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Health Connector: Insurance Signups Up, But Many Unpaid

CommonHealth (WBUR) - Fri, 12/19/2014 - 3:32pm

The Massachusetts Health Connector is preparing for a signup surge as the state’s deadline for enrolling in 2015 insurance coverage approaches.

The agency says more than 100,000 residents who must pay some or all of their premiums have registered online, but so far, only 18 percent have chosen a plan and paid.

Still, those 18,000 people are double the number who had paid a week ago.

The deadline is Tuesday for those who want to be covered on the first of the year. The site’s director, Maydad Cohen, is urging residents to take action this weekend.

“Because we expect high, high volumes Monday and Tuesday,” Cohen said. “High volume typically results in longer wait times. And we do want to make sure people can access health insurance, and make sure that they pick and pay for that plan.”

The Connector office will be open during the day for residents who do not have access to a computer.

Categories: Health Care

Magna Carta Replica in the Capitol Crypt

In Custodia Legis - Fri, 12/19/2014 - 1:43pm

The Magna Carta replica in the Capitol crypt was presented to Congress by the British Parliament in 1976. [Photo by Donna Sokol]

If you are planning a trip to Washington, D.C., to see the Magna Carta exhibition, may I suggest another stop on your itinerary?  You’ve heard the phrase “hidden gem,” but the object I am sharing with you today truly takes that term to a new level.  It is a Magna Carta replica tucked into the crypt of the Capitol Building (“hidden”) and encrusted with jewels (“gem”).  It is part mini-monument, part objet d’art.

While I think this is something that must be appreciated in person, the panel accompanying the replica provides a good description and gives its background:

Magna Carta Replica and Presentation Case

Gift of the Parliament of the United Kingdom of Great Britain and Northern Ireland

This display features a presentation case with a gold replica of the English document whose principles underlie much of the United States Constitution.  Magna Carta (Latin for “Great Charter”) was sealed by King John of England in 1215 after his barons, dissatisfied with his capricious rule, united to limit the king’s powers and forced him to agree to its contents.  Magna Carta forbade arbitrary arrest and imprisonment, established rights to a fair trial and to security of property, and guaranteed that the nation’s government was bound by the same laws as its subjects.

Centuries later, the English colonists in North America were inspired to reassert these rights and liberties.  America’s Declaration of Independence and Constitution were founded upon the basic principles of Magna Carta.

The stainless steel presentation case, which is clad in gold and white enamel tiles intended to suggest feathers, contains two gold panels.

The panel in the front is inscribed with a replica of Magna Carta and holds gilded replicas of the two sides of King John’s seal.  On the vertical glass panel is the English translation of Magna Carta.

On the gold plate at the bottom of the upper half of the case, images of opposites, including the sun and the moon and Adam and Eve, are engraved in contemporary stile and highlighted with pearls and gems.  Fifty diamonds above a dove represent the fifty states.  Above the plate a three-dimensional tree of life springs from the four rivers of paradise.  Around the trunk a snake, representing evil, coils below the Apples of Original Sin and mistletoe.  The tree branches hold the Tudor Rose for England, the shamrock for Ireland, thistles for Scotland, and daffodils for Wales.  From oak leaves and acorns, for Britain, rises the Royal Coat of Arms, with the gold lion and silver unicorn set with precious gems under a crown.  The brilliant colors were created with enamel.

The presentation case rests upon a slab of polished pegmatite, a volcanic stone.  The pedestal of the display case is made of Yorkshire sandstone.

The presentation case was designed by Louis Osman (1914-1996), who had made the crown for the investiture of Prince Charles.  He was assisted by thirty craftsmen, among them his wife, Dilys, who did the enameling.  The display was presented to the United States Congress by the Parliament of the United Kingdom to celebrate the bicentennial of American independence.  Representatives of the Parliament and the Congress formalized the gift at a ceremony in the Capitol Rotunda on June 3, 1976.  The earliest extant original copy of Magna Carta was displayed in the case atop the gold replica for one year and then was returned to England.

The display remained in the Rotunda until 2010.  During its move to this location, the presentation case was conserved.

Detail from the glass panel. The inscription is the English translation of Magna Carta. [Photo by Donna Sokol]

To see this Magna Carta replica, you will need to be on an official tour of the Capitol.  Lucky for you, the Library of Congress Jefferson Building is connected by a tunnel to the Capitol Visitors Center, so you can pop over after seeing our Magna Carta exhibition.


The Library of Congress is commemorating the 800th anniversary of Magna Carta with an exhibition – Magna Carta: Muse and Mentor, a symposium, and a series of talks.  Through January 19, 2015, the Lincoln Cathedral Magna Carta, one of four remaining originals from 1215 is on display along with other rare materials from the Library’s rich collections to tell the story of 800 years of its influence on the history of political liberty. 

Categories: Research & Litigation

Pediatric Politics: How Dire Warnings Against Infant Bed Sharing ‘Backfired’

CommonHealth (WBUR) - Fri, 12/19/2014 - 11:39am


By Dr. Melissa Bartick
Guest Contributor

Every new parent has heard the dire warning: Never sleep with your baby.

