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Medicare Star Ratings Allow Nursing Homes to Game the System

Medicare -- New York Times - Mon, 08/25/2014 - 12:00am
Medicare’s five-year-old rating system to help families select nursing homes relies on unverified, incomplete and often misleading data.
Categories: Elder, Medicare

What's all the hoopla about Hoopla?

Massachsuetts Trial Court Law Library - Sun, 08/24/2014 - 7:30am
As a resident of Massachusetts you can access the Boston Public Library's catalog of streaming movies, television episodes, music, and audio books through Hoopla.  To start streaming today, you need to get your FREE eCard, be using a supported web browser or mobile device, and sign up for a free Hoopla account.  You may borrow up to 10 titles in a calendar month.  The borrowing periods vary depending on what you've borrowed:

  • Movies and TV episodes - 3 days
  • A music album - 7 days
  • An audio book - 21 days

  • Remember, both the BPL eCard and your Hoopla card are free.  All you need is to be a Massachusetts resident and have Internet access! 
    Categories: Research & Litigation

    How To Spend All That Ice-Bucket Money? Multiple ALS Research Leads Heat Up

    CommonHealth (WBUR) - Fri, 08/22/2014 - 4:41pm

    In this image from video posted on Facebook, courtesy of the George W. Bush Presidential Center, former President George W. Bush participates in the ice bucket challenge with the help of his wife, Laura Bush, in Kennebunkport, Maine. (AP)

    I sighed this week when I heard, “Hey, Mom, do we have a clean bucket and some ice?”

    Yes, the viral ALS ice-bucket challenge that has swept the country had reached our household as well. And though my daughter averred that she would never have heard about ALS otherwise, it pushed some of my cynic buttons. (My favorite response so far had come from an acidly hilarious Facebook friend who advised celebrities: “Just write a check to support ALS research. If you still need a gimmick and social media attention, set your hair on fire instead.”)

    For me, the trouble was that I had looked into ALS research a few years ago and it had struck me then as extraordinarily frustrating. It was the field that first taught me that it’s all too common for a potential treatment to look good in initial testing and then fail to pan out when tried in a bigger clinical trial. That happened with ALS over and over again. And meanwhile, patients faced inexorable neurological degeneration and far too early deaths. (One of my most admired colleagues, Dudley Clendinen, died of ALS in 2012 after eloquently chronicling his time with it.)

    But then I thought: Let’s be positive. Whatever the narcissistic elements of the ice-bucket dousings, the challenge is raising millions of dollars — more than $50 million as of Friday, from more than a million new donors, according to the ALS Association. And maybe ALS research has changed?

    Indeed it has, say scientists working in the field. Not that it looks like there’s a cure around the corner, but there has been major progress of late, they say, and we can expect more to come.

    “In about the last seven years, the genetics of ALS has just exploded the field, and just come up with so many new ideas for how we can tackle the disease,” said Avi Rodal, an ALS researcher at Brandeis University whose work is funded by the Blazeman Foundation for ALS.

    Dr. Lucie Bruijn, chief scientist of the ALS Association that is reaping the ice-bucket windfall, also describes a field that is forging ahead in multiple directions. “The understanding of the disease, the research that has gone into it, has grown exponentially,” she says. “So we’re much closer to understanding the complexity of the disease and how to approach it in a very different way from before, when many of the trials were challenging partly because we didn’t understand the disease as closely.”

    The Association, she says, is focusing on six main areas, and the ice-bucket money will likely be divided among them: “We want to invest in many areas,” she says, “to be sure not to dilute it too but to be very strategic that we don’t put all our eggs in one basket.”

    Those areas, in brief and lightly edited, as she described them:

    1. Genetics:
    About five to 10 percent of ALS runs through families, but 90 percent is sporadic. However, we’ve found that many of the genes we identify in familial disease are potential risk factors, and certainly also seem to be involved in the sporadic form. So there’s an underlying genetics in all ALS, but sometimes it’s more dominant than others.

    Through our funding, we’ve been able to build large consortia. In fact, a couple of years ago there was a very exciting finding — a quite tricky gene, one that we couldn’t find so easily, so we invested heavily into it — it affects about 40 percent of familial ALS. Also, in some cases of ALS, there’s a kind of dementia called frontotemporal dementia, and this gene finding affects both ALS and frontotemporal dementia. So there’s an interesting link we’re trying to understand, with different biologies with the same gene, and that really made the field explode.

    The gene has a complicated name — C9orf72 — because it produces a protein that we don’t know anything about, and the name is just a location number — it’s located on chromosome 9, Open Reading Frame 72 — until we understand more about what the gene does.

    So it’s a mystery gene?

    It is, and even more fascinating is that it’s the first for ALS we’ve found where it’s not a point mutation — it’s not one change on the reading code that causes an abnormal protein — it’s actually an expansion that is inserted into this region of the gene. And it’s a repeat, it’s called a hexanucleotide repeat — six things repeating over and over again a thousand times when it should be only 20. So it’s similar to Huntington’s disease and others like it. And experts in those fields are now using their knowledge and bringing it to the ALS field.

    2. Biomarkers:
    Biomarkers are very important because they are signatures of the disease, they tell us if the disease is changing or give us clues for diagnosis.

    What had been really challenging in the clinical trials that you mentioned that had failed is that often we don’t know why they have failed. Partly, we think maybe ALS is a spectrum of diseases — that some might react to the treatment approach differently than others. And we’ve started to see if we can group and discern patients in different categories, some that might have a particular profile in their blood or the fluid around their brain that tells us, for example, that they might have more of an inflammatory profile and they might respond better to drugs if we treat along that pathway.

    So it’s a fascinating area, and it really requires significant investment because all these efforts require large studies, large collaborations. It’s been done very successfully in Alzheimer’s disease, so we are borrowing expertise to see how we could do something like that.

    3.Stem cells (not the embryonic kind) :
    Early studies trying to understand whether stem cell technologies would be of value in ALS were done using embryonic stem cells, but we have really been so lucky with technological advances. Now you can get skin cells from someone with the disease, or someone who doesn’t have ALS, and you can reprogram them to make them be immature cells that can develop into motor neurons and the surrounding astrocytes.

    We are starting to try to develop these model systems in a dish, using these cells from people who live with the disease, and then testing drugs that might change what that looks like. So if the cells are looking different from those that comes from someone who doesn’t have the disease, what are those differences and how can you correct them using drugs? That’s really going to spearhead a new direction.

    Stem cells can also play a role as potential therapy, but it’s very complicated in ALS. We are very excited that there are FDA-approved trials testing the idea, but ALS is unlike Alzheimer’s disease — it does’t happen just in one region, it’s a complex architecture where the nerve cells connect to the muscles, and it’s really quite widespread. So where you have to put the cells is often the big challenge. In the approved stem cell trial, they are injecting them straight into the spinal cord. But it’s extremely difficult. Still, stem cells are also invaluable for their use as model systems.

    4. In the clinic:
    We’re trying to move things forward in clinical management, in day-to-day care of people living with the disease. One example is a trial we’re funding of a compound that has been approved for people who have changing emotions in ALS — laughing and crying that’s exaggerated. This compound, which we are now testing in a trial, has already been approved for that, but one of our clinicians and some anecdotal information seem to indicate that it improves swallowing. It’s not proven yet, but this is the kind of thing that we can provide funding for, to test that idea. So we seed small clinical trials — though trials can be anywhere up from $25 million plus, just for perspective. So these are not small investments.

    5. Understanding disease mechanism:
    A yeast model has helped us understand more risk factors for ALS; flies, worms, zebrafish, yeast, mice — all are models that can be used, and we invest in that.

    What have you come to understand in recent years about the disease?

    We were very fixated on the motor neuron being the main thing that goes wrong — but actually, we’ve learned so much more now: the surrounding cells, the astrocytes, which are important in regulating glutamate, are very important, as are the cells that are the inflammatory cells of the brain, the microglia.

    Now we know that these support cells are critical to the process, we’ve actually started to look for ways to intervene, and one idea is to replace the dying astrocytes — that’s a stem-cell transplant idea that’s moving forward. The other is looking at inflammation and seeing if we can find drug targets.

    6. Drug development: 
    We can bring together all the right players — academia and industry. So we give out contracts — academia-industry contracts — where we mostly fund the academic partner, but the industry partner gives resources in kind and the expertise to really help bring the idea from the laboratory through the process of drug discovery into a treatment.

