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Health Care

Connector Scraps Site, Maps 2 Fixes For Now

CommonHealth (WBUR) - Mon, 05/05/2014 - 4:57pm

The Massachusetts Health Connector has decided that its current website is not salvageable.

In the latest attempt to have a site ready for open enrollment in November, the Connector will pursue two plans. They are:

1) Plan A is a new site, an “off the shelf” model, built by hCentive. The Virginia-based company worked on the health insurance enrollment sites in use in Kentucky and Colorado. But the Connector isn’t sure this new site will be ready in October. Which is why there is a…

2) Plan B is to use the federal site, HealthCare.gov. Some Connector staff and board members don’t like the federal option because they won’t be able to customize it to include extra subsidies Massachusetts offers. The state also has more than 250 individual Medicaid programs that won’t be available on HealthCare.gov.

It will be difficult for health insurers to be prepared for open enrollment on two different sites.

“We may run the risk of some health plans that are on the Connector today that aren’t able to meet the technology specifications in the compressed time frame and may not be available to consumers when open enrollment begins next November,” said Eric Linzer, Senior Vice President, Massachusetts Association of Health Plans.

The Connector board will discuss details of the choices at a meeting this Thursday. Board member Dolores Mitchell supports the dual track plan.

“Is it the happiest of all solutions, no. Is it a solution that has a chance of succeeding, yes,” concludes Mitchell.

The Connector expects to decide between Plan A and Plan B this summer.

“I’ve said all along that no option on the table would be perfect, and the dual track certainly has its benefits and its challenges,” Sarah Iselin, who was appointed by the governor to oversee a site fix, said in a statement. “It does, however, solve for two realities: we need a reliable website to help people during the next open enrollment period, and we need to be in a position to achieve a fully integrated system in 2015.”

The 190,000 residents who are enrolled in temporary coverage will stay there for now. Connector Care members whose plans have been extended since Dec. 1, 2013, will also likely stay in those plans through the fall.

How much will all this cost? The Connector says it can pay for both plans using the original $170-$180 million grants for website preparation and transition.

Many people are questioning this — and the dual-track plan.

“The state has struggled with the capacity and technical expertise to do it once over four years, to be able to take a dual track over five months seems unrealistic to me,” said Josh Archambault, a senior fellow at the Pioneer Institute, a right-leaning research group.

The site that goes up in October will only be available for residents qualifying for subsidized or non-subsidized plans. Everyone on the state’s Medicaid program will have to deal with MassHealth directly.

Earlier:

Here’s the full press release out today. Hat tip to Kyle Cheney for having the story first on Politico.

BOSTON – Monday, May 5, 2014 – State and Optum officials, led by Special Assistant to the Governor for Project Delivery Sarah Iselin and Optum Chief Information Officer John Santelli, will outline to the Health Connector Board of Directors on Thursday a plan to stand up a functioning Health Insurance Exchange (HIX) for Fall 2014 Open Enrollment. The dual-track strategy will include both a successful off-the-shelf solution and the Federally Facilitated Marketplace (FFM), and aims to ensure the Commonwealth continues to expand access to affordable, quality health insurance through the Affordable Care Act (ACA).

“Thursday will mark an important milestone for our turnaround project,” Iselin said. “We will be moving from planning to implementation, and we have developed a well-informed and pragmatic plan to guide us. I’ve said all along that no option on the table would be perfect, and the dual track certainly has its benefits and its challenges. It does, however, solve for two realities: we need a reliable website to help people during the next open enrollment period, and we need to be in a position to achieve a fully integrated system in 2015.”

“Based on our assessment of the Health Connector Exchange, we agree that the dual-track strategy is the optimal approach for the state to take at this point,” said John Santelli, Chief Information Officer of Optum. “We look forward to continuing to work closely with the state to improve the consumer experience and extend high-quality, affordable health coverage to as many Massachusetts residents as possible.”

The dual track plan, which will be detailed in full at Thursday’s Health Connector Board of Director’s meeting (9 AM, One Ashburton Place, 21st Floor, Boston), calls for concurrent implementation of an off-the-shelf solution and the FFM, while also ensuring the programs that make Massachusetts a national leader in health care access, affordability and choice remain intact. This includes the State Wrap program, which through additional state premium assistance helps makes health insurance more affordable for tens of thousands of residents. The plan also seeks new carrier accommodations to reduce the business and operational burdens associated with migrating to an external Exchange.

