Even if you don’t follow sports, you surely know about the Super Bowl. And even if you don’t follow the health care business, you may want to note a judge’s bombshell decision that has just hit the sector in Massachusetts. It may affect your hospital bill someday.
The news: A superior court judge has rejected a deal that would have let the state’s biggest hospital system — Partners Healthcare, which includes academic giants like Massachusetts General Hospital and Brigham and Women’s Hospital — expand.
Partners had been seeking to acquire at least three more hospitals, and had agreed to price caps and other limits that would hold for six-and-a-half to ten years. But Suffolk Superior Court Judge Janet Sanders concluded that letting Partners expand would not be in the public interest; it “would cement Partners’ already strong position in the health care market and give it the ability, because of this market muscle, to exact higher prices.”
To sum up the last decade of Massachusetts health care history in one paragraph: First, the state passed groundbreaking health care reform that presaged Obamacare. But though that reform meant that virtually everyone had health insurance, it didn’t “crack the code” of health care costs, which kept rising. The state created a Health Policy Commission, which was meant to keep an eye on costs among other things. When Partners, which the Boston Globe reports already has $11 billion in revenue, sought to expand, the commission concluded that the expansion would increase health care spending in the state by $39 million to $49 million a year. Partners opponents pushed back, and now the judge has sided with them.
Dominant hospital systems exist in areas around the country; the New York Times has written repeatedly about their tendency to lead to higher costs for patients, including here — 2 Hospital Networks Agree To Merge, Raising Specter of Costlier Care — and here: The Risks of Hospital Mergers. The main risk: The market power of big hospital systems means they can negotiate for higher prices from insurers, prices that tend to be passed down to consumers.
It remains to be seen whether this is an important new national precedent. But we cannot help but note that Massachusetts has certainly set important health care precedents in the past. WBUR’s Martha Bebinger offers a rich, full report of the judge’s landmark decision here, including this memorable quote from Stuart Altman, chair of the Health Policy Commission:
“If we’re going to have the cost of health care grow at a more normal rate, we need to have enough competition in the marketplace so that no part of the system can dictate prices,” said Stuart Altman, chair of the Health Policy Commission. “If you get too big, as Partners has become, it sort of destroys the concept of a competitive marketplace.”
Judge Sanders also wrote in her opinion that the deal would be too difficult to enforce, and offered some examples, Martha Bebinger reports:
What happens, Sanders asked, if Partners seeks to exceed the total medical expense (TME) growth cap in the agreement because of “unanticipated market conditions that affect utilization”? The agreement does not define that phrase, Sanders said, or offer any criteria for deciding if the market has changed enough to justify a possible TME increase request.
The agreement “envisions a ten-year period during which this court could be called upon to resolve disagreements among the parties in at least 10 different areas,” Sanders said.
“The court was very concerned about [resolving disputes],” said Matthew Cantor, an attorney specializing in health care anti-trust cases, “particularly when you consider how dynamic and evolving the health care business is.”
“God Bless Judge Sanders. She has stood up for competition in the Greater Boston health care market; and we applaud her for it,” the Rev. Burns Stanfield, president of the Greater Boston Interfaith Organization, said in a statement. His group submitted a comment to the court in opposition of the deal. “And God Bless the Health Policy Commission, because unlike anywhere else in the United States, we have a regulatory body that is meant to keep things fair.”
It is unusual for a judge to reject any agreement an attorney general presents. Sanders acknowledges that she “owes deference” to Coakley and “does not question her good faith.” But Coakley’s proposed remedies would be “like putting a band-aid on a gaping wound that will only continue to bleed (perhaps even more profusely) once the band-aid is taken off,” Sanders said. Those are tough charges to lodge against the state’s largest group of healers.
In many ways, this was no ordinary anti-trust settlement process.
Hospitals that compete with each other came together to fight the Partners deal. They and other opponents persuaded Judge Sanders to allow public comments and 174 poured in, most in opposition to the agreement. There was that dramatic moment in court when former Attorney General Martha Coakley rose unexpectedly from the audience to defend herself.