    One great example of that, which is thrilling, is the use of antisense technology — which has now been used for all kinds of other diseases — for ALS. Simplistically, what happens with this technology is that it lets you down-regulate or suppress the production of something you don’t want to have. It was first tried on SOD1 [the first ALS gene found] but an attempt is moving forward very, very fast to try the same thing with the new gene, C9orf72. We don’t know yet whether it’s going to be effective in humans but it’s certainly safe.

    Readers, thoughts? Does knowing more about how the money may be spent change your view of the ice-bucket challenge in any way?

    Categories: Health Care

    Criminal Model Jury Instructions for Use in the District Court

    Massachsuetts Trial Court Law Library - Fri, 08/22/2014 - 2:56pm
    The District Court Committee on Criminal Proceedings has recently revised several model jury  instructions, as well as preparing six new Criminal Model Jury Instructions.   The new instructions are:  Failure to Have Ignition Interlock Device, Disabling an Ignition Interlock Device, Wilful Interference with a Fire Fighting Operation, Cruelty to Animals, Furnishing Alcohol to a Minor, and Improper Storage of a firearm.

    The Trial Court Law Libraries have copies of Civil and Criminal Jury Instructions for District and Superior Court.  Our holdings also include jury instructions for particular areas of law, which may be contained in treatises on the topic. Examples include Workplace Harassment, Residential Landlord-Tenant issues, and Property Insurance Litigation.  

    Categories: Research & Litigation

    Religious Employers Are Offered Fix On Birth Control Coverage

    Kaiser Health News - Fri, 08/22/2014 - 1:55pm

    News outlets report that the regulations, expected to be published later today, will allow religious nonprofits -- and perhaps later religious business owners -- to notify the government that they object to providing contraception coverage. Federal officials would then arrange for the workers' insurance.

    The Associated Press: Obama Offers New Accommodations On Birth Control
    The Obama administration will offer a new accommodation to religious nonprofits that object to covering birth control for their employees. The measure allows those groups to notify the government, rather than their insurance company, that birth control violates their religious beliefs (Lederman, 8/22).

    The Wall Street Journal: Obama Administration To Offer Contraception Compromise For Religious Employers
    The Obama administration is set to outline a new compromise Friday designed to shield religious business owners and Christian universities and charities from the health law's contraception-coverage requirements while maintaining the coverage for women, according to people familiar with the new rules. The new rules, expected later in the day, will lay out a multistep process in which employers that are morally opposed to including birth control in workers' insurance would state their objections in writing, and the federal government would take over responsibility for the coverage from there (Radnofsky, 8/22).

    Bloomberg: Obama Provides Birth-Control Coverage Plan For Nonprofits
    Women who work for religious nonprofits will have access to birth control at no cost under a procedure the Obama administration said would also relieve their employers of any moral objections to the coverage. The nonprofits now only have to notify the U.S. government of their objections in writing, the administration said in a regulatory filing to be published today. Coverage will be arranged separately by the government through health-benefit managers (Wayne, 8/22).

    The Washington Post: Administration Offers New Tweak To Birth Control Rule
    The administration is trying to deal with the fallout from the Supreme Court's bitterly debated 5-4 decision in June that owners of closely-held businesses don't have to offer contraception coverage if it conflicts with their religious beliefs. The forthcoming federal guidelines will address a set of ongoing legal challenges to the contraceptive requirement raised by dozens of religious nonprofit groups, such as hospitals and charities, that could again put the contraception mandate before the Supreme Court. The religious nonprofits are challenging the administration's already existing opt-out, in which the groups can ask a third party to provide the contraception coverage to their employees (Millman, 8/22).

    Politico: New Contraceptive Coverage Plan To Be Offered For Religious Nonprofits
    The new plan, which sources familiar with the policy said essentially adds HHS to the notification process for any group that objects to the coverage requirement, addresses a very visible component of Obamacare. The legal challenges brought by scores of organizations across the country have put contraceptive coverage at risk but not threatened the health care law itself (Norman, 8/22).

    CNBC: Government To Deliver Obamacare Contraception Rules Compromise
    Under both rules, employees would have their contraception costs covered by a third-party, which would either be directly reimbursed by the federal government, or whose costs would assumed to be covered by savings realized by minimizing the number of pregnancies covered by the insurance plan. One rule would allow religious non-profit employers to avoid the requirement that they formally fill out a form self-certifying they object to covering contraception for their workers, a form that then had to be turned over to their health-insurance issuer or third-party plan administrator (Mangan, 8/22).

    Catholic News Agency: Obama Administration Announces New HHS Mandate Rules
    Previously, religious groups were instructed to sign a form voicing their objection to the coverage, which would authorize their insurer or a third-party administrator to pay for the products. Many religious groups had objected to this arrangement, saying that it still required them to violate their religious beliefs by authorizing an outside organization to pay for the products they found to be immoral. The new rule announced Friday allows these non-profit groups to notify the Department of Health and Human Services of their objections. The federal government will then contact insurers and third party administrators to provide the coverage (8/22).

    Vox: The White House Has A Plan To Get Birth Control To Hobby Lobby Workers
    The Obama administration wants to extend the accommodation for religious non-profits — where the health insurance plan, rather than the employer, foots the bill for birth control — to objecting for-profit organizations. At a company like Hobby Lobby, for example, this would mean that the owners would notify the government of their objection to contraceptives. The Obama administration would then pass that information along to Hobby Lobby's health insurance plan, which would be responsible for paying for the birth control coverage. This will be a proposed rule that the Obama administration is seeking comment on, meaning it's not fully set in stone – and could change as what will likely be dozens, if not hundreds, of interested parties submit feedback (Kliff, 8/22).

    MSNBC: White House Issues New Fix For Contraceptive Coverage
    The new policies are intended to fill gaps left by two Supreme Court moves: The landmark Hobby Lobby decision saying contraceptive coverage violated the religious liberty of a for-profit corporation, and a preliminary order in Wheaton College v. Burwell. With today’s regulations, employees of for-profit corporations like Hobby Lobby will be able to access an "accommodation" where the insurer directly provides the cost-free coverage with no financial involvement by the employer. That accommodation was originally limited to religiously-affiliated nonprofits like Little Sisters of the Poor; houses of worship are fully exempt (Carmon, 8/22).

    Huffington Post: White House Rolls Out New Birth Control Accommodation For Nonprofits
    The Obama administration announced on Friday a new accommodation for religious nonprofits that object to covering the full range of contraceptives in their employee health care plans. The new accommodation will allow religious nonprofits, such as Catholic schools and hospitals, to opt out of covering birth control by notifying the Department of Health and Human Services of their objections. HHS and the Department of Labor will then arrange for a third-party insurer to pay for and administer the coverage for the nonprofits' employees so that women still receive the contraceptive coverage guaranteed to them by the Affordable Care Act (Basssett, 8/22).

    Categories: Health Care

    Pediatricians in Florida could see relief from low Medicaid payments

    Kaiser Health News - Fri, 08/22/2014 - 12:47pm

    After years of hearings and delays, the possible resolution this fall of a class-action lawsuit against Florida health and child-welfare officials could mean that physicans will at last receive what they consider to be adequate compensation for treating children of the poor.

    Dr. Bruce Eisenberg, a pediatrician, looks at Jordan Ellison, a patient in his office on Miami Beach. (Photo by Peter Andrew Bosch/Miami Herald)

    The lawsuit, filed in 2005 by pediatricians, dentists and nine children against the Agency for Health Care Administration, the Department of Children and Families and the Department of Health, claimed that Florida violated federal law by providing inadequate Medicaid services to children, and that their care had been hampered by low Medicaid payments to doctors. A federal judge is expected to rule on the case in October.

    Medicaid payments to pediatricians — and to primary-care doctors in general — were bumped up for two years by the Affordable Care Act. But that will end Dec. 31, and the Florida Legislature’s passage of $3.4 million in increased Medicaid payments to pediatricians for the coming fiscal year doesn’t come close to achieving parity with federal Medicare levels for comparable services.

    If the lawsuit goes the plaintiffs’ way, the state might have to come up with about $227 million a year, according to AHCA, to permanently increase payment rates to pediatricians and dentists — although an appeal would likely delay the change.

    That leaves some physicians in Florida in a state of limbo, not knowing how much they will be paid or when.

    “I can’t be playing games with the government,” said Bruce Eisenberg, a Miami Beach pediatrician who, like many doctors in Florida, reduced his Medicaid caseload over the years to less than 10 percent of his practice because of the traditionally low payments. He and other physicians say they usually operate at a loss when they treat patients under Medicaid.