The Commonwealth and Optum had been considering rebuilding the current system, or using parts or all of an existing state Exchange or the federal Exchange. They determined that the off-the-shelf software – hCentive – powering Exchanges in Colorado, Kentucky and elsewhere has the best potential to fit the Commonwealth’s short- and long-term needs.

Through the hCentive solution, residents will be able to go online and apply for unsubsidized or subsidized insurance, learn what level of subsidy might be available and select a plan. The launch of an hCentive-based system will provide the end-to-end functionality required to support an ACA-compliant Marketplace, and will include minimal customization in vital areas such as State Wrap and billing. Over time, additional functionality can be added to improve the user experience and achieve the state’s long term vision for integrated eligibility.

The hCentive implementation will be pursued alongside connecting to the federal Marketplace, Healthcare.gov. The FFM provides a viable IT platform and it can be leveraged for one year if hCentive migration takes longer than expected. It does, however, require significant consumer and carrier adjustments. A number of Massachusetts-specific health reform design features will need to be reconciled with federal Marketplace operations, including supporting State Wrap, working on plan management operations with carriers and designing an appropriate billing interface (unlike many states, the Massachusetts Exchange handles billing and payment between members and carriers). State leaders have initiated discussions with CMS and Massachusetts insurers about how to develop the best accommodation strategy for the state’s health plans. The state plans to collaborate closely with CMS, health plans, consumer advocates and other stakeholders in the development of the implementation plan.

In recent months, the Commonwealth brought in Iselin as Special Assistant to the Governor to be the single point of accountability for HIX project management, and added Optum, the firm responsible for helping to fix Healthcare.gov, as an IT advisor. Additionally, the Commonwealth’s Information Technology Department is playing a more strategic and supervisory role for the HIX project, and already has increased project management capacity to steer the project’s implementation. During the first ACA open enrollment period, the Commonwealth enrolled more than 271,000 people into subsidized coverage and nearly 33,000 into unsubsidized plans.

As disclosed upon her appointment in February, Iselin took a four-month unpaid leave from her position at Blue Cross Blue Shield. She will return to BCBS in early June. In addition to presenting the dual track plan this week and completing the development of a state and Optum management structure to support the different work streams associated with both paths, Iselin will be responsible for handing her duties off to Maydad Cohen, currently Governor Patrick’s Deputy Chief of Staff for Cabinet Affairs.

Cohen, a labor attorney who most recently served as Chief of Staff at the Executive Office of Labor and Workforce Development, will succeed Iselin at a natural juncture for the project – planning to implementation. Optum and the same executive steering committee that supported and reported to Iselin will report to Cohen in his capacity as Special Assistant to the Governor for Project Delivery (Executive Steering Committee members: ITD CIO Bill Oates, ANF Secretary Glen Shor, HHS Secretary John Polanowicz, Health Connector Executive Director Jean Yang and MassHealth Director Kristin Thorn).

Categories: Health Care

Hard Call: Your Girlfriend Has Chlamydia, May I Phone In Your Prescription?

CommonHealth (WBUR) - Mon, 05/05/2014 - 11:40am

(tbone_sandwich/Flickr Creative Commons via Compfight)

By Dr. Myechia Minter-Jordan
Guest contributor

Eighteen-year-old Eva had recently had unprotected sex with her boyfriend and came into my office for an urgent appointment to get “checked out.”

While I performed my usual cervical exam and testing, I used my 20-minute visit to talk with Eva (not her real name) about self-empowerment and the importance of protecting herself from disease: 
“I am really glad that you’re here with me today. This is an important first step in taking charge of your health and learning how to take care of yourself…”

The next day I found out that unfortunately, Eva had contracted chlamydia, the most common sexually transmitted disease in the country and the state. My next moves were clear: The job of informing my young patient of her infection is one that I am used to, but never look forward to. What is even less comfortable is the task of informing and treating the partner, an individual who is most likely not my patient, and with whom I do not have a relationship.