And then on Monday, the new attorney general, Maura Healey, submitted a brief to Judge Sanders. Healey told Sanders and WBUR that she didn’t like the deal and would try to stop Partners from acquiring South Shore Hospital.
“I would be prepared to sue to stop the transaction from going forward if need be,” Healey said Monday. She repeated that threat Thursday.
Martha’s report also includes reaction to the ruling:
Partners says it is reviewing its options. CEO Gary Gottlieb told employees the judge blocked a deal that “would have paved a pathway to delivering high-quality care closer to home for patients and their families in a lower cost community-based setting.”
South Shore Hospital spokeswoman Sarah Darcy echoed the commitment to that vision in a statement and added, “it is disappointing that the voices of the people of our broad region, who have spoken out by the thousands in support of this vision, described in the proposed merger, have been lost in the process because of the politics.”
Lots of people are talking about the politics of supporting and opposing Partners.
“I think it took a lot of courage for both the judge and the attorney general to rule against the consent agreement,” said Nancy Kane, a professor at the Harvard School of Public Health who has studied health care and hospital financing in Massachusetts for more than 40 years. “Any elected official has to be very cautious in taking on a system as wealthy and connected as Partners.”
The question going forward, Kane says, is “can we fix the market power problem? Partners was already too big before the deal to acquire these three hospitals took shape.”
Many in Massachusetts who follow health care with the same passion they devote to sports are wondering: What’s next? Does Partners, with a new, soon-to-be named CEO, press ahead with expansion plans or halt them? Will state or federal investigators keep pushing against Partners’ market power? And will the new governor or Legislature campaign for more or less control over health care prices? This isn’t the Super Bowl or “DeflateGate,” but we’ve got game in health care.254128352
For me the Library of Congress exhibition, Magna Carta: Muse and Mentor, actually began on November 5th, a day before the exhibit was open to the public. Those of us who were fortunate enough to be docents for the exhibit had the privilege of meeting with Christopher Woods, director of the British National Conservation Service, and also the man responsible for transporting and working with the Lincoln Cathedral Magna Carta. A witty and informative speaker, he was able to provide us with information about the document and its condition which helped to enhance our presentations to visitors at the exhibition. I was thrilled when I learned he had agreed to give the final gallery talk on the closing day of the exhibit, January 19th. The talk was fascinating as Mr. Woods focused on issues of document preservation and techniques used to mend parchment documents. For me it was a great way to end the exhibit as well as to give my family and friends a chance to enjoy Mr. Woods’ erudition and wit.
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NEW YORK – Robert Ladd, an intellectually disabled person with an IQ of 67, was executed tonight at 7:02 CT in Huntsville, Texas. His death violates the Supreme Court's rulings that the Eighth Amendment prohibits executing the intellectually disabled as cruel and unusual punishment. In any other state Mr. Ladd would be considered ineligible for the death penalty because of his intellectual disability.
Brian Stull, senior staff attorney with the ACLU’s Capital Punishment Project and Mr. Ladd's attorney, had this comment:
"Texas aggressively pursued Mr. Ladd's execution, despite the fact that our constitution categorically prohibits the use of capital punishment against persons with intellectual disability. Mr. Ladd, whose IQ was 67, was executed because Texas uses idiosyncratic standards, based on stereotypes rather than science, to determine intellectual disability. His death is yet another example of how capital punishment routinely defies the rule of law and human decency.
"We are eager for a court to address the fact that Texas' unscientific standards can't be reconciled with the Supreme Court's decision in Hall v. Florida,mandating that states must use universal medical diagnostic practices rather than inaccurate and self-invented methods for determining intellectual disability. However, no future ruling can undo the unconscionable fact that tonight Texas ended the life of an intellectually disabled man who deserved the protection of the Constitution."