    “I sort of do it as a service to the community,” said Eisenberg, who has been a pediatrician for 25 years. Before the ACA hikes went into effect, he said, Medicaid rates paid to Florida doctors for most procedures were about half as much as those set by Medicare, the federal health insurance program for people aged 65 or older. Many physicians have elected to stay out of the system altogether, leaving low-income families with little option but to turn to emergency rooms or urgent-care clinics when they are ill.

    If the payment rates are not permanently improved, “I definitely won’t be increasing my percentage of Medicaid patients,” Eisenberg said. “I could be seeing a lot of other patients who could be paying fairly for my time. My time is valuable.”

    During the Miami trial, which concluded in 2012, plaintiffs argued that the state had failed to comply with federal requirements that children receive certain levels of medical and dental services. The plaintiffs said “structural, financial and administrative barriers result in children not receiving the access to care federal law has bestowed as an enforceable right,” and that state agencies had run Medicaid so badly that almost 2 million poor children were receiving care far inferior to that of kids covered by private insurance.

    “Florida does a terrible job of ensuring that children get access to medical care,” said Stuart H. Singer, a lawyer in Fort Lauderdale who represents the plaintiffs. He noted that in addition to poor children receiving substandard attention, there was “undisputed evidence” presented at trial that in 2009, roughly 268,000 Florida children who were eligible for Medicaid assistance were not enrolled in the program. And the number, Singer said, is “probably a lot higher now.”

    ​The plaintiffs, Singer said, are asking U.S. Circuit Judge Adalberto Jordan to rule that payments to physicians — sometimes called reimbursements — be set at levels that would prompt more doctors to care for children on Medicaid.

    Until the ​temporary rate increases prompted by the ACA, “Florida’s Medicaid reimbursement rate was among the lowest in the nation,​” said a court document prepared by the plaintiffs in 2012.

    Asked to discuss the state’s position, Attorney General Pam Bondi’s office referred questions to AHCA, where press secretary Shelisha Coleman said the agency “is committed to providing children in Florida with access to quality healthcare.”

    During the trial, attorneys for the state said the plaintiffs had not proved their claim of lack of access or that children had been harmed by the rates paid to doctors. Still, Stephanie Daniel, a lawyer for the attorney general’s office, argued that the state’s health administrators were not “deliberately” indifferent to the plight of such children.

    Daniel told Jordan — who was sitting on the District Court bench when he was assigned the case — that the children and their pediatricians had failed to prove that delays in accessing medical care were significant or widespread, or that delays were longer than for children with private insurance.

    Doctors in Florida maintain that low Medicaid rates are just one issue keeping children from adequate access to health and dental care.

    “A lot of the problems essentially have to do with how the program is administered,” said Louis St. Petery Jr., a pediatric cardiologist in Tallahassee. One example he cited: the problem of children unexpectedly being dropped from the rosters, or assigned to new providers, by agencies such as DCF and AHCA.

    “There is nothing more frustrating than having a three-month-old kid no longer covered,” said St. Petery. He said the situation could be caused by computer problems compounded by human errors.

    “Kids don’t choose to be born to poor parents,” said St. Petery, a Medicaid provider since beginning his practice in 1974.

    Florida’s poverty rate of 17.1 percent in 2012 was among the country’s highest, according to Census Bureau statistics. In April, the Commonwealth Fund, a nonpartisan foundation that supports independent research on health and social issues, reported that Florida was one of 13 states that ranked the worst in the nation for access and affordability to healthcare.

    Richard Bucciarelli, a former president of the Florida chapter of the American Academy of Pediatrics, one of the plaintiffs’ groups in the lawsuit, said the trial “identified many families who could not find specialists to provide care” for their children.

    Bucciarelli said some provisions of Medicaid were passed by the Legislature but not implemented by the agencies. One was so-called presumptive eligibility, which was intended to allow a child to be covered by Medicaid for an initial visit to a doctor based on the family’s eligibility to receive food stamps. Another was the notion of “continuous eligibility” for children under 5, to guarantee access to medical care for low-income children during critical times of need.

    Lisa A. Cosgrove, a pediatrician on Merritt Island who testified in the trial, said Florida officials often seek to be exempted from federal requirements regarding such matters “because they wanted to control how many people they have under Medicaid.”

    But when patients cannot get consistent care, she said, they become “very much out of control with their chronic illnesses, like asthma or diabetes.”

    Cosgrove said she was grateful for the ACA payment raises. Once they kicked in, she said, the number of Medicaid patients in her practice went to 37 percent from 23 percent, and she hired an additional nurse practitioner.

    If the lawsuit were to go against the plaintiffs, however, Cosgrove said she would not take on any more patients under Medicaid. But, she added, “I wouldn’t get rid of the ones I have.”

    Categories: Health Care

    Even In Mass., Hundreds Of Young Central American Refugees Seek Care

    CommonHealth (WBUR) - Fri, 08/22/2014 - 12:18pm

    “Flor” (Photo: Richard Knox)

    By Richard Knox

    The young Honduran woman appeared at the Chelsea HealthCare Center last February, fearing she was pregnant.

    “Flor” – a pseudonym to protect family members back in Honduras – had paid a “coyote” $8,000 to escort her and her three-year-old daughter to the US-Mexican border. But when they got to the border town of Nuevo Laredo, the coyote sold her to a gang that held her in a tiny room with seven other women.

    They raped her, then told her to pay $17,000 or they’d sell her daughter’s organs and force her into sex slavery.

    Up in Massachuetts, her mother and father scrambled to borrow the money and wire it to Nuevo Laredo. Her kidnappers released Flor and the little girl; she doesn’t know what happened to the other women.

    Flor and her daughter are among hundreds of Central American immigrants who’ve made their way to the blue-collar town of Chelsea, Mass., over the past year.

    They represent a quiet influx that began months before the phenomenon hit the headlines and protests began flaring in communities from Cape Cod to California.

    They come to Chelsea because many of them have family there. Sixty-two percent of the town’s 35,000 residents are Latino, and many are from Honduras, El Salvador and Guatemala.

    As we sit in a conference room at the Chelsea health center, the sun back-lights the thick dark hair that frames Flor’s broad face as she tells me how and why she made the 2,300-mile trek from the Honduran capital of Tegucigalpa.

    “The decision I made, why I came here, was to give a better future to my daughter,” Flor says in Spanish, silent tears trickling down her cheeks. “In Honduras, it is very difficult. The gangs, they’re killing a lot of people. You have to give money month-to-month or they go to your house and they kill you.”

    To Flor’s enormous relief, the doctors determined she was not pregnant. But she still lives with constant anxiety. “I am very scared that they send me back,” she says. “But I believe in my God, that I’ll have the opportunity to stay here.”

    Many other American clinics and health centers are seeing these new asylum-seekers, even if their presence often hasn’t registered in a public way.

    The MGH Chelsea HealthCare Center, run by Massachusetts General Hospital, is by far the most heavily affected in the state. The Joseph M. Smith Community Health Center in Allston has also seen a significant uptick in these new immigrants, according to the Massachusetts League of Community Health Centers.

    Although the flow has slowed in recent weeks, Central American immigrants are showing up at the Chelsea health center in a steady stream. They reveal their harrowing stories to caregivers only slowly.

    “We do eventually get the whole story, but it may take a long time,” says pediatrician Kimberly Montez. “We try to do it in ways that don’t uncover things before we’re in a position to address them. We don’t want to pull all this trauma back up and then say, ‘OK, we’ll call you in a few weeks when we can get you a mental health counselor.’”

    The refugees’ ability to stay in this country may be unknown for months or years, pending hearings before an immigration judge.

    Under international treaties, the United States “may not return an individual to a country where he or she faces persecution from a government or a group the government is unable or unwilling to control based on race, religion, nationality, political opinion, or membership in a particular social group,” according to a recent report from the American Immigration Council.

    But establishing this can take considerable time and legal support. “It can be difficult, and often complicated, to determine whether an individual has a valid claim for asylum,” the report notes.

    Meanwhile, the new Central American refugees need medical care, immunizations, psychological and social support. They often need psychiatric care for post-traumatic stress syndrome, depression, and threatened suicide.

    “They have a lot of needs,” says Dr. Brent Ragar,  the Chelsea center’s chief of urgent care. He first noticed something unusual was going on in March, although a look back at the numbers showed the influx began last fall and winter.

    “In urgent care, the first thing we touched on were needs related to their journey,” Ragar tells CommonHealth. “They’d been on the road for weeks or months in some cases. They’d eaten bad food and bad water and had lost a lot of weight from diarrheal disorders. They had untended injuries. They had problems with their feet from walking so much.”

    One thing Ragar and his colleagues did not see were cases of infectious disease. Worry about that has garnered a lot of attention among people who believe these asylum-seekers could pose a public health threat and should be returned to their home countries as quickly as possible.