State and local health departments in Massachusetts and around the U.S. have prioritized this message. Millions of dollars have been invested in promoting it, and millions more spent on giving away cribs to poor families. It all comes from the official recommendations of the influential American Academy of Pediatrics published in 2011.

Some localities have even backed this message up with scary ads: a baby in an adult bed with a meat cleaver, stating “Your baby sleeping with you can be just as dangerous,” and another ad that says “Your baby belongs in a crib, not a casket.”

Studies Misrepresented

The problem with this widespread advice is that the AAP’s statement from which it comes is based on just four papers. Two of the studies are misrepresented, and actually show little or no risk of sharing a bed when parents do not smoke, and two of the studies do not collect data on maternal alcohol use, a known and powerful risk factor.

In addition, the AAP statement ignores many other more recent excellent papers that are not even mentioned or cited. My colleague, Linda J. Smith, and I recently published an analysis of all AAP’s statement and all the literature to date, “Speaking out on Safe Sleep: Evidence-Based Sleep Recommendations.” Along with this dissection of the AAP statement, we found that that any risk of death from a parent sharing a bed with an infant is greatly overshadowed by other risks that get far less attention.

Dangerous Sofas

We concluded that the only evidence-based universal advice to date is that sofas are hazardous places for adults to sleep with infants; that exposure to smoke, both prenatal and postnatal, increases the risk of death; and that sleeping next to an impaired caregiver increases the risk of death.

Formula feeding increases the risk of Sudden Infant Death Syndrome. No sleep environment is completely safe. But public health efforts must address the reality that tired parents must feed their infants at night somewhere and that sofas are highly risky places for parents to fall asleep with their infants.

The fact is, across the United States and the world, across all social strata and all ethnic groups, most mothers sleep with their infants at least some of the time, despite all advice to the contrary, and this is particularly true for breastfeeding mothers.

When You Avoid Bed Sharing

Unfortunately, we also know that parents who try to avoid bed sharing with their infants are far more likely to feed their babies at night on chairs and couches in futile attempts to stay awake, which actually markedly increases their infants’ risk of suffocation.

According to a 2010 study of nearly 5,000 US mothers, “in a possible attempt to avoid bed sharing, 55% of mothers feed their babies at night on chairs, recliners or sofas. Forty–four percent (25% of the sample) admit that they [are] falling asleep with their babies in these locations.” Rather than prompting an immediate review of its original 2005 infant sleep recommendations, the AAP chose to completely ignore this data when it rewrote its sleep recommendations it published in 2011.

Advice Backfired

As states have adopted the AAP 2011 recommendations, the advice to never sleep with your baby has backfired in the worst possible way. Rather than preventing deaths, this advice is probably even increasing deaths. Included in 2009 study that the AAP even cited in its statement for other conclusions, parents of two SIDS babies who slept with their infant on a sofa did so because they had been advised against bringing their infants into bed but had not realized the dangers of sleeping on a sofa. In fact, deaths from SIDS in parental beds has halved in the UK from 1984-2004, but there has been a rise of deaths from cosleeping on sofas.

In contrast, medical authorities in Canada, Great Britain, and Australia have different messages than the American Academy of Pediatrics. They all acknowledge that most mothers do share a bed with their infant at least some of the time. If one chooses to bedshare, they educate the public on risks and on ways to markedly decrease the risk of infant death.

In addition, research shows that bedsharing facilitates breastfeeding and is associated with longer breastfeeding duration.

Breastfeeding mothers who try not to share a bed with their baby either end up giving up breastfeeding or bed share anyway. The nutritional content of human milk necessitates frequent feeding both day and night and frequent close contact.

The Formula Risk

But one of the biggest risk factors, formula feeding, is not discussed at all in social marketing campaigns to prevent infant deaths. It may be more effective to support women to stick with breastfeeding than it is to convince them not to sleep with their babies. 

If advice not to bedshare may inadvertently end up decreasing breastfeeding duration, that would affect many diseases in addition to Sudden Infant Death Syndrome and infant suffocation. Breastfeeding duration impacts obesity, a host of infections of infancy, and breastfeeding duration affects a host of maternal diseases as well. 

Suboptimal breastfeeding duration in the U.S. results in nearly 5,000 excess cases of breast cancer per year, nearly 14,000 excess heart attacks per year, and over 50,000 excess cases of high blood pressure per year. Thus, any recommendations that may negatively impact breastfeeding must take into account all the health implications of breastfeeding, not just a single disease.

Telling mothers never to share a bed with their infants is a message doomed to fail, and has likely contributed to at least some infant deaths on sofas.

The lowest hanging social marketing fruit: Ads educating people about the dangers sofas and recliners would go a long way to decreasing risk of death, provided that women also got the message that a bed is a safer place to feed their baby than the couch or recliner. If we are serious about preventing infant deaths, we should be also focusing on parental smoking and supporting mothers to breastfeed and decreasing sleeping with a parent under the influence of alcohol or drugs.

Rethinking Sleep

The AAP is in the process of revising its safe sleep recommendations, and this effort could not come too soon. Let’s hope that they take into account all available literature and the unintended consequences of their current recommendations to make sure their recommendations do not result in unintended deaths.