However, because of state legislation passed in 2011, I now have the ability to prescribe or dispense antibiotics to treat chlamydia in the sex partner of patients with diagnosed infection. “Expedited Partner Therapy” does not require a provider to examine the partner prior to treatment. Research studies have shown that the treatment is safe and effective in reducing chlamydia infection compared to the traditional practice of just notifying — but not treating — the partner. Additionally, in several other states that have Partner Therapy programs, there have been no reports of adverse events.

Eva and I made this difficult call together. We weathered the denial, shock and anger from her boyfriend. It took a minute to shift the conversation from blame to education, then learning and most importantly, assurance. I assured Eva’s boyfriend that this disease was treatable and this was an opportunity to get treatment and get better.

Yes, such calls are hard, but necessary. Over the last ten years, cases of chlamydia in Massachusetts have more than doubled from 8,725 in 1999 to 18,811 in 2009, according to the Massachusetts Department of Public Health.

This disease is overwhelmingly a scourge of the young. In fact, the incidence of reported infection for adolescents and young adults is more than four times the overall Massachusetts chlamydia infection rate per 100,000. Yet, in spite of its increasing prevalence, chlamydia is often undiagnosed because it is usually asymptomatic.

Without signs of obvious infection, patients are at risk of remaining untreated, passing the disease unknowingly or becoming reinfected after treatment. If left untreated, chlamydia can cause serious damage to a woman’s reproductive system, making it difficult or even impossible to get pregnant in the future.

Anyone who has unprotected sex can get chlamydia through anal, vaginal, or oral sex. However, sexually active young people are at higher risk, due to behaviors and biological factors common among the younger demographic. Men who have sex with other men are also in a higher risk demographic. Most people who have chlamydia have no symptoms. If you do have symptoms, they may not appear until several weeks after you have sex with an infected partner.

Symptoms in women may include:
• An abnormal vaginal discharge
• A burning sensation when urinating

Symptoms in men may include:
• A discharge from their penis
• A burning sensation when urinating;
• Pain and swelling in one or both testicles (although this is less common)

As Eva and I spoke with her boyfriend, I gave them information about the infection and treatment. He and I worked together to find the pharmacy closest to him so that I could call in his prescription. Although it wasn’t easy or comfortable for any of us, I think we all knew this was something that we had to do.

As a primary care provider, I see the bigger picture: the obligation that we all have to public health. Eva and her boyfriend were doing their part; it’s up to us as health care providers to help them — to take advantage of the license we now have to treat sexual partners as well. I hope this post will encourage and empower more young people to fearlessly seek help not only for themselves but for their partners. We are here to support you.

Dr Myechia Minter-Jordan is president and CEO of the Dimock Center, a nationally recognized community health center in Roxbury.

Categories: Health Care

Laid-Off Workers Must Be Notified Of Health Exchange Options

Kaiser Health News - Mon, 05/05/2014 - 9:43am

The Obama administration issued a rule Friday requiring employers to inform laid-off workers that, in addition to paying the full cost of their former work-based coverage under COBRA, former employees also have the option of buying insurance through the health law's online marketplaces.

The Wall Street Journal: Employers Must Notify Laid-Off Workers Of Health-Care Options, New Rule Says
Employers must inform laid-off employees that they are eligible to buy health-care coverage through new online insurance exchanges as an alternative to paying full premiums for their old employer policies, the Obama administration said Friday. Under the Consolidated Omnibus Budget Reconciliation Act of 1985, or COBRA, workers who lose their jobs have long had the option of staying on their company insurance as long as they pay their share of the premium, as well as the share their employer had been paying for them. Since employers often pay the majority of workers' premiums, the cost of continuing coverage often came as a shock to people, although some elected to bear the expense anyway because they needed to continue receiving care (Radnofsky, 5/2).

The Hill: Regs To Clarify O-Care Eligibility For People Leaving Jobs
The Obama administration proposed regulations Friday to clarify that people leaving a job may choose to purchase health coverage on ObamaCare's marketplaces rather than obtain it through COBRA. COBRA, or the Consolidated Omnibus Budget Reconciliation Act, allows workers the right to continue their health benefits for a certain amount of time after leaving a job or undergoing other qualifying life changes (Viebeck, 5/2).

Also in the news --

The Wall Street Journal: Head Of HHS Office Of Health Reform To Retire 
Michael Hash, a top Department Health and Human Services official overseeing the rollout of the Affordable Care Act, will be retiring, agency staff confirmed on Friday. Mr. Hash, 70 years old, joins a long list of health-care officials leaving the administration in the aftermath of the rollout of the law (Radnofsky, 5/2).

Categories: Health Care

Obama Uses Health Law As Laugh Line

Kaiser Health News - Mon, 05/05/2014 - 9:42am

President Barack Obama poked fun at the troubled launch of the health law's online insurance marketplaces during his speech at the White House Correspondents' Association dinner.

The New York Times: Comedian In Chief’s New Punch Line: Obamacare
Five and a half years into President Obama’s time in office, the jokes are getting a bit stale: Fox News is a “shadowy right-wing organization.” The 47 percent “called Mitt Romney to apologize.” The whole “Kenyan president” bit. Thank goodness for healthcare.gov. Mr. Obama started his annual remarks at the White House Correspondents’ Association dinner Saturday night with the recognition that the rollout of his health care website could have gone better, admitting that “in 2008, my slogan was ‘Yes, we can!’ In 2013, my slogan was ‘Control-Alt-Delete’” (Shear, 5/3).

The Wall Street Journal: Obama Cracks Jokes At White House Correspondents Dinner 
At the White House Correspondents Dinner on Saturday, President Barack Obama poked fun at the clumsy rollout of his health-care reform plan, relations with Congress and Vice President Joe Biden’s presidential aspirations (Williamson, 5/3).

Politico: Obama Jokes ‘Stellar 2013’ At White House Correspondents' Dinner
Taking the stage, Obama deadpanned that while the launch of healthcare.gov “could’ve gone better,” it was made into one of the year’s biggest movies -- before showing a title screen for the film “Frozen.” At the end of his 20-minute remarks to the crowd of 2,600 in the Hilton ballroom, Obama even brought out former Health and Human Service Secretary Kathleen Sebelius to “fix” a technical problem that he was supposedly having with a video the president pretended he wanted to play for those in attendance at the Hilton (McCalmont, 5/3).

Los Angeles Times: Obama Slings Jokes, Jabs At White House Correspondents' Dinner 
Joel McHale, who stars on NBC's “Community” and hosts “The Soup,” followed Obama with his own roast of the president, 2016 hopefuls and gridlock in Washington. ... McHale's best jokes: ... On Obamacare: “Over 8 million people have signed up for Obamacare, which is impressive, until you realize that Ashley Tisdale has 12 million Twitter followers” (Rothberg, 5/4).

Categories: Health Care

Political Cartoon: 'Call Of Duty: Take A Number?'

Kaiser Health News - Mon, 05/05/2014 - 9:17am

Kaiser Health News provides a fresh take on health policy developments with 'Call Of Duty: Take A Number?' By Rick McKee. 

Here's today's health policy haiku: 

UNDER INVESTIGATION

Cover Oregon
You might think it can't get worse
Here come the G-Men.
-Anonymous 

If you have a health policy haiku to share, please send it to us at http://www.kaiserhealthnews.org/ContactUs.aspx and let us know if you want to include your name. Keep in mind that we give extra points if you link back to a KHN original story.

Categories: Health Care

Health Spending Increases Hit Fastest Pace Since 1980

Kaiser Health News - Mon, 05/05/2014 - 9:15am

USA Today reports on this development, noting some of the factors that will continue to drive up costs. Also, Kaiser Health News explores issues related to who should get costly hepatitis C drugs and The Wall Street Journal reports on the delay in implementing the ICD-10. 

USA Today: Health Care Spending Surges In First Quarter
Health care spending rose at the fastest pace since 1980 in the first quarter as the new health insurance law prompted many more Americans to visit doctors and hospitals. But analysts say the sharp increase also reflects other trends that should continue to drive up both medical spending and costs in 2014 after years of slow growth (Davidson, 5/3).

Kaiser Health News: Who Should Get Pricey Hepatitis C Drugs?
Simple math illustrates the challenge facing U.S. taxpayers, consumers and insurers following the launch late last year of two expensive new drugs to treat hepatitis C. If all 3 million people estimated to be infected with the virus in America are treated at an average cost of $100,000 each, the amount the U.S. spends on prescription drugs would double, from about $300 billion in one year to more than $600 billion (Appleby, 5/5).

The Wall Street Journal: Medical Code Delay Costing Hospitals Big Bucks
A delay in the implementation of ICD-10, a new health-care coding system, will cost some hospitals hundreds of thousands of dollars, increase complexity for an already-complex system, and increase the risk that something will go wrong when the new coding system eventually kicks in (Boulton, 5/2).

Categories: Health Care

Do Hospices Decline To Treat Dying Patients In Crisis?

Kaiser Health News - Mon, 05/05/2014 - 9:14am
The Washington Post: Terminal Neglect? How Some Hospices Decline To Treat The Dying
For more than a million patients every year, the burgeoning U.S. hospice industry offers the possibility of a peaceful death, typically at home. But that promise depends upon patients getting the medical attention they need in a crisis, and hundreds of hospices provide very little care to such patients, a Washington Post investigation has found (Whoriskey and Keating, 5/3).
Categories: Health Care

Highlights: High Colo. Insurance Rate Changes; La. Hospital Plan Rejected; VA Delays In Care

Kaiser Health News - Mon, 05/05/2014 - 9:14am

A selection of health policy stories from Colorado, Louisiana, Arizona, California, Florida and Michigan.

Health News Colorado: Rate Relief Is Sight For Mountain Resorts
Fending off a potential lawsuit from angry western Colorado residents who face the highest insurance premiums in the nation, Colorado Insurance Commissioner Marguerite Salazar on Friday announced she supports a new health insurance rating map for the state. Salazar unveiled the plan and will review comments on it before deciding by next Friday which health insurance rating map will apply for 2015. Colorado currently has 11 rating areas across the state: seven in metropolitan areas and another four that group rural counties together. The new plan would group all the western Colorado counties together — except for Mesa County, home to the City of Grand Junction. It would also group together all the counties on the Eastern Plains and in rural parts of southern Colorado (McCrimmon, 5/2).

The Associated Press: Louisiana: Hospital Plan Rejected
Federal officials have rejected financing plans by Gov. Bobby Jindal’s administration for privatization deals involving six state-run hospitals. The federal Centers for Medicare and Medicaid Services told the state on Friday that the deals do not meet federal Medicaid guidelines (5/2).

USA Today: VA Treatment Records Falsified, Probe Finds
A VA investigation of one of its outpatient clinics in Colorado reveals how ingrained delays in medical care may be for an agency struggling to rapidly treat nearly 9 million veterans a year amid allegations that dozens have died because of delays. Clerks at the Department of Veterans Affairs clinic in Fort Collins were instructed last year how to falsify appointment records so it appeared the small staff of doctors was seeing patients within the agency's goal of 14 days, according to the investigation (Zoroya, 5/4).

The Arizona Republic: Second VA Doctor Blows Whistle On Patient-Care Failures
Late on Sunday night, Dr. Katherine Mitchell said she received a phone call from a fellow employee at the Phoenix VA hospital who needed advice on how to handle a sensitive situation. Her co-worker explained that patient appointment records in the Phoenix VA Health Care System were in danger of being destroyed. But he had printed paper copies to ensure that accurate wait times for patient care would not be lost if removed from computers. The purported "secret lists," along with accusations that up to 40 Arizona veterans died awaiting care, are the subject of national controversy and investigations by Congress and the VA Inspector General (Wagner, 5/2).

The Wall Street Journal: SEIU, California Hospitals In Talks On Cooperative Deal
The nation's biggest health-care union and the California hospital industry are in talks on a deal that could allow the union to boost its ranks by thousands with the cooperation of management, according to documents reviewed by The Wall Street Journal (Trotter and Maher, 5/2).

Reuters: Florida Lawmakers Approve Medical Marijuana Bill
Florida legislators voted on Friday to allow doctors to prescribe a special strain of "non-euphoric" marijuana for treatment of chronic epileptic seizures and some other severe illnesses.Governor Rick Scott said he will sign the bill into law when it reaches his desk (Cotterell, 5/2).

The Associated Press: Health Bill Dies In Florida Legislature
Florida lawmakers ended the session Friday with a lot of last minute wrangling on an omnibus health bill that ultimately died, taking down provisions that would have expanded the powers of nurse practitioners and promoted the use of telemedicine. The House tacked on a massive amendment late Friday night by Rep. Jason Brodeur addressing everything from assisted living facilities and laser dermatology to HIV testing, orthotics and pneumonia vaccines for new nursing home residents. The changes came after the Senate killed proposals that would allow nurse practitioners to work without a doctor's supervision and promote the use of telemedicine. Proponents said both measures would reduce health care costs and address a critical shortage of primary care physicians in the state (5/3).

The Detroit Free Press: Michigan Health Officials In Tug-of-war Over Funds 
The head of the state’s health department wants to know why services to the mentally ill are being slashed when the entities that fund them have millions of dollars -- including about $41.4 million in southeast Michigan -- in unused, unrestricted funds. But local mental health officials argue that those dollars, in fact, are being tapped and that spending them down completely would be irresponsible (Erb, 5/3).

Politico Pro: Courts Diverge On Abortion Restrictions
Federal courts across the country are splitting over challenges to new state abortion restrictions, potentially setting up one or more cases that could lead to a Supreme Court ruling. Two types of laws are most likely to grab the justices’ attention, legal experts on both sides of the issue say: measures requiring abortion providers to obtain admitting privileges at a local hospital or placing stricter limitations on how medication abortions can be administered. States have passed dozens of such statutes over the past few years, leading to major legal battles between abortion-rights proponents who say the moves are just designed to limit access and shut down clinics and abortion opponents who insist they’re necessary to protect women’s health (Cunningham and Villacorta, 5/4).

Categories: Health Care

Health Law Will Factor Into North Carolina Primary

Kaiser Health News - Mon, 05/05/2014 - 9:14am

GOP leaders are lining up in support of North Carolina's House Speaker Thom Tillis in hopes that he can unseat Sen. Kay Hagan, D-N.C., who has faced heavy criticism for her support of the health law. 

The Wall Street Journal: Thom Tillis Faces Test In North Carolina Primary
Republicans have criticized Ms. Hagan, who was elected on President Barack Obama's strong coattails in 2008, for consistently supporting Democratic priorities, particularly the Affordable Care Act. Conservative groups already have spent millions attacking her in ads. Mr. Tillis has the support of most party leaders, including Senate Minority Leader Mitch McConnell (R., Ky.), House Speaker John Boehner (R., Ohio) and the head of the Republican campaign arm in the Senate (O'Connor, 5/4). 

In other news, the Democratic National Committee will return a donation -

The New York Times: Democratic Group To Return Donations
The Democratic National Committee, faced with the possibility that it had accepted illegal campaign contributions from straw donors, decided Thursday to return sizable donations made last fall in the names of the children of a Florida cardiologist whose lucrative medical practice has caught the attention of Medicare regulators. The doctor, Asad U. Qamar, 50, is a prolific campaign donor who found himself politically sidelined last year once word got out that he had asked his contacts in Congress for help with a federal review of his Medicare payments (Robiles, 5/2).

Categories: Health Care

Calif. Enrollment Campaign Focused On Exchange At Expense Of Medicaid Backlog

Kaiser Health News - Mon, 05/05/2014 - 9:13am

The California Health Report examines how the state's efforts prioritized the marketplace issues but fell short in handling Medicaid enrollment. In other Medicaid expansion news, the Arkansas director announces he's leaving and Maine's legislature cannot override the governor's veto.

The California Health Report: State Officials Prioritized Insurance Exchange Over Enrollment System For The Poor
As they scrambled to open the insurance gates to millions of Californians under the federal health law, state officials prioritized the open-marketplace enrollment system over one for low-income residents, according to state documents and officials. That decision significantly contributed to the backlog of about 900,000 applications to Medi-Cal, the state's low-income health program. "People who don't have health care are all in need," said Frank Mecca, executive director of the County Welfare Directors Association, which closely monitors enrollment in Medi-Cal. "One group was prioritized over another, and I don't think that's good public policy" (Guzik, 5/4).

The Associated Press:  Arkansas Medicaid Director Allison To Leave Post
The director of Arkansas' