Leana Wen hands out awards to business owners for their efforts to support breastfeeding at the Baltimore City Health Department on Tuesday.

Meredith Rizzo/NPR

Neighborhoods in Baltimore are still struggling to recover from the riots that broke out following the funeral of Freddie Gray, who suffered a fatal injury to his spine while in police custody. In the aftermath of the unrest, we here at NPR spent many hours trying to understand the raw anger on display. We looked at police brutality, economic disparities and housing segregation in Baltimore.

Our conversations eventually led us to Leana Wen.

Wen, a 32-year old emergency physician, had become Baltimore's health commissioner just a few months earlier. With Baltimore leading the news day after day, she seized the moment to get her message out, including on this blog, where she has been an essayist.

She wrote about the health department's immediate response to the unrest, making sure hospitals were protected and that staff and patients could get to them, and that ensuring seniors could still get prescriptions when their pharmacies were looted and burned.

After calm was restored, she turned her focus to the city's more chronic issues. For years, she argued, Baltimore has been traumatized by poverty, violence and drug abuse, problems that can be treated through public health.

"We have to make the case that actually, everything comes back to health," she told us in May. "My hope is that we can really make Baltimore into a model for the rest of the country to follow when it comes to treating the core roots of our problems."

A man walks past a blighted building in the Penn-North neighborhood of Baltimore.

Patrick Semansky/AP

That left us wondering, does everything actually come back to health? If so, what can you accomplish in city government? And can a health commissioner really make a difference?

Starting today, we're going to try to answer those questions. We're following Leana Wen over the coming months as she takes on some of Baltimore's thorniest problems. One thing already clear is that she's in a hurry.

Deputy Commissioner Olivia Farrow, a veteran at the health department, laughs remembering how Wen was holding meetings before she'd even officially started the job.

"Someone was telling me a joke," she says. "It's not 'Wen,' it's 'Went.' I mean, she's already ahead of you and gone, trying to make the fix."

New to Baltimore, Wen is relying heavily on Farrow and other senior staff to help her navigate the often murky politics of the city. Farrow believes Wen's lack of political experience is a plus.

"There's something about people who come from the outside," she says. "Just their ability to kind of say, 'Hey, let's think about things differently.' A lot of times that can rub people the wrong way. Some people survive that and some people don't."

Wen chats with a member of her staff at the Sandtown Winchester Senior Center.

Meredith Rizzo/NPR

Leana Wen was born in Shanghai and came to the United States at the age of 8. Her parents were Chinese dissidents who sought political asylum here, first landing in Logan, Utah, and a couple of years later moving on to Los Angeles. They lived in Compton and East Los Angeles, neighborhoods Wen describes as not so different from the poorer parts of Baltimore.

As a child, she dreamed of becoming a doctor. She entered college at the age of 13 and majored in biochemistry. After medical school, however, she was confronted by a sad reality. In the emergency room you can resuscitate victims of gun violence and overdose, she found, but you can't prevent them from returning over and over again.

"It is not a satisfying cycle for us to be in, when we're treating problems at the very end of those problems, rather than preventing them from happening in the first place," she recently told her staff.

Wen speaks during an ice cream social at the Sandtown Winchester Senior Center in Baltimore on Tuesday.

Meredith Rizzo/NPR

This summer, homicides in Baltimore have soared to levels not seen in four decades. The heroin epidemic is showing no sign of abating, and throughout the city there is a sense of frustration that no matter what happens, and no matter how many leaders speak out, nothing changes.

So Wen is asking her team to think big, to come up with innovative approaches to these festering problems. She believes that given all the focus on Baltimore since the death of Freddie Gray, this is a rare opportunity to act.

"I don't want that window of opportunity to close for us," she says. "I don't want to be the person who isn't leading us toward this vision at a time that's so critical in Baltimore's history."

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States Haven't Embraced Later School Start Times For Teens

Thu, 08/06/2015 - 1:03pm

Maybe she goes to school in Wyoming, where no schools start after 8:30 a.m.


Here's a number to help frame the debate over whether middle schools and high schools should start later in the morning: A study finds that only 18 percent of these public schools start class at 8:30 a.m. or later, as the American Academy of Pediatrics recommends.

The figure comes from a U.S. Department of Education survey conducted in the 2011-12 school year, so it predates the 2014 AAP recommendation for a later starting time. But assuming the situation hasn't changed much, most schools are not accommodating the sleep needs of teenagers.

Countless PTA meetings and school board sessions have been devoted to appropriate start times for schools. Public health officials say teenagers need more than eight hours of sleep a night, and early start times stand in the way.

Shots - Health News Pediatricians Say School Should Start Later For Teens' Health

"Obtaining adequate sleep is important for achieving optimal health," epidemiologist Anne Wheaton of the Centers for Disease Control and Prevention and her colleagues write in the latest Morbidity and Mortality Weekly Report, published Thursday. "Among adolescents, insufficient sleep has been associated with adverse risk behaviors, poor health outcomes and poor academic performance."

But changing the starting time for schools isn't so easy. Bus fleets that serve children from elementary to high school have to be scheduled to accommodate more than just the sleep-deprived teenagers. Later starts also push after-school activities later into the day — and potentially into dark winter evenings.

This survey finds that the push for later starting times has a long way to go. The survey of nearly 40,000 public middle schools and high schools found that only 17.7 percent started at 8:30 a.m. or later. High schools alone were even worse, with just 14.4 percent starting at 8:30 or later.

The northerly states of Alaska and North Dakota led the state-by-state tally published in MMWR, with nearly 80 percent of high schools and middle schools starting class after 8:30. The early bird states included Hawaii, Mississippi and Wyoming, where not a single school in the survey started later than 8:30 in the morning.

Teenagers are biologically inclined to stay up later, so early school starts generally cut short their sleep, the CDC report notes. Parents can help teens get more sleep by enforcing earlier bedtimes, the report suggests, and by limiting the use of TVs, game consoles, smartphones and other screens in the bedroom (which parents know is far more easily said than done).

"Among the possible public health interventions for increasing sufficient sleep among adolescents, delaying school start times has the potential for the greatest population impact," the study notes.

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Patients In Iowa Worry About Private Management Of Medicaid

Thu, 08/06/2015 - 12:02pm
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Brenda Hummel and her 7-year-old daughter Andrea in their home near Des Moines, Iowa. Andrea was born with severe epilepsy and gets her health care through Medicaid.

Clay Masters/Iowa Public Radio

Brenda Hummel's 7-year-old daughter Andrea was born with severe epilepsy. Like many children with significant diseases or disabilities, she has health insurance through Medicaid. Hummel navigated Iowa's Medicaid resources for years to find just the right doctors and care for her daughter. But now Iowa's governor, Republican Terry Branstad, is moving full speed ahead with a plan to put private companies in charge of managing Medicaid's services, and that has Hummel worried.

Everywhere in the Hummel household, there are signs of just how much care Andrea needs. Her bedroom, for instance, looks like a typical kid's room — stuffed animals, a frog light that shines images on the ceiling, and a butterfly mobile. But the bed stands out – the head of the bed goes up and down so Andrea can have her head elevated when she sleeps.

Shots - Health News Iowa Opens The Doors To Medicaid Coverage, On Its Own Terms

"When she was throwing up all the time when she was in a regular bed, I hardly got any sleep," Hummel explains, "because if I heard her coughing, I knew she was choking."

Andrea has this bed thanks to Medicaid — as well as her wheelchair and nurses, like Nate Lair who's been with the family for years. When Hummel gets home from work, Lair says, Andrea's personality changes.

"That's when she turns on the diva attitude," he says, laughing.

That diva attitude is significant progress. For years, Hummel says, her daughter showed very little personality. Seizures interrupted her development.

Now Andrea is able to go to school and do normal activities. But her mom worries that having a private business in charge of Medicaid will jeopardize the level of care Andrea gets.

"She hasn't been in the hospital for 2 1/2 years, I think," says Hummel. "So when they look at that, they may think, '[Her services] are not medically necessary. She's doing great and doesn't need these services that are costing money.' But, in my eyes, she can fall back to having seizures any time. We're not out of the woods at all."

Maybe it'll be OK, Hummel says, but she just doesn't know enough.

Medicaid serves a large population in Iowa. The state expanded Medicaid under the Affordable Care Act, and is now open to not only its traditional population — the poor and disabled — but also to adults who earn as much as about $16,000 a year for a single person, and as much as $32,000 for a family of four.

Amy McCoy, who is with Iowa's Department of Human Services, says patients will continue to receive the same care under the new system, and the changes will save money and streamline the services.

Iowa Senate President Pam Jochum wants to make sure the transition of Medicaid recipients to private companies has good oversight.

Clay Masters/Iowa Public Radio

"Some people might have five doctors," McCoy says. "Through this care-coordination effort, they can make sure everybody's on the same page with their treatment."

McCoy says having private insurers manage Medicaid is nothing new.

"Thirty-nine states are using some kind of managed care," she says. "So other people have done this. We have models to look after, and we have companies who have experience."

But a lot of states, including Kansas and Kentucky, have not done so well, says Pam Jochum, president of the Iowa Senate and a Democrat.

"You know, when I was a kid growing up my mother would say, 'If everybody jumps off the bridge, are you going to, too?' " Jochum says. "Of course not! The point is that just because everyone else is doing it doesn't make it better."

Families like Brenda Hummel's have a natural ally in Jochum; she, too, has a daughter with special needs who has been on Medicaid all of her life. Still, even with Jochum's opposition to the changes in Medicaid, the process in Iowa is moving forward. Gov. Branstad did not need legislative approval when he announced the switch to managed care in January.

In response, some lawmakers, including Jochum, insisted on a committee to oversee the transition and to make sure that consumers are treated fairly.

"There is no way," Jochum says, "you can put that many people into a system all at once, with various degrees of disabilities and need, and think anyone can manage that and manage it well."

Shots - Health News Health Insurance Startup Collapses In Iowa

Eleven companies have submitted bids to manage most of the $4 billion program, and Iowa plans to announce later this month which insurers will win the bid.

Brad Wright studies health policy at the University of Iowa. He says a lot of states have experimented with this idea, but on a smaller scale.

"They've not ... done what Iowa is proposing to do — or at least most have not done this — which is to put everyone into it," Wright says.

The only hurdle that stands in the way of approval, he says, is an OK from the federal government.

"If that happens," Wright says, "starting in January, it's full steam ahead."

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

Copyright 2015 Iowa Public Radio. To see more, visit
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On Yelp, Doctors Get Reviewed Like Restaurants — And It Rankles

Thu, 08/06/2015 - 5:00am
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Patient reviews of doctors tend to focus on non-medical issues like wait time, billing and front office staff.

Mahafreen H. Mistry/NPR

Dental patients really don't like Western Dental. Not its Anaheim, Calif., clinic: "I hate this place!!!" one reviewer wrote on the rating site Yelp. Or one of its locations in Phoenix: "Learn from my terrible experience and stay far, far away."

In fact, the chain of low-cost dental clinics, which has more Yelp reviews than any other health provider, has been repeatedly, often brutally, panned in some 3,000 online critiques — 379 include the word "horrible." Its average rating: 1.8 out of 5 stars.

Patients on Yelp aren't fans of the ubiquitous lab testing company Quest Diagnostics, either. The word "rude" appeared in 13 percent of its 2,500 reviews (average 2.7 stars). "It's like the seventh level of hell," one reviewer wrote of a Quest lab in Greenbrae, Calif.

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Indeed, doctors and health professionals everywhere could learn a valuable lesson from the archives of Yelp: Your officious personality or brusque office staff can sink your reputation even if your professional skills are just fine.

"Rudest office staff ever. Also incompetent. I will settle for rude & competent or polite & incompetent. But both rude & incompetent is unacceptable," wrote one Yelp reviewer of a New York internist.

ProPublica and Yelp recently agreed to a partnership that will allow information from ProPublica's interactive health databases to begin appearing on Yelp's health provider pages. In addition to reading about consumers' experiences with hospitals, nursing homes and doctors, Yelp users will see objective data about how the providers' practice patterns compare to their peers.

As part of the relationship, ProPublica gets an unprecedented peek inside Yelp's trove of 1.3 million health reviews. To search and sort, we used RevEx, a tool built for us by the Department of Computer Science and Engineering at the NYU Polytechnic School of Engineering.

Though Yelp has become synonymous with restaurant and store reviews, an analysis of its health profiles shows some interesting trends. On the whole people are happy — there are far more 5-star ratings than 1 star. But when they weren't, they let it be known. Providers with the most reviews generally had poorer ratings.

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Of the top 10 most-reviewed health providers, only Elements Massage, a national chain, and LaserAway, a tattoo and laser hair removal company with locations in California and Arizona, had an average rating of at least 4 stars.

Western Dental did not return phone calls and emails seeking comment.

Dennis Moynihan, a spokesman for Madison, N.J.-based Quest Diagnostics, said the company has more than 2,200 patient service centers around the country and had 51 million customer encounters last year. He said all feedback is valued.

"While one negative customer experience is one too many, we don't believe the numbers presented are representative of the service that a vast majority of our customers receive every day," he said.

For years, doctors have lamented the proliferation of online rating websites, saying patients simply aren't equipped to review their quality and expertise. Some have gone so far as to threaten — or even sue — consumers who posted negative feedback.

But such reviews have only grown in popularity as consumers increasingly challenge the notion that doctor knows best about everything. Though Yelp's health reviews date back to 2004, more than half of them were written in the past two years. They get millions of page views every month on Yelp's site alone.

In many ways, consumers on Yelp rate health providers in the same way they do restaurants: on how they feel they've been treated. Instead of calling out a doctor over botched care or a possible misdiagnosis (these certainly do happen), patients are far more likely to object to long wait times, the difficulty of securing an appointment, billing errors, a doctor's chilly bedside manner or the unprofessionalism of the office staff.

Health providers as a whole earned an average of 4 stars.

But sort by profession and the greater dissatisfaction with doctors stands out.

Doctors earned a lower proportion of 5-star reviews than other health professionals, pushing their average review to the lowest of any large health profession, at 3.6. Acupuncturists, chiropractors and massage therapists did far better, with average ratings of 4.5 to 4.6.

Other providers, like dentists and physical therapists, are "actively seeking out customers to review them, whereas doctors have a lot of antipathy toward reviews and as a result have been trying to suppress reviews for many years," said Eric Goldman, a professor at Santa Clara University School of Law and co-director of its High Tech Law Institute. He has written extensively about physician review websites and physician arguments against them, but did not review the Yelp data.

Doctor visits also tend to be more complex than visits to the dentist or chiropractor. A typical dental visit is for a specific service — a teeth cleaning, a cavity filled or a root canal. In general, expectations are clear, and ways to gauge success are easier than with a doctor visit.

Healthgrades, a site which focuses solely on health providers, also sees slightly lower ratings for doctors than for dentists and other health providers, though the differences are smaller than those on Yelp.

Unlike Yelp, Healthgrades, which says it has 6 million survey scores, has not allowed consumers to post comments. But Evan Marks, Healthgrades' chief strategy officer, said the health rating systems are in their infancy. Soon, he said, patients could see different questions based on the type of doctor they see to provide far more useful feedback to those searching the site.

None of this has yet gained favor with physicians. The American Medical Association encourages patients to talk to their doctors if they have concerns, not post views anonymously. And those looking for doctors should be similarly skeptical, the group says in a statement. "Choosing a physician is more complicated than choosing a good restaurant, and patients owe it to themselves to use the best available resources when making this important decision."

The AMA has called on all those who profile physicians to give the doctors "the right to review and certify adequacy of the information prior to the profile being distributed, including being placed on the Internet."

In 2012, the group partnered with a company called to offer discounts to doctors for a service that monitors their online presence and tries to combat negative reviews.

Western Dental's average rating of 1.8 stars on Yelp is well below the average of 4 for all dentists nationwide. About 1,250 of its 3,000 reviews used the words "wait" or "waiting" and about 15 percent of them, the word "worst."

When patients leave angry comments, the chain's "social media response team" often replies, inviting patients to call or email and citing a federal patient privacy law known as HIPAA for not responding in more detail. "Thank you for reaching out and providing the opportunity to improve our services. We hope to speak with you soon," the notes say.

At least one patient gave a Yelp follow-up review of the social media response team's performance: "I responded to the info in their response twice and got no reply at all ... they are just attempting to minimize the PR damage caused by undertrained and rude, lazy staff."

Periodically doctors, dentists and other providers threaten or even file lawsuits against people who post negative reviews on Yelp or against Yelp itself. Their track record is poor: Courts have ruled in favor of the company and various consumers.

In June, New Jersey resident Christina Lipsky complained in a 1-star review on Yelp that Brighter Dental Care had recommended $6,000 worth of work that a another dentist subsequently determined was unnecessary.

Within days, she received a letter from a lawyer who said he was retained by Brighter Dental "to pursue legal action against you and all others acting in concert with you." The letter was signed by Scott J. Singer, an attorney whose office is in the same building as a Brighter Dental clinic. A man named Scott Singer was also listed in 2012 as the non-clinical chief executive officer of Brighter Dental. Singer did not return a call or email seeking comment.

After Lipsky took her story to local media, Singer sent her a letter saying Brighter Dental was dropping its legal pursuit. In an email to ProPublica, Lipsky said "People put a lot of trust into their health care providers, and if my review could help others make an informed decision regarding their treatment, then it was worth it."

Charles Ornstein is a senior reporter at ProPublica, an independent nonprofit newsroom.

Copyright 2015 ProPublica. To see more, visit .
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Sharing Art Helps Medical Students Connect With Dementia Patients

Wed, 08/05/2015 - 4:11pm

A New York study found that getting medical students together with dementia patients and their families at museums to view, discuss and create art for 90 minutes made the students better communicators.

Colin Hawkins/Getty Images

Hannah Roberts was a first-year-medical student at Columbia University College of Physicians in 2013 when she noticed her classmates were having an especially tough time relating to dementia patients.

"There's a misconception that dementia patients are like toddlers in a way," Roberts says. Many medical students, she says, "are intimidated at the challenge of having to get accurate histories and establish a connection with someone who has a limited ability to communicate."

Inside Alzheimer's

Roberts had some previous work experience with Alzheimer's patients and knew the encounters didn't have to be so strained. "These are adults who've led full rich lives, who have lots of knowledge and personalities that are still very present," she says. But that's not always initially apparent "unless you dig a little."

Could a field trip together to the local art museum help?

Roberts and one of her teachers, Dr. James Noble, a neurologist at Columbia University Medical Center, suspected it might. The results of their small study, recently published online in the medical journal Neurology, suggests they may be on to something important.

Noble has been interested since 2009 in how Alzheimer's patients express themselves through art. He noticed in other art programs aimed at patients and their families that discussing and making art can cement emotional connections and transform relationships in other ways.

"An adult son would be sitting next to their mom and dad; something would be said, and the son would suddenly realize his father could still do more than he thought possible," Noble says.

Noble went on to start his own nonprofit, called Arts & Minds, to provide museum-based experiences for people with dementia and their caregivers. The program has been running in the Studio Museum in Harlem for about five years and at the New York Historical Society for roughly three years.

But the idea of bringing medical students along was something new.

Roberts and Noble recruited 19 medical students for their study. Students, family and patients gathered in a gallery or museum to view, discuss and create art together for 90 minutes.

Before and after the session, the medical students completed the standardized Dementia Attitudes Scale survey, answering 20 questions about their comfort level and knowledge of dementia. They were asked to rate statements such as, "I feel confident around people with Alzheimer's diseases and related disorders" or "people with Alzheimer's disease and related disorders can enjoy life."

The students' scores afterward suggested a "modest increase" in comfort level in dealing with dementia patients, the researchers say, but the students' comments suggested the lessons ran even deeper.

"It gave us a chance to interact with patients with dementia in a context where their dementia isn't the main focus," one student told the researchers. "We get to see what they are capable of — more so than what they are incapable of — which so often is what cognitive tests force a patient to do."

"It's frightening to take care of someone you don't understand," says Marcia Childress, associate professor of medical education at the University Of Virginia School Of Medicine. Childress wasn't involved in the Columbia study but co-wrote an editorial about the experiment in the same issue of Neurology.

"It's important for students to see people with chronic illnesses that affect their function and daily life and to see them outside a clinical setting," Childress says. "What is it like to be housebound? What is it like to be the caregiver — to see this and appreciate the burden."

Such lessons are only getting more important. An estimated 5.3 million Americans have Alzheimer's disease, with the number of cases steadily rising.

Will this changed perspective among the students last?

"We don't know," says Noble. But he sure hopes so and plans to follow up.

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HIV Prevention Pill Remains A Tough Sell Among Gay Latinos

Wed, 08/05/2015 - 1:09pm

Louis Arevalo holds his Truvada pills at his home in Los Angeles. The drug can be over 90 percent effective at preventing spread of HIV.

Heidi de Marco/Kaiser Health News

At the New Jalisco Bar in downtown Los Angeles, a drag show featuring dancers dressed in sequined leotards and feathered headdresses draws a crowd on a Friday night, most of them gay Latino men.

Inside the bar and out, three health workers chat with customers, casually asking questions: Do you know about the HIV prevention pill? Would you consider taking it? A few men say they have never heard of it. Others simply say it isn't for them.

"It hasn't really hit the Latino community yet," Jesse Hinostroza, an HIV prevention specialist with AltaMed health clinics, says while sitting at a table with a bowl of condoms and a stack of bilingual pamphlets about the pill. "They aren't educated about it."

In California, New York, Texas and elsewhere, health workers are trying to get more high-risk Latino men to use the drug, Truvada. AltaMed's efforts are being paid for by Gilead, the pharmaceutical company that makes Truvada.

The medication, which is used for "pre-exposure prophylaxis," or PrEP, was approved by the FDA in 2012 for HIV prevention and has been shown to be more than 90 percent effective when used correctly. But health workers are encountering barriers among Latinos.

Those barriers include a lack of knowledge about the drug, and the stigmas attached to sleeping with men and to perceived promiscuity. Many Latinos also have concerns about costs and side effects.

"Even for people who have heard about it, [these concerns make] them reluctant to use, or hesitant to even inquire about, it," says Phillip Schnarrs, assistant professor of health promotion at the University of Texas at San Antonio and research director for the Austin PrEP Access Project.

Schnarrs, who is conducting a study with gay and bisexual Latino men in Texas, says 58 percent of those surveyed see themselves as good candidates for PrEP, compared with 82 percent of non-Hispanic whites, according to preliminary data.

In an ongoing study of 20 Latino gay couples in New York City, 37 of the 40 people had never heard about PrEP when interviewed last year, says Omar Martinez, assistant professor of social work at the Temple University College of Public Health.

Martinez says doctors and health workers need to focus on reaching young minority men at highest risk of getting HIV and transmitting it to others, including those who don't regularly use condoms.

"We need to do something," he says. "And PrEP may be the solution."

Latinos are disproportionately affected by HIV. They make up about 21 percent of new infections nationally, though they represent about 17 percent of the population, according to the Centers for Disease Control and Prevention. Latinos are also more likely than non-Hispanic whites and blacks to get diagnosed later in the course of their illness, raising the risks to their health and the likelihood of transmission to others.

At the same time, Latinos are less likely than non-Hispanic whites to be insured or have a regular doctor, although the Affordable Care Act has helped reduce that gap.

Truvada can cost up to $1,300 a month. Most insurance companies and Medicaid programs are covering at least part of that, and many local governments are also covering the pill for uninsured residents. But the high sticker price can dampen interest among patients.

Truvada, which blocks the virus from spreading in the body, is helping to significantly reduce new infections, says Robert Grant, a professor at the University of California, San Francisco School of Medicine who leads research on PrEP's effectiveness.

But the pill does not protect against other sexually transmitted diseases, requires daily use and can cause side effects in some patients, including kidney problems.

"It is a very valuable option, but it is only one option," Grant says. "Condoms are still a very important part of a sexual health strategy."

Back at the New Jalisco Bar, while customers dance to traditional Mexican music beneath a disco ball and rainbow lights, Jaime Cardenas conducts HIV tests in a mobile unit parked in front. Anyone who tests on the spot receives a free drink coupon, courtesy of AltaMed and the bar.

One of the first to agree is Erik Quezada, 35, a counselor at a Los Angeles high school. Cardenas draws a few drops of blood and within minutes gives Quezada the good news: He doesn't have HIV. Cardenas quickly follows up with information about the HIV prevention pill. Quezada says he has heard it's like a birth control pill for gay people. He agrees to be contacted by phone but quickly adds, "I don't know I would ever sign up for it."

Erik Quezada, 35, says he has heard Truvada is like the birth-control pill for gay people. Quezada, a counselor at a Los Angeles high school, says he's not sure he would sign up for it.

Heidi de Marco/Kaiser Health News

Others are even less interested. Jose Arriola, 25, a self-described "diva," says he doesn't want to take any medication. "It's better to use condoms," he says, sitting by his boyfriend at the bar.

A short video produced by AltaMed plays between acts at the bar. The video features different Latino men getting dressed: a cowboy for a night out, a day laborer for work, a buff young man for the gym. Each takes the HIV-prevention pill as part of their routine.

"We are really trying to project the message that taking PrEP can be a normal part of your everyday life," says Dr. Scott Kim, medical director of HIV Services for AltaMed, which runs more than 40 health clinics in Southern California.

That, he hopes, will reduce stigma. Kim says health workers need to be more creative in places like East Los Angeles, where many gay and bisexual Latinos are still in the closet and aren't getting information through traditional health-care sources. Talking about PrEP at a doctor's office may not be as effective as doing so on social media, by text message or in a bar, he says.

"There are a lot of social obstacles and challenges we have to negotiate here because it's harder to be out," Kim says.

The goal of Gilead's $80,000 grant to AltaMed is to help 100 high-risk gay Latino men throughout Los Angeles County get prescriptions for PrEP. The grant pays for the outreach but does not cover the cost of the medication.

Since the project began late last month, about half a dozen patients have received prescriptions. Hinostroza of AltaMed says there is more interest and more knowledge in gay-friendly Hollywood and West Hollywood.

"But for East Los Angeles, where we are, it's a struggle," she says.

Louis Arevalo, 27, a college student and AltaMed patient who lives in Los Angeles, says he decided to go on the medication last month after getting scared when a condom broke. But Arevalo says he understands the stigma that might prevent others from taking the drug. For years, he says, he has hidden his boyfriends from his mother, an immigrant from El Salvador. Arevalo says her church pastor repeatedly says that homosexuality is a sin.

Louis Arevalo, 27, says he decided to go on the medication last month after getting scared when a condom broke. The college student from Los Angeles says he uses the pill as an extra layer of protection.

Heidi de Marco/Kaiser Health News

"It's just part of the culture, and it's the religion," he says.

AltaMed's efforts are just one part of a larger effort to get the word out about Truvada. The nonprofit Latino Commission on AIDS, based in New York, also recently started a campaign in five cities — Long Beach, Calif.; New York City; Chicago; Miami; and San Juan, Puerto Rico.

Gustavo Morales, the commission's director of access to care services, says now is the time to educate people about PrEP, lest too many people form negative opinions about it and health workers become "like salmon swimming against the current."

Morales says patients aren't the only ones who need more information. When he decided to go on PrEP late last year, he went to two different doctors who didn't know about Truvada. A third asked him why he wanted to poison himself. Finally, he got a prescription from an HIV specialist.

"I was definitely disappointed," says Morales. "There is a lot of work that still has to be done."

This story is part of a reporting partnership between NPR and Kaiser Health News.

Copyright 2015 Kaiser Health News. To see more, visit
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Untangling The Many Deductibles Of Health Insurance

Wed, 08/05/2015 - 6:08am
Illustration Works/Corbis

Sure, there's a deductible with your health insurance. But then what's the hospital deductible? Your insurer may have multiple deductibles, and it pays to know which apply when. These questions and answers tackle deductibles, whether an ex-spouse has to pay for an adult child's insurance, and balance billing.

Recently I took my son to see a pediatric gastroenterologist. When I arrived at the office, I saw it was located adjacent to the hospital. My insurance has a large hospitalization deductible so I worried that the visit would not be covered. Nobody in the office could tell me how much an office visit would cost. Why not? Isn't that something I should be able to expect?

Your plan's hospital deductible won't affect how much you pay for the visit to the specialist, whether or not his office is affiliated with the hospital, says Richard Gundling, vice president at the Healthcare Financial Management Association, a professional group.

Here's how it works. Most health plans have medical deductibles that must be satisfied before the plan starts paying for most services. Preventive care is an important exception; there's no deductible for that. Some plans like yours also have separate hospital deductibles. But your hospital deductible would generally only come into play if you were admitted as an inpatient.

"Even if the facility is hospital based, her visit would still be an outpatient procedure and wouldn't affect her hospital deductible," Gundling says.

Though your hospital deductible wouldn't be an issue in this case, if your plan has a regular medical deductible and you haven't yet satisfied it for the year, you may have to pay for the specialist visit anyway.

The doctor's office should have been able to tell you how much the office visit would cost, Gundling says, but you may be better off checking with your insurer to find out how much you'll actually owe out of pocket. Your insurer will have information about both how much it has agreed to pay the provider for an office visit and how much you'll owe based on your health plan deductible and copayment details.

I have insurance coverage through the Affordable Care Act's marketplace. When I visited a cancer clinic for a routine blood check, I asked upfront three times (first over the phone and again when I was there) if all services would be in-network. The answer was yes each time. Afterward I received a bill from an out-of-network lab for $570. Is there anything I could have done to avoid this charge?

In theory, you could have asked the clinic for the name of the lab that it would use for your blood work and checked with your insurer to make sure that it too was in network, says Kevin Lucia, a senior research fellow at Georgetown University's Center on Health Insurance Reforms who co-authored a recent study on state efforts to protect consumers from surprise out-of-network bills.

However, "that seems to be a lot of work for the consumer," Lucia says.

New rules take effect next year for plans sold on the marketplace that will require health plans to maintain up-to-date lists of providers that are easily accessible to consumers.

A CMS official was unable to clarify whether plans must also provide up-to-date listings of labs in addition to other providers.

In the meantime, check with your insurer, Lucia advises. It's not unusual for providers to bill patients for services that are ultimately covered by their plan.

My ex-husband is responsible for health care premiums for our dependent daughter who will turn 21 in October. Under the Affordable Care Act, children can remain on their parents' plans until age 26, but my ex is planning to drop our daughter's coverage when she turns 21. Can he do that?

Yes, he probably can. Although the law requires health plans to offer coverage until adult children turn 26 in most instances, there's nothing that requires parents to provide it. If your divorce agreement required him to pay for your daughter's health insurance until she turns 21, his obligation will likely be satisfied at that point.

If your ex-husband chooses to drop your daughter's coverage and she doesn't sign up for her own plan, however, he may be on the hook for any financial penalty she owes for not having insurance.

Under the health law, most people have to have insurance or face penalties. In 2015, the penalty is the greater of 2 percent of household income or $325 per person.

If he claims her as his dependent, "When he does his taxes he'll have to show that everyone in his household has insurance, and then he'll have to pay the penalty," says Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

Since she's part of his household, the penalty would be based on his income, not hers.

As for your daughter, if she loses coverage she'll be eligible for a special enrollment period to sign up on the exchange, or she may be eligible for Medicaid if she lives in one of the roughly two-thirds of states that have expanded coverage to adults with incomes up to 138 percent of the federal poverty level, currently $16,243.

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