For more information about the case Ex Parte Ladd, visit: https://www.aclu.org/capital-punishment/ex-parte-ladd
For information about the ACLU’s Capital Punishment Project, visit: https://www.aclu.org/capital-punishment
A Superior Court judge has rejected a closely watched and controversial deal brokered by former state Attorney General Martha Coakley and Partners HealthCare.
The agreement would have cleared the way for the health care giant to acquire at least three more hospitals — South Shore Hospital in Weymouth and two owned by Hallmark Health — in exchange for limits on price and the size of its physician group.
Judge Janet Sanders wrote in her denial order that the deal is “not in the ‘public interest.’ ”
Sanders’ decision came Thursday, just three days after Coakley’s successor, Attorney General Maura Healey, said Partners HealthCare should not be allowed to complete the hospital acquisition and that she would sue to block it.
In a lengthy statement in response to the order, Partners CEO Gary Gottlieb said, “The judge has said ‘no’ to an agreement that we believe would have paved a pathway to delivering high-quality care closer to home for patients and their families in a lower cost community-based setting.”
He added: “Our leadership team will now take the time to evaluate all of our options.”
State Health Policy Commission Chair Stuart Altman, whose panel expressed concerns about the deal, agreed with Judge Sanders.
“The problem if you get too big, as Partners has become, where they can pretty much dictate the prices, it destroys the commonsense of competitive marketplaces,” he told our Newscast Unit.
In separate statements, South Shore Hospital and Hallmark Health said they are disappointed in the ruling.
Coakley defended the deal during her unsuccessful run for governor last year.
With reporting by WBUR’s Benjamin Swasey and Martha Bebinger. This story was updated at 7 p.m. and will be updated further with Martha’s Morning Edition feature.254128352 Related:
You know the feeling: you’re tired, cranky, low or just have a serious, relentless desire for something sweet. Part of your brain cries out, “No, don’t do it, this will end badly.” But another (louder) part wants what it wants and won’t let up until that pint of Cherry Garcia, or red velvet cupcake or Caramel Macchiato is in plain sight. It’s an itch that must be scratched.
Now, brain scientists at MIT say they’ve identified a specific neural circuit in mice that can increase that compulsive overeating of sweets, but doesn’t interfere with normal eating patterns necessary for survival. More specifically, turning on this set of neurons drove mice to seek the reward of a sugary drink even in the face of punishment (a shock to the foot); and compelled them to eat voraciously even when full. When the researchers shut down this pathway, however, the compulsive sucrose-seeking decreased.
Why does this matter? The new research, published in the journal Cell, may ultimately provide a target for the treatment of compulsive overeating and sugar addiction in humans, without undermining the clearly critical drive of eating to live, the scientists say.
“Imagine if I told you that in the future, we could change the way our neural circuits communicate in a way that I did not want to binge on sweets, but still allowed me to eat healthy foods when I’m hungry?” says Kay Tye, the study’s senior author and an assistant professor in the Department of Brain & Cognitive Sciences at MIT. “Obviously there is a ton of work that needs to be done to make this vision a reality, but our study suggests that it is possible.”
A Binge-Free Future?
As obesity rates have spiked in recent decades, experts say that overeating in general and consuming too much sugar in particular are major threats to human health.
But Tye says “the real underlying problems are the cravings that lead to compulsive eating, and the behavior of compulsive overeating itself.”
To tease out what might be driving that compulsion, Tye looked to a particular set of neurons in the mouse brain.
She and her colleagues showed that when mice perform reward-seeking actions enough that they become habits, that activates neurons connecting two key areas: a brain region called the lateral hypothalamus (an area important for hunger, feeding and homeostasis) and the ventral tegmental area (a brain region important for motivation and reward).
“If we want to understand how the brain gives rise to these feelings, thoughts and actions, we need to know more than what they are saying, we need to know who they are talking to,” Tye said. The team used so-called “optogenetic projection-defined phototagging” [essentially using laser light to activate or silence neurons] to see “which neurons…were saying what…and who they were talking to…”
These neural communications are quite distinct, Tye said; for instance, it’s important to distinguish between two types of reward-seeking behavior: binge-eating and drug addiction: “You don’t need cocaine to survive, you need food to survive,” she said.