    “A lot of times, children come with vaccination records, or we can access them fairly quickly by fax from clinics in their home countries,” Ragar says. “Their vaccinations are equivalent to what’s given here, for the most part.”

    Children in Honduras, Guatemala and El Salvador are usually vaccinated against tuberculosis, something not done in the United States. Chelsea clinicians say they have not seen any active cases of TB among the new immigrants.

    One thing Ragar and his colleagues have seen frequently are women, teenagers and children who have been victims of rape and other assault on their journey north.

    While some immigrants are young women like Flor, many are teenagers and children as young as five – many or most of them unaccompanied by adults. The Chelsea health center has seen about 250 such children since last winter.

    This reflects the nation’s overall experience. Children under five are the fastest-growing group of unaccompanied children crossing the US border, doubling in the past year. A growing number of these children are girls, especially among those from Honduras.

    Chelsea pediatrician Rebecca Cronin says many of her young patients have suffered trauma of various kinds in their home countries, rather than en route to the United States.

    “I think there’s a reason people are leaving those places,” Cronin says. “They don’t feel it’s safe there. The only way is to leave. Otherwise, I think everyone would choose to stay there.”

    The American Immigration Council agrees. “Conditions in El Salvador, Honduras and Guatemala have reached a tipping point,” the group reports, “and more people are reaching the conclusion that they can no longer stay safely in their homes.”

    But once they have reached Chelsea and other U.S. havens, these refugee children are not beyond risk.

    Mary Lyons Hunter (Photo: Richard Knox)

    “We think, ‘Wow, these kids are getting a better opportunity,’ and they are,” says Mary Lyons Hunter, chief of the behavioral health unit at MGH Chelsea Health Center. “But we still have to realize that they’ve left behind all that they knew.”

    Hunter says these young asylum-seekers are currently in a “honeymoon period,” experiencing relief and elation at escaping desperate circumstances, surviving the long journey here and, in many cases, reuniting with families they haven’t seen in years.

    But by October, she predicts, serious behavioral problems will surface.

    “The reality sets in,” Hunter says. “Kids will be acting out in school. We’ll see anxiety, an inability to sit still. The younger ones might be throwing tantrums and the older ones might be very disrespectful, mouthy, angry.”

    She also expects family troubles. “The kids will say, ‘I haven’t seen my mom in eight years, I don’t know who this mom is.’ And the mom will say, ‘This child I’ve fantasized about reuniting with isn’t what we expected.’”

    Hunter says the mental health needs are beginning to show up. “These kids are terrified. They were terrified there, they’re terrified here,” she says. “They have flashbacks. They can’t sleep. They have fear of attachment or [they have] over-attachment, which comes under the heading of PTSD for kids. We see the gamut.”

    The Chelsea health center will be strained by these needs, Hunter says, but it will find a way to meet them.

    “The ethos here in Chelsea is we’ve got to support what’s coming to us,” she says. “The ethos is to welcome.”

    Categories: Health Care

    Thomas Jefferson in Paris – Pic of the Week

    In Custodia Legis - Fri, 08/22/2014 - 11:05am

    I was recently in Paris for my friends’ wedding and thought it might be a great opportunity to find something to photograph for a pic of the week.  I recalled that we previously posted a pic of the Bibliothèque Nationale de France, so that option was out.  Then, during a walk around the city, I noticed a statue of Thomas Jefferson and knew that was it!

    From the front of the base: Thomas Jefferson, 1743-1826

    From Jefferson’s hand:
    Drawing by Th. Jefferson
    First draft Monticello

    The statue, installed on July 4, 2006, is right along the Seine River and across from the Musée d’Orsay.  It is also across street from the Hotel de Salm.

    I noticed a drawing of Monticello in Jefferson’s hand (see photo on the right).  It was only later that I learned that the Hotel de Salm served as inspiration for an update to Jefferson’s home.  I found a blog post that compares the two, using the picture of Monticello on the back of the nickel and a photo of the Hotel de Salm.

    I have spent years working on the federal legislative information website THOMAS, named after Thomas Jefferson (by the way, after typing THOMAS all these years it is rather difficult for me to type the name in lowercase), and of course the Library of Congress has a lot of wonderful material related to him, including:

    From the side of the base:
    Tribute to Thomas Jefferson
    President of the United States of America 1801-1809
    Ambassador to Paris 1785-1789

    When researching this post I noticed many resources that relate to Jefferson’s time in Paris, including a few websites and some books I may need to add to my “to read” list.

    Categories: Research & Litigation

    Criminal records sealing alert for advocates

    Massachsuetts Trial Court Law Library - Fri, 08/22/2014 - 9:45am
    MassLegalServices.org has posted the latest alert for advocates of clients with CORI records.  The alert, along with their recent appellate case of Commonwealth v. Pon has changed the landscape for sealing criminal records.  Under the new standard, people only have to show "good cause" to seal their records.

    For the pro se wishing to go through the process on their own, MassLegalServices has a helpful page with the latest updates as well.

    Categories: Research & Litigation

    State Highlights: Only 1/3 Chose Medicaid Plan In Florida; Ore. Reforms Threatened After Federal Criticism; Calif. Prop 46 Money

    Kaiser Health News - Fri, 08/22/2014 - 9:19am

    A selection of health policy stories from Florida, Oregon, California, New York, Missouri, Iowa, Illinois, Massachusetts, Minnesota and New Jersey.

    The Associated Press: One-Third In Florida Chose Medicaid Plan
    Only about one-third of Medicaid recipients transitioning into managed care statewide chose their own health insurance plans. Enrollment for the general population started in May and ended in August. Consumers received a letter in the mail two months before enrollment and were given at least 30 days to choose an insurance plan. Those who did not choose a plan were automatically enrolled into a plan by state health officials (Kennedy, 8/21).

    The Oregonian: Oregon Health Reforms Threatened By New Federal Directive, Officials Say
    Federal officials have thrown a wrench into the state's high-stakes reforms to the Oregon Health Plan, threatening a program that serves one in four Oregonians. A new directive could eventually even force the state to return hundreds of millions of dollars received from the federal government -- money that's already largely spent. The federal agency that holds the purse strings for care of nearly 1 million low-income Oregon Health Plan members recently harshly criticized the state's system for distributing money to regional coordinated care organizations under the reforms (Budnick, 8/21).

    The Washington Post: One Of The Nation’s Most Expensive Ballot Campaigns Is Heating Up
    California is the location of what ... may become the two most expensive ballot campaigns of this election cycle and one of them is heating up this week. Proposition 46 pits doctors against trial lawyers in a battle over raising the limit on malpractice payouts, a fight that has already raised $61.5 million on both sides. The vast majority of the money -- roughly $56 million, according to Ballotpedia -- has been raised by groups opposed to the measure, financed by professional associations and large insurance companies. This week, the group that has raised more than 99 percent of that money is launching its first TV and radio ads in English and Spanish (Chokshi, 8/21).

    The Associated Press: NY City Council Passes Bill On Rikers Transparency
    The City Council on Thursday passed a bill that would force correction officials to publish information about Rikers Island jail inmates in solitary confinement, including any injuries suffered behind bars and the state of their mental health. The legislation awaits the signature of Mayor Bill de Blasio, who supports it (8/21).

    St. Louis Post-Dispatch: Hospital Mistakes Get Harder For Missouri Patients To Find
    Medicare has stopped providing information about eight serious medical errors in hospitals, including wrong blood type transfusions, patient falls and foreign objects left in patients’ bodies after surgery. The count of medical errors for each hospital was recently removed from the federal agency’s Hospital Compare website, in part because the data were considered inaccurate. The agency is working on new ways to collect and present the information, according to a Medicare spokesman. Other poor outcomes, including bed sores, blood clots and catheter infections, are still included on the website (Bernhard, 8/21).

    Des Moines Register: Cancer Society: Iowa Should Target Tanning Beds, Tobacco 
    The American Cancer Society wants Iowa legislators to take stronger action against tobacco and tanning beds. The national group on Thursday released an annual report card, which said Iowa met just three of 12 benchmarks for fighting cancer.The report noted that Iowa lawmakers increased spending on anti-tobacco programs by $100,000, to $5.1 million. But it said that level is only 17 percent of what federal experts recommend. "It certainly doesn't come close to what tobacco companies are spending to market their products," Jen Schulte, Iowa government relations director for the group's Cancer Action Network, said in a prepared statement (Leys, 8/21).

    ProPublica: In California, Some Efforts To Toughen Oversight Of Assisted Living Falter
    California legislators and activists say attempts to reform the state's troubled assisted living industry are being obstructed — and they are placing much of the blame on the administration of Democratic Gov. Jerry Brown. Early this year lawmakers began crafting more than a dozen bills intended to strengthen California's oversight of the state's roughly 7,700 assisted living facilities, which provide housing and day-to-day help to seniors and people with disabilities (Thompson, 8/21).

    Chicago Sun Times: Cubs Cut Grounds Crew’s Hours To Avoid Paying Health Benefits 
    Thanks a lot, Obama. Add the Affordable Care Act – or, specifically, the big-business Cubs’ response to it – to the causes behind Tuesday night’s tarp fiasco and rare successful protest by the San Francisco Giants. The staffing issues that hamstrung the grounds crew Tuesday during a mad dash with the tarp under a sudden rainstorm were created in part by a wide-ranging reorganization last winter of game-day personnel, job descriptions and work limits designed to keep the seasonal workers – including much of the grounds crew – under 130 hours per month, according to numerous sources with direct knowledge. That’s the full-time worker definition under “Obamacare,” which requires employer-provided health care benefits for “big businesses” such as a major league team (Wittenmyer, 8/21).

    The Boston Globe: ‘Concierge Medicine’ Service Says Rival Has Monopoly
    Two companies are battling in court over the Greater Boston market for premium health care services known as “concierge medicine,” a lucrative business that is growing nationally even as the broader industry comes under pressure to control costs. Concierge practices charge patients annual fees -- typically about $1,500 to $1,800 -- for quick access to, and more time with, their doctors. The national leader in concierge medicine, MDVIP Inc. of Florida, dominates the Boston market. Its smaller competitor, SignatureMD Inc. of California, has sued to break MDVIP’s grip in Boston and other metropolitan areas (McCluskey, 8/22).

    The Boston Globe: At Health Care Forum, Coakley Defends Partners Deal
    Under attack from gubernatorial rivals at a forum Wednesday night, Attorney General Martha Coakley defended her decision to allow Partners HealthCare to acquire South Shore Hospital and Hallmark Health System instead of filing a lawsuit to stop the merger. She said the agreement -- which still must be approved by a judge -- would help “put a net over the bigness of Partners” and reduce the rise of health care costs (Miller, 8/21).

    Minnesota Public Radio: Health Care Success Cuts Revenue To Uptown Clinic, Forcing It To Close
    A clinic in Minneapolis that provides medical care to thousands of uninsured and underinsured people is closing its doors next week, in large part because more people are obtaining health insurance through the Affordable Care Act and seeking care elsewhere. When the Neighborhood Involvement Program shuts down Aug. 29, the 3,000 patients that visit its Uptown clinic will be without a medical provider. But its dental and mental health clinics, as well as its senior and youth programs, will continue operating in Uptown (Sepic, 8/22).

    Politico Pro: Study Looks At Impact Of Massachusetts Individual Mandate
    The individual mandate obligates people to buy health insurance, although whether it actually drives down uninsured rates remains unclear. Yet researchers are increasingly able to isolate the areas where it is making a difference, drawing lessons from the Massachusetts experience under Romneycare. The latest numbers were discussed Thursday during a webinar sponsored by the University of Minnesota’s State Health Access Data Assistance Center (Wheaton, 8/21).

    The Wall Street Journal’s CFO Journal: A Patient-Focused Health Care CFO
    In the health care industry, CFOs have to preserve or improve patient care while meeting financial goals. Robert Glenning, chief financial officer for Hackensack University Health Network, which runs the largest hospital in New Jersey with 10,000 employees, spoke to CFO Journal’s John Kester about how the he prioritizes saving patients over saving money and how the Affordable Care Act is affecting the hospital business (Kester, 8/22).

    Categories: Health Care

    Seniors Are Less Able To Afford Prescriptions, Study Finds

    Kaiser Health News - Fri, 08/22/2014 - 9:17am

    In its first few years, Medicare's Part D prescription drug program helped seniors pay for their medications, but that trend appears to be reversing, researchers found. Meanwhile, drugmakers fight over the rules for naming cheaper versions of biologic drugs.

    The New York Times' The New Old Age: Part D Gains May Be Eroding
    [I]n its first few years, national data shows, Part D did help elderly Medicare beneficiaries make modest progress. Out-of-pocket costs decreased. Better able to afford their medications, seniors were less likely to stop taking them for financial reasons. And they were less likely to do without other basic needs — like food and heat — in order to pay for drugs. "I expected that to keep going,” said Jeanne Madden, a health policy analyst at Harvard Medical School. Instead, as she and a team researchers from Harvard and the University of Massachusetts report in the most recent issue of Health Affairs, those downward trends took a U-turn in 2009. "Things improved after Part D, continued to improve for a few years, and then reversed," she said in an interview (Span, 8/21).

    The Washington Post’s Wonkblog: A Drug Naming Dispute, With Billions On The Line
    In health care, even how you name something can become a debate with billions of dollars on the line. With a new wave of cheaper versions of biologic drugs expected to soon become available in the United States, the health-care industry is still fighting over key ground rules for these drugs — more than four years after the Affordable Care Act cleared a pathway for this new drug classification. That includes what names these copy-cat version of biologic drugs should actually go by (Millman, 8/21).

    Categories: Health Care

    Patient Deaths Raise Questions About Lethal Doses In Hospice

    Kaiser Health News - Fri, 08/22/2014 - 9:16am

    The Washington Post examines the deaths of some hospice patients who were not close to death but who received large doses of powerful pain-killers.

    The Washington Post: As More Hospices Enroll Patients Who Aren't Dying, Questions About Lethal Doses Arise
    The hospice industry in the United States is booming and for good reason, many experts say. Hospice care can offer terminally ill patients a far better way to live out their dying days, and many vouch for its value. But the boom has been accompanied by what appears to be a surge in hospices enrolling patients who aren't close to death, and at least in some cases, this practice can expose the patients to the more powerful pain-killers that are routinely used by hospice providers. Hospices see higher revenues by recruiting new patients and profit more when they are not near death (Whoriskey, 8/21).

    The Washington Post: End-Of-Life Care: An Industry With Soaring Profits, Funded By Taxpayers
    But what happens when hospices, in part to improve profits, attempt to care for people who aren’t terminally ill? Whoriskey wrote about a 77-year-old North Carolina man, Clinard “Bud” Coffey, who entered hospice care for pain management — and died two weeks later. ... Before you consider hospice care, know the facts (Paquette, 8/21).

    Categories: Health Care

    Some Embattled Democrats Embracing Obamacare

    Kaiser Health News - Fri, 08/22/2014 - 9:16am

    News outlets look at Democratic Sen. Mark Pryor's promotion of the health law in a campaign ad as a sign the law may be less radioactive. Meanwhile, Politico notes that 30 of the 34 House Democrats who voted against the law are no longer in office as the partisanship that it engendered grows.

    The Associated Press: Democrats Reframe Debate On Health Care
    One of the most vulnerable Senate Democrats is standing by his vote for President Barack Obama's health care law, a fresh sign that the unpopular mandate may be losing some of its political punch. In an ad released this week, two-term Arkansas Sen. Mark Pryor says he voted for a law that prevents insurers from canceling policies if someone gets sick, as he did 18 years ago when he was diagnosed with cancer. That prohibition on ending policies is one of the more popular elements of the 4-year-old law that Pryor never mentions by its official name — the Affordable Care Act (Cassata, 8/22).

    The Hill: Dems Find Obamacare Ammo
    Vulnerable Democrats are finding ways to tout ObamaCare in an election cycle where the unpopular law was expected to be a liability for their party. The most overt emphasis on healthcare came this week, when Sen. Mark Pryor (D-Ark.) debuted an ad centered on his 1996 bout with cancer and his vote for the 2010 legislation, which protects people with pre-existing medical conditions from losing insurance coverage. "No one should be fighting an insurance company while you're fighting for your life," Pryor says in the ad while sitting next to his father, David Pryor, a beloved former senator in Arkansas (Viebeck, 8/22).

    Politico: Only 4 Anti-Obamacare House Dems Left For Fall Elections
    Thirty-four House Democrats bucked their party to vote against Obamacare when it passed in 2010. Today, only four of those lawmakers are still in office and running for reelection this fall. The dramatic downsize underscores not only how consequential the health care law vote was but how quickly moderate Democrats have been eliminated on Capitol Hill. Even those who opposed the law had trouble surviving the highly partisan atmosphere it helped to create (Haberkorn, 8/22).