Melissa Bartick, M.D., M.Sc, is an assistant professor of medicine at Harvard Medical School and internist at Cambridge Health Alliance.

Categories: Health Care

Armpit Fat? There’s A YouTube Video For That

CommonHealth (WBUR) - Fri, 12/19/2014 - 10:54am
[Watch on YouTube]

By Jessica Alpert

Did YouTube kill the video star?

That’s what some fitness-types are saying. Consumers can access exercise programs of all stripes. From old-world Jack LaLanne to ’80s Jane Fonda, from Insanity to the current YouTube HIIT (high intensity interval training) sessions — the American fitness diet continues to evolve. At the moment, it’s all about free and on-demand.

When Cassey Ho made her first YouTube exercise video, she had her pilates students in mind. Thirty of them. It was 2009 and Ho had recently moved from California to Boston to try a career in fashion buying. A few months later, she checked in on that YouTube video and there were thousands of views.

So she decided to make more.

The Blogilates App allows users to search for fellow “POPsters” in their area. (Courtesy of Cassey Ho/Blogilates)

By 2011, Cassey Ho was posting one video a week, calling her unique brand of pilates “POP Pilates,” essentially pilates to pop music. She named her channel “Blogilates” and an empire was born. Today, Cassey Ho was 1.8 million subscribers to her YouTube channel — 60,000 page views a day and 8 million views a month.

Ho credits humility as key to her success. “I think the reason for it’s [Blogilates] growth is the fact that I love teaching. I genuinely want to help people.”

Reach people she does — Blogilates is now the top fitness channel on the network. Ho also has a book deal, a DVD release and more original designs from her clothing line in the works for 2015.

YouTube has become the DIY video destination, from cupcakes to cosmopolitans, appliance repairs and yes — ab workouts — there’s a video for every problem. Even armpit fat. Huge audiences combined with social media savvy has made the everyday people who dole out this advice into celebrities. “People cry and shake and get crazy when they see me,” says Ho. She occasionally does tours to give live classes around the country. “When you go to Blogilates meet-ups, there are hundreds of people there and I get to hear their stories…and how these videos helped them battle eating disorders, lose a ton of weight. They are so positive and kind — they don’t mind having to wait five hours in line to meet me.”

[Watch on YouTube]

And it’s these young enthusiastic fans that are driving the YouTube content bonanza. In the first quarter of 2014, according to Nielsen, consumers aged 18-24 viewed 2 hours and 28 minutes of online videos per week — that’s nearly an hour more than the average for all adults.

Cassey Ho isn’t alone. There’s the two friends behind “Tone It Up,” Elliot Hulse who creates videos like “Exercise for Heartbreak and Pain,” and the husband and wife team behind “Fitness Blender” (known simply as Daniel and Kelli). Daniel and Kelli started their channel in their garage — in fact they still record videos there.

According to OpenSlate, a video analytics platform that analyzes all ad-supported content on YouTube, Fitness Blender averages around 8 million views per month. In an introduction video, Daniel explains that they started their channel because they “there weren’t any fitness websites out there that actually focused on fitness — they were all about make-up, all about clothes, all about what you look like — not about what you do.” Kelli adds that “everyone should have access to health fitness information regardless of their income or access to a gym.”

Tolga Ozyurtcu, a clinical assistant professor in the department of kinesiology and health education at the University of Texas at Austin, says the YouTube brand of exercise is more “personalized and more personal.

“In the past, the marketplace of exercise television or videos had to be more middle-ground…the new stuff is hyper-focused.”

From Jack LaLanne to Jane Fonda

YouTube fitness gurus join the complex and interesting history that is American fitness. Jack LaLanne opened the very first modern Health Club in 1936 in Oakland. He then became a fixture on the Santa Monica “Muscle Beach” scene, often called the birthplace of 20th century physical fitness. The original Muscle Beach dates back to the 1930s and was literally a section of beach with Works Progress Administration (WPA) installed fitness equipment and platforms.

Ozyurtcu, who has studied Muscle Beach, likes to call it the “CBGB scene for fitness….nothing sounds the same or looks the same but they all get each other.” LaLanne worked out next to Vic Tanny the man who created the first high-end fitness club (think cucumber water and beautiful spa-like amenities). Joe Weider was there, too — the creator of the contemporary fitness magazine such as Shape and Men’s Fitness. Weider was the first person to focus on “looking good naked,” says Ozyurtcu. Muscle Beach also proved important for women. It was here that women were introduced to barbells and dumbbells. According to Ozyurtcu, Muscle Beach made it “good for women to exercise and lift weights…you can be beautiful and strong and have curves.”

LaLanne made women’s fitness his business. He began broadcasting his half-hour television show in 1951 and ending in the early 1980s. He often started an episode by asking for help. “Boys and girls….wherever mother is, grab her by the arm and tell her ‘mother, come quick over to the television.” But as Slate’s Emily Yoffe so eloquently put it — “these vintage workouts are barely more strenuous than brewing a pot of tea.”