The “Wanting” Neurons
Tye says that one of the biggest challenges with treating the obesity that comes from compulsive overeating disorders is that “most treatments are just a band-aid — treating the symptoms instead of the core problems. Gastric bypass for example, is something that just makes it harder to eat, it doesn’t always change a person’s habits and eventually many people relapse and regain the weight.” Again, she theorizes that it’s the craving embedded in the brain that drives the compulsive behavior. She says there may be a distinctive set of “wanting neurons” as opposed to “liking neurons.”
Tye offers more context:
The treatment of food addiction has to be more delicate because you want to shut down the compulsive overeating, but you need to keep the desire to eat healthy food to survive intact. Our study suggests this is possible…. we hope that our work inspires more effort in developing circuit-based treatments using deep brain stimulation or non-invasive methods like focal ultrasound or transcranial magnetic stimulation, perhaps in combination with cognitive behavioral therapy. So far our study tells us that this type of treatment is possible because they are different circuits, and it gives us a starting point of where to look.”
How About A Milk Shake?
MIT graduate student Edward Nieh, the study’s lead author, offers more of the technical nitty gritty in an email:
We used a novel viral technique to identify two populations of neurons based on how they are connected with each other and discovered that they encode different parts of reward.
The first population, which are LH [lateral hypothalamic] neurons that send information to the VTA [ventral tegmental area], are activated when the mouse approaches the reward port where it can drink a sugar reward. In a human, this would be like these cells firing when you approach the counter at a fast food restaurant to get your milk shake, i.e. “reward seeking”.
A second population, which are LH neurons that receive information from the VTA, are activated by a cue that predicts the sugar delivery and the sugar itself. In a human, this would be like these cells firing when you see the sign for the restaurant (e.g. a big golden arch) and drinking the milk shake itself.
So the first thing we did was characterize in detail how this part of the brain processes reward. Once we knew how this part of the brain worked, we could move on to changing how it functions and manipulating animals’ behavior.
What would happen if we could artificially activate or silence these cells that fire when you approach the counter to get your milk shake? Could we make an animal more or less likely to seek a reward?
To study reward seeking behavior, we used a task where the mouse was placed in a chamber in which it had to cross a shock floor giving mild electric foot shocks in order to obtain a sugar reward. Indeed, when we activated the LH-VTA pathway, the mice were willing to endure more shock in order to obtain the sugar reward. In contrast, when we turned the signaling in this pathway off, the mice were willing to endure less shock for their reward. Importantly, turning off the signaling in this pathway didn’t affect normal feeding behavior.
I asked Mark Andermann, an assistant professor at Harvard Medical School and Beth Israel Deaconess Medical Center, in Boston, (and not involved with this research) to offer an assessment of the work.
He emailed me a long, thoughtful answer which I can sum up this way: The research is tantalizing, but much more must be done before it can be deemed a slam dunk.
Some of Andermann’s comments, via email, are here:
Motivational circuitry is complex…which likely reflects the fact that motivated decisions are almost always dependent on many contexts so that we can meet current needs with minimal risk to safety, as well as anticipation of future needs that might be met by taking action.
…The problem, historically, in studying this circuitry is that it wasn’t possible to record from specific groups of neurons within an area, or to stimulate or silence these specific groups. The current studies in Cell are using ever-more-refined methods that involve recording from, and turning on or off of, different genetically-labeled cell types within motivation-related areas deep within the brain. In this way, these studies provide key insights into how to carve up individual areas involved in motivation into specific subtypes of neurons with increasingly specific contributions to a given behavior.
In general, this type of ‘circuit-mapping’ approach is appealing in the context of developing more specific therapies for brain disorders. For example, if neighboring groups neurons either facilitate or deter a motivated behavior, you’d want to figure out the signature of each group, and then target your drug or other therapy to one group but not the other, rather than stepping on the gas and the brake at the same time.
In terms of developing rational therapies for compulsive eating, the field likely has a long way to go. While the authors argue for a specific, causal role of specific lateral hypothalamus neurons in compulsive sucrose seeking, they also note that much of the data is consistent with “increases in motivational drive of the urge to seek appetitive reinforcers”. More experiments will be required to tease apart whether different areas involved in motivated behavior can be fully separated into compulsive (eating sweet foods even when sated) and need-based (eating when hungry) circuits.
Further, the lateral hypothalamus has classically been viewed as an area that is involved in the approach to the object of a motivation. Thus, the contribution of the lateral hypothalamus to the “urge to seek appetitive reinforcers” could be quite general to whatever appealing object is currently available (e.g. a sugar treat, a mate, a friend, etc.), which might make it difficult to target with therapies for overeating while avoiding a blunting of other healthier ‘compulsive’ behaviors (such as social behavior). This work provides the impetus for future studies to investigate the degree of specificity of these neurons to seeking of food vs. other rewards. Regardless, the findings of Tye and colleagues provide a fascinating new window on how two brain areas critical for coordinating motivated behavior communicate with each other.”
In a related paper also published in Cell, researchers led by Garret Stuber of the University of North Carolina School of Medicine, also used “an optogenetic approach in mice to identify neurons in the lateral hypothalamus that control both feeding and reward-seeking behavior. By imaging the activity of hundreds of individual lateral hypothalamus neurons as the mice freely explored an area with food or worked to obtain a sweet reward, they further uncovered distinct subsets of neurons that either mediate food-seeking behavior or respond to reward consumption,” says the news release.
Don’t forget to watch the video, in which researchers evoke some serious gnawing behavior by a mouse. “As soon as we activate the inhibitory component of the pathway, the animal starts to lick the floor,” notes MIT’s Nieh. “And at one point in the video, you can actually see the animal make the motions of picking up an object and gnawing on it, when no object is actually present.”
By Barbara Moran
As the 100 million viewers tuning in to this Sunday’s Super Bowl can attest, Americans adore football. And for many, the love affair begins in childhood: Pop Warner Tiny-Mites start as young as age 5, and many adults retain warm memories and friendships from their youth football days.
But a new study from BU School of Medicine researchers points to a possible increased risk of cognitive impairment from playing youth football. The National Institutes of Health–funded study, published online in the Jan. 28 edition of the journal Neurology, finds that former National Football League players who participated in tackle football before the age of 12 are more likely to have memory and thinking problems as adults.
The study contradicts conventional wisdom that children’s more plastic brains might recover from injury better than those of adults, and suggests that they may actually be more vulnerable to repeated head impacts, especially if injuries occur during a critical period of growth and development.
“Sports offer huge benefits to kids, as far as work ethic, leadership and fitness, and we think kids should participate,” says study lead author Julie Stamm (MED’15), a PhD candidate in anatomy and neurobiology. “But there’s increasing evidence that children respond differently to head trauma than adults. Kids who are hitting their heads over and over during this important time of brain development may have consequences later in life.”
“This is one study, with limitations,” adds study senior author Robert Stern, a MED professor of neurology, neurosurgery and anatomy and neurobiology and director of the Alzheimer’s Disease Center’s Clinical Core. “But the findings support the idea that it may not make sense to allow children—at a time when their brain is rapidly developing—to be exposed to repetitive hits to the head. If larger studies confirm this one, we may need to consider safety changes in youth sports.”
In the study, researchers reexamined data from BU’s ongoing DETECT (Diagnosing and Evaluating Traumatic Encephalopathy Using Clinical Tests) study, which aims to develop methods of diagnosing chronic traumatic encephalopathy (CTE) during life. CTE is a neurodegenerative disease often found in professional football players, boxers and other athletes who have a history of repetitive brain trauma. It can currently be diagnosed only by autopsy.
For this latest study, scientists examined test scores of 42 former NFL players, with an average age of 52, all of whom had experienced memory and thinking problems for at least six months. Half the players had played tackle football before age 12, and half had not. Significantly, the total number of concussions was similar between the two groups. Researchers found that the players exposed to tackle football before age 12 had greater impairment in mental flexibility, memory and intelligence—a 20 percent difference in some cases. These findings held up even after statistically removing the effects of the total number of years the participants played football. Both groups scored below average on many of the tests.
“We were surprised by how striking the results were,” says Stamm. “Every single test was significantly different, by a lot.”
Stamm says that the researchers were especially surprised by the scores on a reading test called the WRAT-4, which has participants read words of increasing difficulty. A person’s score depends on the ability to pronounce the words correctly, indicating the person’s familiarity with complex vocabulary. The low scores may be significant, she says, because they suggest that repeated head trauma at a young age might limit peak intelligence. She emphasizes, however, that there may be other reasons for a low score, and that more research is needed.
The authors chose age 12 as the cutoff because significant peaks in brain development occur in boys around that age. (This happens for girls a bit earlier, on average.) Around age 12, says Stern, blood flow to the brain increases, and brain structures such as the hippocampus, which is critical for memory, reach their highest volume. Boys’ brains also reach a peak in their rate of myelination—the process in which the long tendrils of brain cells are coated with a fatty sheath, allowing neurons to communicate quickly and efficiently. Because of these developmental changes, Stern says, this age may possibly represent a “window of vulnerability,” when the brain may be especially sensitive to repeated trauma.
“If you take just the hippocampus, that’s a really important part of your brain,” he says. “It may be that if you hit your head a lot during this important period, you might have significant memory problems later on.”
Stern adds that a study by another group of researchers of the number and severity of hits in football players aged 9 to 12, using accelerometers in helmets, found that players received an average of 240 high-magnitude hits per season, sometimes with a force similar to that experienced by high school and college players.
With approximately 4.8 million athletes playing youth football in the United States, the long-term consequences of brain injury represent a growing public health concern. This study comes at a time of increasing awareness of the dangers of concussions—and subconcussive hits—in youth sports like football, hockey, and soccer. In 2012, Pop Warner football, the oldest and largest youth football organization in the country, changed its rules to limit contact during practices and banned intentional head-to-head contact. When reached by phone at the organization’s headquarters in Langhorne, Pa., a Pop Warner spokesman declined to comment on the study until they had more time to examine the results in detail.
“Football has the highest injury rate among team sports,” writes Christopher M. Filley, a fellow with the American Academy of Neurology, in an editorial accompanying the Neurology article. “Given that 70 percent of all football players in the United States are under the age of 14, and every child aged 9 to 12 can be exposed to 240 head impacts during a single football season, a better understanding of how these impacts may affect children’s brains is urgently needed.”
Filley’s editorial cautions that the study has limitations: Because the researchers could not precisely determine the players’ lifetime number of head impacts, it may be the total number of hits—rather than the age of a player—that is the more critical measurement. In addition, because the study focuses on professional athletes, the results may not apply to recreational players who participated in youth football, but did not play beyond high school.
Stamm says that the next stage of research is to work with colleagues at Brigham and Women’s Hospital to conduct detailed neuroimaging of the same types of players involved in the current study, looking for underlying changes in brain anatomy that might correlate to the cognitive impairment.
She adds that this paper is a small, first-of-its-kind study, and needs to be expanded and replicated before scientists can make further recommendations about children playing contact sports. But she hopes the study will shed more light on the possible consequences of repeated head trauma in children. She notes that some youth football organizations have taken great steps in reducing the numbers of hits to the head. However, more research is needed to see if these measures are sufficient, or if additional precautions, like substituting flag football for tackle football in those under 12, may be necessary.
“Sports are important, and we want kids to participate in football,” says Stamm. “But no 8-year-old should play a sport with his friends and end up with long-term problems. We just want kids to play sports more safely.”
Barbara Moran can be reached at firstname.lastname@example.org.