    Another health-related issue is also coming up on the campaign trail -

    The Hill: Groups Attack Vulnerable Dems On Late-Term Abortion Bill
    Anti-abortion groups are campaigning against three Democratic senators in key battleground states who oppose a ban on late-term abortions.  A coalition of groups including Concerned Women for America, Family Research Council Action, Students for Life of America and the Susan B. Anthony List is traveling to the home states of Sens. Mark Udall (Colo.), Kay Hagan (N.C.) and Mark Pryor (Ark.) to hit them for opposing a bill banning abortions after five months. Last year the House passed the Pain-Capable Unborn Child Protection Act. Sen. Lindsey Graham (R-S.C.) has picked it up in the Senate, but the bill has not seen any traction (Al-Faruque, 8/21).

    Categories: Health Care

    Viewpoints: Employers And Health Benefits; Sen. Pryor's ACA Endorsement; Waging War On Hep C

    Kaiser Health News - Fri, 08/22/2014 - 9:15am

    The Wall Street Journal: Unemployed By ObamaCare
    Most of the political class seems to have decided that ObamaCare is working well enough, the opposition is fading, and the subsidies and regulation are settling in as the latest wing of the entitlement state. This flight from reality can't last forever, especially as the evidence continues to pile up that the law is harming the labor market. On Thursday the Federal Reserve Bank of Philadelphia reported the results of a special business survey on the Affordable Care Act and its influence on employment, compensation and benefits. Liberals claim ObamaCare is of little consequence to jobs, but the Philly Fed went to the source and asked employers qualitative questions about how they are responding in practice (8/21). 

    Bloomberg: Don't Worry About Losing Your Health Care ... Yet
    [E]mployees value the health benefits highly enough to trade off a lot of wages for them. For all the talk about how people are insulated from the cost of their insurance, if you follow union negotiations, you’ll know that when it comes to making explicit trade-offs between more expensive benefits and higher wages, the union representatives very frequently choose the benefits. That suggests that as long as employees are afraid of the exchanges, employers are going to be reluctant to force them there. This effect will probably be weakest at the low end, where the workforce is already struggling to find and keep jobs, but among middle-class people with relatively secure employment, I'd expect relatively little dumping in the near- to medium-term (Megan McArdle, 8/21).

    The Washington Post’s Plum Line: Can Dems Defend Expanding Coverage To Poor In Red States?
    Ever since embattled Dem Senator Mark Pryor went up with a new ad discussing his cancer and touting his vote for the health law as the right thing to do, critics have pointed out that he failed to name the whole law in the spot, so the ad doesn't really count as a full-throated defense of it. I think that’s a silly standard. But it does raise an interesting question: Can Democrats in difficult states stand behind the goal of expanding coverage to poor people? (Greg Sargent, 8/21). 

    The Wall Street Journal's Washington Wire: Sen. Mark Pryor Spotlights The Health Law's Rx For Pre-Existing Illnesses
    Democrats generally are not campaigning on the Affordable Care Act, but in a new campaign ad Arkansas Sen. Mark Pryor does just that. Some have commented on the fact that Mr. Pryor does not mention the ACA by name in the ad, referring to it as "a law he helped pass." Just as interesting is the part of the law the ad features: its protections for people with pre-existing medical conditions. With all of the focus on the ACA’s rollout problems last fall and the ACA’s coverage expansion, we have not heard much about "pre-x" in some time, but in many respects it's the mega benefit in the law (Drew Altman, 8/21). 

    The Star Tribune: Hennepin Health Is Delivering Health Care Innovation
    The expansive, not-limited-to-the-doctor’s-office approach taken to improve Johnson’s health is a key reason why the Hennepin Health program is among the nation’s most innovative health reform efforts. Now in its third year, the county-led program, which serves some of the metro’s poorest and sickest patients, keeps delivering impressive results. The latest data released by the program underscored why it continues to accrue accolades and should be looked to as a national model. It's also a reminder that the private sector doesn't have a monopoly on health care innovation (8/21).

    The Washington Post: The Cure For Cancer That Parents Won't Use
    Not so long ago, when my sons still had smooth cheeks and children's voices, I had them vaccinated against human papillomavirus, the most common sexually transmitted disease. It was late 2011, and the Centers for Disease Control and Prevention had just recommended that boys join girls in being vaccinated at age 11 or 12. I was certainly receptive: HPV, as it's commonly called, causes cervical cancer, cancer of the tonsils, cancer of the back of the tongue and, less often, cancers of the vulva, vagina, anus and penis. It seemed important to ensure that my kids were protected. Yet numbers released last month by the CDC show that my sons, now 14 and 15, are among a small minority of adolescent males who have been vaccinated (Meredith Wadman, 8/21). 

    Bloomberg: Waging War On Hepatitis C
    Instead of complaining about how much Sovaldi costs and trying to tamp down its use, why not use the drug to stage a war on hepatitis C? Why not try to get the drug into as many bodies as possible, as fast as possible, with the hope of knocking this horrible disease back down to much lower infection rates? ... The point is, we should be able to come to a deal where we treat more patients, knock down the new infection rate, and give Gilead a nice, fat profit for developing a great drug that saves lives (Megan McArdle, 8/21).

    Categories: Health Care

    Parsing The Mixed Messages Regarding The Costs Of 'Obamacare' Coverage

    Kaiser Health News - Fri, 08/22/2014 - 9:15am

    The Huffington Post breaks down the good and bad news surrounding what people may pay next year for coverage in the wake of the health law. Meanwhile, Modern Healthcare takes a look at how the Obama administration decision to let people keep health coverage that didn't comply with the overhaul's standards is impacting premium rates.  

    Huffington Post: Here's What's Going On With Obamacare Premium Increases
    Health insurance premiums are going to skyrocket under Obamacare next year, maybe even double! No, wait -- they're only increasing a little, and less than before Obamacare! No, wait -- they're … decreasing in some places? The crucial question about the second year of enrollment on the Affordable Care Act's health insurance exchanges is: How much will coverage cost? Actual prices won't be available in most states until the exchanges open Nov. 15, or shortly before that, so consumers are left to sort through political spin and preliminary reports that don't make things any clearer. So what's going on? First, most people will pay more for health insurance next year. ... The good news is that available information indicates the doomsayers were wrong, and premiums under President Barack Obama's health care law aren't going through the roof (Young, 8/21).

    Modern Healthcare: People Keeping Noncompliant Plans; Rate Impact Varies By State
    When the Obama administration in November 2013 decided to allow states to decide if individuals could keep noncompliant insurance plans, speculation began about what effect that decision would have on premiums and enrollment for plans that did comply with provisions of the Patient Protection and Affordable Care Act. Subsequently, the administration this March gave states the option of a maximum two-year extension into 2016. Early indications of how many individuals opted to keep those plans have begun to emerge as have signs of the effect on premiums. As with so much else related to the ACA, the results depend on what state is being discussed. Twenty-five states are allowing noncompliant plans to continue through 2015, which creates a continuing impact for insurers attempting to formulate premium levels in 2014, according to data compiled by America's Health Insurance Plans, an insurer trade group. Twenty-one states are taking the full extension option, through 2016, according to AHIP (Tahir, 8/21).

    Also in the news, the Denver Post tracks the total number of cancelled health plans in Colorado while the Seattle Times offers reports on how the Washington state exchange is doing, and the CT Mirror checks in on what's ahead in terms of enrollment assistance. 

    Denver Post: Colorado Says 2,100 Health Plans Were Canceled In Last Two Months
    The Colorado Division of Insurance has reported that there were about 2,100 health-plan cancellations in the state over the past two months, bringing this year's total to more than 6,150. The division reported the figures for June 15-Aug. 15 to Senate Minority Leader Bill Cadman last week. Senate Republicans have requested monthly on the numbers. Since 2013, there have been about 340,000 policy cancelations in Colorado. Many customers received notices last fall as the Affordable Care Act was rolling out (Draper, 8/21).

    Seattle Times: Healthplanfinder: ‘Moderately Effective,’ Could Improve
    How does Washington’s online exchange marketplace compare with those in other states? As part of an ongoing study, the nonprofit Urban Institute assessed how well state exchanges created under the Affordable Care Act provide the sort of information consumers want to know about insurance plans they’re considering buying. The report — Physician Network Transparency: How Easy Is It for Consumers to Know What They Are Buying? — gives Washington’s  wahealthplanfinder.org creditable marks. At the same time, the report notes room for improvement. The report judged Washington’s site to be in the “moderately effective” group, which also included Colorado and Oregon. On the lower end of the transparency scale were the District of Columbia and Rhode Island. Top scorers were California, Healthcare.gov, Massachusetts and Minnesota (Marshall and Ostrom, 8/21).

    The CT Mirror: Future Of Obamacare Enrollment Assistance Still Being Determined
    Eva Bermudez was one of nearly 300 people tasked with helping the uninsured get covered as Obamacare rolled out last fall. Her job might have seemed easy compared to those of her counterparts. An organizer with the union CSEA SEIU Local 2001, Bermudez focused her efforts on union members, many of whom had technological experience, Internet access and the ability to sign up for coverage online or by telephone. Even so, they came to her for help (Becker, 8/21).

    Categories: Health Care

    Research Roundup: Surgical Site Infections; Medicare Drug Plans; Arkansas' Medicaid Innovations

    Kaiser Health News - Fri, 08/22/2014 - 9:14am

    Each week, KHN compiles a selection of recently released health policy studies and briefs.

    Urban Insitute/RWJF: Physician Network Transparency: How Easy Is It for Consumers to Know What They Are Buying? 
    Urban Institute researchers studied nine marketplace websites (California, Colorado, Connecticut, District of Columbia, Massachusetts, Minnesota, Oregon, Rhode Island and Washington) ... Most websites studied did not list plan (e.g. HMO) or network (e.g., narrow or tiered) type. Only three of nine websites studied embedded provider directories for each plan on the Marketplace website. The remaining websites diverted consumers to insurance company websites in order to access provider directories. This report shows that states need to make improvements in the clarity, accessibility and functionality of their online insurance marketplaces to make them more consumer-friendly and transparent (Blumberg, Peters, Wengle, and Arnesen, 8/21).

    JAMA Surgery: Effect Of Minimally Invasive Surgery On The Risk For Surgical Site Infections
    Surgical site infection (SSI) represents the second most common cause of hospital-acquired infection .... We abstracted the data [from the American College of Surgeons National Surgical Quality Improvement Program database] on 30-day SSIs and compared patients undergoing open procedures and MIS [minimally invasive surgery] .... MIS was associated with lower rates of postoperative SSIs in patients undergoing MIS vs open procedures for appendectomy (3.8% vs 7.0%), colectomy (9.3% vs 15.0%), hysterectomy (1.8% vs 3.9%), and radical prostatectomy (1.0% vs 2.4%) (Gandaglia et al., 8/20).

    JAMA Internal Medicine: Patients' Understanding Of Their Hospitalizations And Association With Satisfaction
    A total of 177 eligible internal medicine patients who had 2 or more medical conditions, 2 or more medical procedures, and 2 or more days of hospital stay between June 2012 and February 2013 were interviewed on the day of discharge. Patients were ... asked to (1) list all their medical diagnoses, (2) identify the indications for their medications from the discharge instruction sheet, and (3) identify the tests and/or procedures they underwent from a list of common tests and procedures provided. ... Patients’ shared understanding with their physicians in the domains of diagnosis, medication indications, and tests and/or procedures was suboptimal, yet patients' perceived understanding and their satisfaction with the quality of communication they received was fairly high (Kebede et al., 8/18).

    Kaiser Family Foundation: Medicare Part D In Its Ninth Year: The 2014 Marketplace And Key Trends, 2006-2014
    Growth in average monthly Part D premiums has essentially flattened since 2010 after rising about 10 percent annually before then. Rising use of generic drugs, triggered by patent expirations for many popular brand-name drugs, has been a major factor in slowing premium growth—paralleling slower prescription drug spending growth in the broader health system. ... In 2014, more than 37 million Medicare beneficiaries are enrolled in Medicare drug plans, an increase of 2 million compared to 2013 and 15 million since 2006. ... In 2014, about three-fourths of all plans ... use five cost-sharing tiers .... Only 5 percent of PDP enrollees are in plans with the highest star ratings (4 stars or more) (Hoadley, Cubanski et al., 8/18).

    The Commonwealth Fund: Arkansas: A Leading Laboratory For Health Care Payment And Delivery System Reform
    In crafting their [Medicaid] reform strategies, states can learn from early innovators. This issue brief focuses on one such state: Arkansas. Insights and lessons from the Arkansas Health Care Payment Improvement Initiative (AHCPII) suggest that progress is best gained through an inclusive, deliberative process facilitated by committed leadership, a shared agreement on root problems and opportunities for improvement, and a strategy grounded in the state’s particular health care landscape (Bachrach, du Pont and Lipson, 8/19) 

    Here is a selection of news coverage of other recent research:

    news@JAMA:  Using Antipsychotics For Elderly Patients Boosts Kidney Risks
    Older adults treated with atypical antipsychotics are at increased risk of kidney injury, according to a study published today in the Annals of Internal Medicine. The findings add to previous evidence that this class of drugs is risky for older adults. Although atypical antipsychotics are commonly prescribed for older adults to treat agitation and other behavioral symptoms of dementia, the US Food and Drug Administration has not approved the drug for this purpose. In fact, since 2005 the agency has warned that use of these drugs to treat older adults with dementia was associated with a 2-fold increased risk of death (Kuehn, 8/18).

    Bloomberg:  Too Many Cancer Screenings Wasted On Those Facing Death
    Older patients who aren't expected to live more than another decade are still being screened too often for cancers, causing more harm than good, a study found. More than half of men 65 and older who had a very high risk of dying in nine years were screened for prostate cancer, a slow-moving disease, according to research today in JAMA Internal Medicine. Almost 38 percent of older women with a similar life expectancy were screened for breast cancer and 31 percent were screened for cervical cancer despite some having undergone a hysterectomy, which means they often had no cervix (Ostrow, 8/18).

    USA Today: Hospitalizations, Deaths For Heart Disease Fall
    Hospitalizations for heart disease and stroke fell by about one-third over the past decade, according to a new study of nearly 34 million Medicare recipients. The number of Medicare patients hospitalized with heart attacks fell 38% from 1999 to 2011, while the number hospitalized with blood-clot-related strokes fell 34%, according to a study in Circulation. Hospitalizations fell 31% for heart failure, which occurs when the heart is too weak to pump efficiently, and 84% for unstable angina, a sudden chest pain that often leads to heart attacks, partly because some of these cases were reclassified as heart attacks (Szabo, 8/18).

    Reuters: Preventable Hospital Deaths After Urological Surgery Rising: Study
    As more urological surgeries are performed outside hospitals, deaths from preventable complications among men and women getting inpatient surgery have risen, according to a new study. It’s likely that older, sicker and poorer people make up more of the population having inpatient surgery, not that the surgeries are getting more dangerous, researchers say (Doyle, 8/19).

    Reuters: Doctors May Be Missing Chances To Talk To Teens About Smoking
    Less than a third of teens say their doctors have spoken to them about tobacco use, according to a new study. "Given that tobacco is still the number one preventable cause of death and disease in the U.S., it is surprising that more clinicians are not intervening with adolescent patients to help them avoid or quit tobacco," lead author Gillian L. Schauer, of Carter Consulting, Inc., told Reuters Health. ... She and her colleagues write in the journal Pediatrics that most current smokers started as teenagers or young adults (Doyle, 8/19).

    Los Angeles Times: Simple Measures Made Hospital Patients 70% More Likely To Quit Smoking
    A free supply of nicotine replacement medication and a handful of automated phone calls made smokers who wanted to quit much more likely to succeed, according to results of a clinical trial published Tuesday in the Journal of the American Medical Assn. ... They estimated that once their 90-day program was set up, it could be maintained at a cost of less than $1,000 per quitter (Kaplan, 8/19).

    Reuters:  More Evidence Adult Daycare Eases Stress On Dementia Caregivers
    The stress of caring for a family member with dementia may take a toll on health over time, but a new study suggests that even one day off can shift caregivers' stress levels back toward normal. Based on measurements of the stress hormone cortisol, researchers found that caregivers had healthier stress responses on days when the dementia patient went to adult daycare. Even anticipation of the day off had an effect on cortisol levels (Lehman, 8/19).

    MinnPost: Late In Life Care: Stressful, Complicated World Of Surrogate Decision-Makers
    Within 48 hours of being hospitalized, almost half of all adults aged 65 or older will need someone else — a trusted relative or friend — to help them make at least one medical decision, and almost one-fourth will need that surrogate to make all of their medical decisions, according to the findings of a study published earlier this year in JAMA Internal Medicine. The most common decision made by surrogates in the study involved life-sustaining care (Perry, 8/20).

    Reuters: Researchers Reverse Autism Symptoms In Mice By Paring Extra Synapses
    Although many things have gone wrong in the autistic brain, scientists recently have been focusing on one of the most glaring: a surplus of connections, or synapses. Neuroscientists reported Thursday that, at least in lab mice, a drug that restores the healthy “synaptic pruning” that normally occurs during brain development also reverses autistic-like behaviors such as avoiding social interaction (8/21).

    Categories: Health Care

    Political Cartoon: 'Phantom Pain?'

    Kaiser Health News - Fri, 08/22/2014 - 9:14am

    Kaiser Health News provides a fresh take on health policy developments with "Phantom Pain?" by Chris Wildt.

    Meanwhile, here's today's haiku:

    OUT OF BALANCE

    Needed: docs for old
    But no one wants to pay them
    Health care paradox
    -Anonymous

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    Categories: Health Care

    First Edition: August 22, 2014

    Kaiser Health News - Fri, 08/22/2014 - 7:02am

    Today's headlines include coverage of issues related to hospice care.

    Kaiser Health News: Some Insurers Refuse To Cover Contraceptives, Despite Health Law Requirement
    Kaiser Health News consumer columnist Michelle Andrews writes: “How much leeway do employers and insurers have in deciding whether they’ll cover contraceptives without charge and in determining which methods make the cut? Not much, as it turns out, but that hasn’t stopped some from trying. Kaiser Health News readers still write in regularly describing battles they’re waging to get the birth control coverage they’re entitled to” (Andrews, 8/22). Read the article.

    Politico: Only 4 Anti-Obamacare House Dems Left For Fall Elections
    Thirty-four House Democrats bucked their party to vote against Obamacare when it passed in 2010. Today, only four of those lawmakers are still in office and running for reelection this fall. The dramatic downsize underscores not only how consequential the health care law vote was but how quickly moderate Democrats have been eliminated on Capitol Hill. Even those who opposed the law had trouble surviving the highly partisan atmosphere it helped to create (Haberkorn, 8/22).

    The Washington Post: As More Hospices Enroll Patients Who Aren’t Dying, Questions About Lethal Doses Arise
    The hospice industry in the United States is booming and for good reason, many experts say. Hospice care can offer terminally ill patients a far better way to live out their dying days, and many vouch for its value. But the boom has been accompanied by what appears to be a surge in hospices enrolling patients who aren’t close to death, and at least in some cases, this practice can expose the patients to the more powerful pain-killers that are routinely used by hospice providers. Hospices see higher revenues by recruiting new patients and profit more when they are not near death (Whoriskey, 8/21).

    The Washington Post: End-Of-Life Care: An Industry With Soaring Profits, Funded By Taxpayers
    But what happens when hospices, in part to improve profits, attempt to care for people who aren’t terminally ill? Whoriskey wrote about a 77-year-old North Carolina man, Clinard “Bud” Coffey, who entered hospice care for pain management — and died two weeks later (Paquette, 8/21).

    The Wall Street Journal’s CFO Journal: A Patient-Focused Health Care CFO
    In the health care industry, CFOs have to preserve or improve patient care while meeting financial goals. Robert Glenning, chief financial officer for Hackensack University Health Network, which runs the largest hospital in New Jersey with 10,000 employees, spoke to CFO Journal’s John Kester about how the he prioritizes saving patients over saving money and how the Affordable Care Act is affecting the hospital business (Kester, 8/22).

    The Washington Post’s Wonkblog: A Drug Naming Dispute, With Billions On The Line
    In health care, even how you name something can become a debate with billions of dollars on the line. With a new wave of cheaper versions of biologic drugs expected to soon become available in the United States, the health-care industry is still fighting over key ground rules for these drugs — more than four years after the Affordable Care Act cleared a pathway for this new drug classification. That includes what names these copy-cat version of biologic drugs should actually go by (Millman, 8/21).

    The New York Times’ The New Old Age: Part D Gains May Be Eroding
    But in its first few years, national data shows, Part D did help elderly Medicare beneficiaries make modest progress. Out-of-pocket costs decreased. Better able to afford their medications, seniors were less likely to stop taking them for financial reasons. And they were less likely to do without other basic needs — like food and heat — in order to pay for drugs. “I expected that to keep going,” said Jeanne Madden, a health policy analyst at Harvard Medical School. Instead, as she and a team researchers from Harvard and the University of Massachusetts report in the most recent issue of Health Affairs, those downward trends took a U-turn in 2009. “Things improved after Part D, continued to improve for a few years, and then reversed,” she said in an interview (Span, 8/21).

    The Wall Street Journal: DEA Restricts Narcotic Pain Drug Prescriptions
    The Obama administration moved Thursday to restrict prescriptions of the most commonly used narcotic painkillers in the U.S. in an attempt to curb widespread abuse. The Drug Enforcement Administration said it would reclassify hydrocodone combination drugs such as Vicodin and put them in the category reserved for medical substances with the highest potential for harm. The "rescheduling" means people will be able to receive the drugs for only up to 90 days without obtaining a new prescription. The opioid pills are taken by millions of Americans, including after dental surgery, for back problems and broken bone (Radnofsky and Walker, 8/21).

    The Washington Post: One Of The Nation’s Most Expensive Ballot Campaigns Is Heating Up
    California is the location of what will may become the two most expensive ballot campaigns of this election cycle and one of them is heating up this week. Proposition 46 pits doctors against trial lawyers in a battle over raising the limit on malpractice payouts, a fight that has already raised $61.5 million on both sides. The vast majority of the money—roughly $56 million, according to Ballotpedia—has been raised by groups opposed to the measure, financed by professional associations and large insurance companies. This week, the group that has raised more than 99 percent of that money is launching its first TV and radio ads in English and Spanish (Chokshi, 8/21).

    The Associated Press: NY City Council Passes Bill On Rikers Transparency
    The City Council on Thursday passed a bill that would force correction officials to publish information about Rikers Island jail inmates in solitary confinement, including any injuries suffered behind bars and the state of their mental health. The legislation awaits the signature of Mayor Bill de Blasio, who supports it (8/21).

    Reuters: Researchers Reverse Autism Symptoms In Mice By Paring Extra Synapses
    Although many things have gone wrong in the autistic brain, scientists recently have been focusing on one of the most glaring: a surplus of connections, or synapses. Neuroscientists reported Thursday that, at least in lab mice, a drug that restores the healthy “synaptic pruning” that normally occurs during brain development also reverses autistic-like behaviors such as avoiding social interaction (8/21).

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    Categories: Health Care

    Some Insurers Refuse To Cover Contraceptives, Despite Health Law Requirement

    Kaiser Health News - Fri, 08/22/2014 - 6:05am

    How much leeway do employers and insurers have in deciding whether they’ll cover contraceptives without charge and in determining which methods make the cut?

    Not much, as it turns out, but that hasn’t stopped some from trying.

    The NuvaRing (Photo by Sandy Huffaker/Getty Images)

    Kaiser Health News readers still write in regularly describing battles they’re waging to get the birth control coverage they’re entitled to.

    In one of those messages recently, a woman said her insurer denied free coverage for the NuvaRing. This small plastic device, which is inserted into the vagina, works for three weeks at a time by releasing hormones similar to those used by birth control pills. She said her insurer told her she would be responsible for her contraceptive expenses unless she chooses an oral generic birth control pill. The NuvaRing costs between $15 and $80 a month, according to Planned Parenthood.

    Under the health law, health plans have to cover the full range of FDA-approved birth control methods without any cost sharing by women, unless the plan falls into a limited number of categories that are excluded, either because it’s grandfathered under the law or it’s for is a religious employer or house of worship.  Following the recent Supreme Court decision in the Hobby Lobby case, some private employers that have religious objections to providing birth control coverage as a free preventive benefit will also be excused from the requirement.

    In addition, the federal government has given plans some flexibility by allowing them to use "reasonable medical management techniques" to keep their costs under control. So if there is both a generic and a brand-name version of a birth-control pill available, for example, a plan could decide to cover only the generic version without cost to the patient.

    More From This Series Insuring Your Health

    As for the NuvaRing, even though they may use the same hormones, the pill and the ring are different methods of birth control. As an official from the federal Department of Health and Human Services said in an email, "The pill, the ring and the patch are different types of hormonal methods … It is not permissible to cover only the pill, but not the ring or the patch." 

    Guidance from the federal government clearly states that the full range of FDA-approved methods of birth control must be covered as a preventive benefit without cost sharing. That includes birth control pills, the ring or patch, intrauterine devices and sterilization, among others. 

    But despite federal guidance, “we’ve seen this happen, plenty,” says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. “Clearly insurance companies think things are ambiguous enough that they can get away with it.”

    If you are denied coverage, your defense is to appeal the decision, and get your state insurance department involved.

    “The state has the right and responsibility to enforce this law,” says Sonfield.

    Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

    Categories: Health Care

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