[Watch on YouTube]

Jane Fonda arrived in the 1980s and her first video “Workout” sold 17 million copies, making it one of the best selling videos of all time. She told the Daily Mail in 2012 that her earlier workouts were about “going for the pain.” The endless leg lifts weren’t just supposed to make you burn — she was aiming for agony. Fast forward to Cassey Ho and her HIIT videos: endless planks, ceaseless push-ups, scores of sit-ups. The pain is still there but the vibe has shifted. Unlike Fonda, Cassey Ho makes you feel like she’s suffering, too. It’s that accessibility and friendliness that attracts legions of fans, according to Ozyurtcu. You don’t just work-out with Cassey Ho; if you follow her on Instagram, you know what she ate for breakfast.

But Are YouTube Videos Safe?

One of Eddie Phillip’s biggest goals in life is to get people moving.  As a Harvard Medical School professor and founder and Director of the Institute for Lifestyle Medicine at the Joslin Diabetes Center, he’s made exercise his business. While he can’t endorse any specific YouTube fitness plans, he does think it’s a good thing. “We have to bottle that momentum….if it takes a bra commercial to get someone moving, whatever … it’s not like medicine has figured this out.” Phillips is primarily focused on the couch potato.  “There is a saying in medicine ‘don’t take a temperature unless you’re willing to treat a fever.’ ”

A prescription from Dr. Deborah Cohan, a physician in San Francisco. (courtesy Deborah Cohan)

So if your patient is obese, prescribe exercise. Literally. His “Exercise is Medicine” program now has 43 chapters around the world with doctors taking a more active interest and role in their patient’s levels of physical activity.

Eddie Phillips watched a Blogilates video for this article. So is it safe? “Sedentary behavior will universally harm you.” he says. “Everything has a relative risk. It’s relative to the most dangerous thing you can do….going from 0-60. You are on the couch and if Jan. 1 rolls around and say I’m 65 with heart disease and I do 1,000 planks…you’re probably still ahead of the curve compared to sitting on the couch.”

Phillips points out that many of the most famous and powerful fitness gurus were not traditionally trained. As Jane Fonda points out, when she was approached to create her first video she had misgivings: “[I said] No way, I’m an actor and it would be bad for my career.” Richard Simmons has a BA in Art but that didn’t stop him from producing 65 videos selling over 20 million copies.

Jane Roper, a mother of twin girls, gets it. When she can’t do her five-mile run, she clicks on a video from the PopSugar channel. “I like the variety of workouts available, so I don’t get bored. The vibe is ridiculously enthusiastic — fit, pretty, preternaturally peppy women with ponytails. I think if I was in a live version of those workouts, I’d feel sort of annoyed and embarrassed by the psychotic level of positivity and encouragement, but in the privacy of my living room or home office I don’t mind it — and it actually seems to work.”

The key when starting any fitness routine is using commonsense, says Phillips. “Life is not without risks.  I would rather see my patients do a YouTube video than sitting on the couch.”

Categories: Health Care

Hospital-Acquired Condition Penalties By State

Kaiser Health News - Fri, 12/19/2014 - 10:18am

Medicare is reducing payments to 721 hospitals with high rates of infections or other medical complications. About 1,400 hospitals, including all in Maryland, are excluded from the program and Medicare did not assess their rates of patient harm.
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Categories: Health Care

721 Hospitals Penalized For Patient Safety

Kaiser Health News - Fri, 12/19/2014 - 10:08am

Medicare is penalizing 721 hospitals with high rates of potentially avoidable mistakes that can harm patients, known as “hospital-acquired conditions.” Penalized hospitals will have their Medicare payments reduced by 1 percent over the fiscal year that runs from October 2014 through September 2015. To determine penalties, Medicare evaluated three types of HACs. One is central-line associated bloodstream infections, or CLABSIs. The second is catheter-associated urinary tract infections, or CAUTIs. The final one, Serious Complications, is based on eight types of injuries, including blood clots, bed sores and falls. Here are the hospitals that are being penalized: ( function() { var func = function() { var iframe_form = document.getElementById('wpcom-iframe-form-229dd7b4561f1d02fbcc32a1f42b4ac7-5494788759178'); var iframe = document.getElementById('wpcom-iframe-229dd7b4561f1d02fbcc32a1f42b4ac7-5494788759178'); if ( iframe_form && iframe ) { iframe_form.submit(); iframe.onload = function() { iframe.contentWindow.postMessage( { 'msg_type': 'poll_size', 'frame_id': 'wpcom-iframe-229dd7b4561f1d02fbcc32a1f42b4ac7-5494788759178' }, window.location.protocol + '//' ); } } // Autosize iframe var funcSizeResponse = function( e ) { var origin = document.createElement( 'a' ); origin.href = e.origin; // Verify message origin if ( '' !== ) return; // Verify message is in a format we expect if ( 'object' !== typeof || undefined === ) return; switch ( ) { case 'poll_size:response': var iframe = document.getElementById( ); if ( iframe && '' === iframe.width ) iframe.width = '100%'; if ( iframe && '' === iframe.height ) iframe.height = parseInt( ); return; default: return; } } if ( 'function' === typeof window.addEventListener ) { window.addEventListener( 'message', funcSizeResponse, false ); } else if ( 'function' === typeof window.attachEvent ) { window.attachEvent( 'onmessage', funcSizeResponse ); } } if (document.readyState === 'complete') { func.apply(); /* compat for infinite scroll */ } else if ( document.addEventListener ) { document.addEventListener( 'DOMContentLoaded', func, false ); } else if ( document.attachEvent ) { document.attachEvent( 'onreadystatechange', func ); } } )();

Categories: Health Care

Doctors In Massachusetts Now Required To Offer End-Of-Life Counseling

CommonHealth (WBUR) - Fri, 12/19/2014 - 6:40am

Under new state regulations, patients with a terminal condition will be offered end-of-life information like this sample brochure, as well as counseling about their options. (Robin Lubbock/WBUR)

About nine months ago, John Polanowicz was in a hospital room at Brigham and Women’s watching his 44-year-old brother-in-law Bobby struggle to breathe. Bobby had advanced lung cancer. Now, with a tube down his throat, he was trying to respond to questions about his end-of-life wishes using a marker on a white board.

“We were all trying to decide,” Polanowicz recalled, “would we keep him trached and vented, and hope against hope that there would be some change in the disease process?”

Bobby was losing the battle with cancer. He had wanted to fight to the end, but no one had talked to Bobby about how to deal with the end.

“It would have been much easier for the family to have had some of these conversations before 4 in the afternoon on the day that he passed,” Polanowicz said.

On Friday, Polanowicz, Massachusetts’ secretary for health and human services, posts regulations designed to help patients like his brother-in-law avoid describing their final medical wishes with an erasable marker. Doctors, hospitals, nursing homes and other health providers in Massachusetts are now required to offer end-of-life counseling to terminally ill patients. The requirement, part of a 2012 law, takes effect Friday with the posting of rules about how it will work.

It’s believed to be the first such rule in the country. A similar proposal in 2009 for Medicare patients triggered claims that the government was trying to create death panels.

In Massachusetts, hospitals are to identify patients who are in their last six months of life — something state regulators acknowledge is not an exact science.

“Nobody has a crystal ball, so it can be challenging,” said Dr. Madeleine Biondolillo, an associate commissioner of public health. “But there is plenty of evidence in the literature that can guide the providers.”

A nurse or physician caring for the patient will then ask if they want to discuss care options. Do they want to be kept alive by any means possible, are they ready to stop treatment, or do they want to consider some options in between?

The state has a sample brochure that providers can give patients, available in nine languages.

Biondolillo says the hope is that asking patients if they have an end-of-life plan will become as routine as checking their meds.

The state will review whether hospitals are following the rule and compliance could become an issue in a facility’s licensing review. But the state is not focused on enforcement right now.

“This is new, this is important,” Biondolillo said. “It’s ground that hasn’t been covered by all these organizations before. We’re going to learn as we evaluate what’s going on on the ground.”

The Massachusetts Hospital Association does not expect opposition to the requirement. Vice President Tim Gens says hospitals are already having end-of-life conversations with appropriate patients, and that rules will help standardize efforts across the state.

State regulators say patients will not have to choose between continuing treatment and talking to their doctor about how they want to die. “There’s nothing in the regulations that will slow down treatment for a disease,” Polanowicz said.

Some doctors may worry that the government is interfering with the physician-patient relationship by imposing these rules. Providers can skip the requirement if talking about death conflicts with a patient’s religion or if the patient has said they aren’t interested. But there is widespread agreement in Massachusetts that more end-of-life planning is a good idea and that this requirement will help.

“This is going to be a major step forward in preventing the problem we have, which is we know we ought to talk about these things but it’s always too early until it’s too late. And now it’s going to start happening earlier when it needs to,” said Dr. Lachlan Forrow, who chaired an expert panel on end-of-life care in 2011.

Andrew Beckwith, president of the Massachusetts Family Institute, has one caveat in his support for end-of-life counseling. If assisted suicide becomes law in Massachusetts at some point, Beckwith wants to be sure doctors are not required to discuss that option with their patients.

“We know that the vast majority of doctors want to help their patients die a natural and dignified death, not to include this ethical Pandora’s Box of assisted suicide,” Beckwith said.

Of course, offering counseling is not effective unless patients take up the offer. So we’ll see now how many of us are ready to have that very difficult conversation.

Categories: Health Care

Medicare Cuts Payments To 721 Hospitals With Highest Rates Of Infections, Injuries

Kaiser Health News - Thu, 12/18/2014 - 4:27pm

In its toughest crackdown yet on medical errors, the federal government is cutting payments to 721 hospitals for having high rates of infections and other patient injuries, records released Thursday show.

Medicare assessed these new penalties against some of the most renowned hospitals in the nation, including the Cleveland Clinic, Brigham and Women’s Hospital in Boston, the Hospital of the University of Pennsylvania in Philadelphia and Geisinger Medical Center in Danville, Pa.

One out of every seven hospitals in the nation will have their Medicare payments lowered by 1 percent over the fiscal year that began Oct. 1 and continues through September 2015. The health law mandates the reductions for the quarter of hospitals that Medicare assessed as having the highest rates of “hospital-acquired conditions,” or HACs.  These conditions include infections from catheters, blood clots, bed sores and other complications that are considered avoidable.

The penalties, which are estimated to total $373 million, are falling particularly hard on academic medical centers: Roughly half of them will be punished, according to a Kaiser Health News analysis.

Dr. Eric Schneider, a Boston health researcher who has interviewed patient safety experts for his studies, said research has demonstrated that medical errors can be reduced through a number of techniques. But “there’s a pretty strong sense among the experts we talked to that they are not widely implemented,” he said. Those methods include entering physician orders into computers rather than scrawling them on paper, better hand hygiene and checklists on procedures to follow during surgeries. “Too many clinicians fail to use those techniques consistently,” he said.

The penalties come as the hospital industry is showing some success in reducing avoidable errors. A recent federal report found the frequency of mistakes dropped by 17 percent between 2010 and 2013, an improvement U.S. Health and Human Services Secretary Sylvia Burwell called “a big deal, but it’s only a start.” Even with the reduction, one in eight hospital admissions in 2013 included a patient injury, according to the report from the federal Agency for Healthcare Research and Quality, or AHRQ.

Download the data

Penalties for hospital-acquired infections

Medicare is penalizing hospitals with high rates of infections. View by hospital, state and other data:

The new penalties are harsher than any prior government effort to reduce patient harm. Since 2008, Medicare has refused to pay hospitals for the cost of treating patients who suffer avoidable complications. Legally, Medicare can expel a hospital with high rates of errors from its program, but that punishment is almost never done, as it is a financial death sentence for most hospitals. Some states issue their own penalties — California, for instance, levies fines as high as $100,000 per incident on hospitals that are repeat offenders.

The government has also been giving money to some hospitals and quality groups to help improve patient safety efforts.

The HAC program has “put attention to the issue of complications and that attention wasn’t everywhere,” said Dr. John Bulger, Geisinger’s chief quality officer. However, he said hospitals such as his now must spend more time reviewing their Medicare billing records as the government uses those to evaluate patient safety. The penalty program, he said, “has the potential to take the time that could be spent on improvement and making sure the coding is accurate.”

This KHN story can be republished for free (details).

Hospitals complain that the new penalties are arbitrary, since there may be almost no difference between hospitals that are penalized and those that narrowly escape falling into the worst quarter.

“Hospitals may be penalized on things they are getting safer on, and that sends a fairly mixed message,” said Nancy Foster, a quality expert at the American Hospital Association.

Hospital officials also point out those that do the best job identifying infections in patients may end up looking worse than others. “How hard you look for something influences your results,” said Dr. Darrell Campbell Jr., chief medical officer at the University of Michigan Health System. “We have a huge infection control group, one of the largest in the country. I tell them to go out and find it.” Campbell’s hospital had a high rate of urinary tract infections but was not penalized because it had fewer serious complications than most hospitals, records show.

The penalties come on top of other financial incentives Medicare has been placing on hospitals. This year, Medicare has already fined 2,610 hospitals for having too many patients return within a month of discharge. This is the third year those readmission penalties have been assessed. This is also the third year Medicare gave bonuses and penalties based on a variety of quality measures, including death rates and patient appraisals of their care. With the HAC penalties now in place, the worst-performing hospitals this year risk losing more than 5 percent of their regular Medicare reimbursements.

In determining the HAC penalties, Medicare judged hospitals on three measures: the frequency of central-line bloodstream infections caused by tubes used to pump fluids or medicine into veins, infections from tubes placed in bladders to remove urine, and rates of eight kinds of serious complications that occurred in hospitals, including collapsed lungs, surgical cuts, tears and reopened wounds and broken hips. Medicare tallied that and gave each hospital a score on a 10-point scale. Those in the top quarter — with a total score above 7 — were penalized.

About 1,400 hospitals are exempt from penalties because they provide specialized treatments such as psychiatry and rehabilitation or because they cater to a particular type of patient such as children and veterans. Small “critical access hospitals” that are mostly located in rural areas are also exempt, as are hospitals in Maryland, which have a special payment arrangement with the federal government.

The AHRQ study found that the biggest decreases in errors among those it studied occurred in the two categories of infections Medicare used in setting the penalties. Central-line associated bloodstream infections decreased by 49 percent and catheter-associated urinary tract infections dropped by 28 percent between 2010 and 2013. By contrast, pneumonia cases picked up by patients on ventilators that help them breathe – a condition not covered by the new penalties — decreased by only 3 percent during the same period.

Some of the errors on which the Medicare HAC penalties are based are rare compared to other mistakes the government tracks. For instance, AHRQ estimated that in 2013 there were 760,000 bad drug reactions to medicine that controls blood sugar in diabetics, but only 9,200 central-line infections. Infections from tubes inserted into urinary tracts are more common — AHRQ estimated there were 290,000 in 2013 — but those infections tend to be easier to treat and less likely to be lethal.

On the other measures, the study estimated there were 240,000 falls and more than 1 million bedsores.

In evaluating hospitals for the HAC penalties, the government adjusted infection rates by the type of hospital. When judging complications, it took into account the differing levels of sickness of each hospital’s patients, their ages and other factors that might make the patients more fragile. Still, academic medical centers have been complaining those adjustments are insufficient given the especially complicated cases they handle, such as organ transplants.

Medicare penalized 143 of 292 major teaching hospitals, the KHN analysis found. Penalized teaching hospitals included Ronald Reagan UCLA Medical Center and Keck Medicine of USC in Los Angeles; Grady Memorial Hospital in Atlanta; Northwestern Memorial Hospital and University of Illinois Hospital in Chicago; George Washington University Hospital and Washington Hospital Center in Washington, D.C.

“We know some of the procedures we do — heart transplants or resecting cancerous portions of the esophagus — are going to be just more prone to having some of these adverse events,” said Dr. Atul Grover, the chief public policy officer of the Association of American Medical Colleges. “To lump in all of those things that are very complex procedures with simple things like pneumonia or hip replacements may not be giving an accurate result.”

An analysis of the penalties that Dr. Ashish Jha, a professor at the Harvard School of Public Health, conducted for KHN found that penalties were assessed against 32 percent of the hospitals with the sickest patients. Only 12 percent of hospitals with the least complex cases were punished. Hospitals with the poorest patients were also more likely to be penalized, Jha found. A fourth of the nation’s publicly owned hospitals, which often are the safety net for poor, sick people, are being punished.

“I’ve worked in community hospitals, I’ve worked in teaching hospitals. My personal experience is teaching hospitals are at least as safe if not safer,” Jha said. “But they take care of sicker populations and more complex cases that are going to have more complications. The HAC penalty program is really a teaching hospital penalty program.”

Medicare levied penalties against a third or more of the hospitals it assessed in Colorado, Connecticut, Delaware, Nevada, New Jersey, New Mexico, Rhode Island, Utah, Washington and the District of Columbia, the KHN analysis found.

The penalties are reassessed each year and Medicare plans to add in more kinds of injuries. Starting next October, Medicare will assess rates of surgical site infections to its analysis. The following year, Medicare will examine the frequency of two antibiotic-resistant germs: Clostridium difficile, known as C. diff, and methicillin-resistant Staphylococcus aureus, known as MRSA.

Categories: Health Care

Persistent Stigma, Skepticism About Mental Illness Causes Real Harm

CommonHealth (WBUR) - Thu, 12/18/2014 - 10:32am

By Dr. Steve Scholzman
Guest Contributor

Profound misunderstanding about mental illness — its causes, its legitimacy and its treatment — permeate our culture. And the stigma that accompanies this lack of understanding hurts, a lot. Take this example — hardly original or rare.

Imagine a 15-year-old adolescent girl with fairly severe depression. She may be a classmate of your child, or the daughter of a friend. Let’s call her Sally.

Sally’s not so ill that she needs to be in the hospital, but she’s close. Her family and I — her psychiatrist — are doing our best to get her better as quickly as possible so she can get back to school. She’s been out now for about three days. Why? She literally lacks the capacity to think clearly. It’s all she can do to drag herself out of her bed and run a toothbrush across her teeth.

(Michael Summers/Flickr)

There’s a big family history of depression so Sally’s parents are both familiar with and frightened by her struggles.

“Can you call the school and ask them to give her more time on some work?” the parents ask.

“Sure,” I say, and I get in touch with the school administrator.

“Well,” I’m told by the very well-meaning administrator, “It IS a tough time of year. The other kids are getting through it somehow. I don’t see why she should get special treatment.”

“Because she has the equivalent of the flu,” I say. I like to use analogies at these crossroads.

“But the flu feels awful. Does she have a fever? Because if she does, she shouldn’t come to school…”

“No, she doesn’t have a fever,” I say. I try another analogy. “What if she had been in a car accident, God forbid?”

“Well, that’s pretty different, isn’t it?”

“How?” I ask.

“She’d be hurt,” I’m told. “This is an entirely different thing. You’ll need to get her pediatrician to call.”

I ask the pediatrician to call, and I can feel his discomfort over the phone. “I’m not very good at making this case,” he acknowledges. “It’s probably better if you just call them back.”

(I have to wonder whether he’d be so uncomfortable if I were a gastroenterologist asking him to call the school about a patient with ulcerative colitis?)

Skeptics Abound

So, I call the school back, and, to be fair, we usually get the extra time (though sometimes we don’t). But what a struggle! I feel like an attorney arguing a case, as if the people I’m talking to think I’m trying to pull a fast one.

But why? Why, in this day and age, does this scenario so stubbornly persist?

I think it’s because plenty of people still feel that psychiatric suffering isn’t real. And this causes genuine harm. If Sally encounters resistance to the fact that she’s suffering, she’ll almost certainly be less likely to seek care. If she feels that her non-psychiatric doctors don’t take her suffering seriously, then she’s going to suffer quietly and dangerously.

There’s even evidence that doctors themselves don’t believe this type of pain is real — and they sometimes wonder whether depression results from a moral failing.

Looking at the problem from another perspective, consider this anonymous comment I got from a medical student in the psychiatry course I teach: “Dear Dr. Schlozman: The psychiatry course convinces even the biggest skeptics.”

This comment, entirely well meaning, is also deceptively profound. Whenever I contemplate the vexing world of stigma with regard to mental health, I think first of this comment.

Let’s deconstruct what this student is saying.

“The psychiatry course convinced skeptics.”

Does the doctor teaching cardiology have to convince skeptics? Does anyone refuse to believe in nephrology? The burdens placed on psychiatric patients stem largely from the skepticism that many in the community, including the medical community, still patently feel and express. Simply put, quite a few health care providers do not believe that many psychiatric illnesses are real. This is despite data-laden policy papers from the Office of the Surgeon General, from the CDC and even from the World Health Organization.

Doctors, policy makers and the general population still have a long way to go toward accepting psychiatric suffering as part of the medical canon.

That’s not to say that we haven’t made huge strides. In fact, one might argue that the increasingly vocal debates that are happening now with regard to psychiatric suffering are happening precisely because we have allowed ourselves to discuss these issues in open forums. To that end, these discussions are absolutely necessary if we’re to move forward.

Culture And Illness

But for individuals, these debates can be extremely painful. Some will argue, for example, that psychiatric suffering is a cultural construct. Well, try telling someone who is paralyzed with depression that he suffers from a cultural construct. Others claim that psychiatric treatments are untested and unproven; try saying that to the millions of people who have benefited from treatment, and then seen their care denied by insurance companies for “lack of proof.”

Here are responses to these ongoing criticisms.

First of all, of course psychiatry is culturally bound. All of medicine is culturally bound. Psychiatry IS very likely tied more closely to the culture in which it exists than are other fields of medicine. That, however, does not at all mean that psychiatric diseases are not real. To the extent that culture shapes brain development, and that brain development in turn affects culture, you really can’t separate cultural experience from psychological experience.

Still, there are constructs for anxiety, psychosis, pathological mood and social relatedness that are impressively consistent across ethnic and cultural boundaries. In other words, despite cultural differences, these diagnoses are consistent and common.

Second, there exist a huge number of studies that demonstrate the effectiveness of psychiatric treatments. These include psychotherapy studies, medication studies and combination treatments. To be sure, we have a great deal more to learn, but needing to learn more doesn’t in any way separate psychiatry from the rest of medicine’s frontiers.

It Hurts

What’s the bottom line? The stigma against mental health hurts.

We know that stigma hurts us economically, stifles us socially, and paralyzes our creative prowess. Most importantly, we know that the stigma hurts us individually. Twenty percent of us will suffer from some form of psychiatric illness in our lifetime. That means that 20 percent of our population will endure unfair and unfound prejudices.

Of course, if you’re reading this post, then you might already agree with what we’re saying. You might also be preparing your rebuttal. That’s how social change happens.

Stigma against mental health is definitely going away. But we could stand for it to go away a lot faster.

Steven Schlozman, M.D. is an assistant professor of psychiatry at Harvard Medical School and a staff child psychiatrist at Massachusetts General Hospital. He is also associate director of The Clay Center for Young Healthy Minds. Please post or ask questions below, or tweet Dr. Schlozman at @zombieautopsies.

Categories: Health Care

Magna Carta Lecture Series – Law in the Lives of Medieval Women: Beyond Magna Carta

In Custodia Legis - Thu, 12/18/2014 - 10:07am

Ruth Mazo Karras, professor and chair of the History Department at the University of Minnesota, will join the Law Library of Congress on Wednesday, January 14, 2015 for the next program in the Magna Carta Lecture Series, “Law in the Lives of Medieval Women: Beyond Magna Carta.”

The lecture is scheduled to begin at 1:00 p.m. in the Mumford Room on the sixth floor of the Library’s James Madison Building, 101 Independence Ave., S.E., Washington, D.C. The event is free and open to the public. Tickets are not required.

Ruth Mazo Karras is professor and chair of the History Department at the University of Minnesota. Photo Source: University of Minnesota.

Professor Karras will discuss, through an analysis of the lives of three women, the way law affected (or not) women at different levels of society in medieval England. According to Professor Karras, “We know about the lives of aristocratic women mainly through documents recording transfers of land, which show some of them to have been active in managing property; borough records tell us about women who engaged in commerce; and records from church courts, coupled with family letters, tell us something about the extent to which women were able to make their own choice of husband. While the legal system did constrain women, they were nevertheless able to maneuver within it.”

The Law Library is holding a series of lectures in conjunction with the exhibition, “Magna Carta: Muse and Mentor.” Cosponsored by the American Bar Association Standing Committee on the Law Library of Congress, the lecture series is designed to provide further context on how the Great Charter fits into expansive historical and contemporary topics. Previous lectures focused on jury trials; techniques used in selecting and conserving primary sources for exhibitions and educational outreach; and the relationship between Magna Carta and the U.S. Constitution.

We hope you can join us! For those readers who will not be able to attend the program, a member of the In Custodia Legis team will be live-tweeting the event via Twitter @LawLibCongress, using #1215MCLC.

The Library of Congress is commemorating the 800th anniversary of Magna Carta with an exhibition – Magna Carta: Muse and Mentor, a symposium, and a series of talks.  Through January 19, 2015, the Lincoln Cathedral Magna Carta, one of four remaining originals from 1215 is on display along with other rare materials from the Library’s rich collections to tell the story of 800 years of its influence on the history of political liberty. 

Categories: Research & Litigation


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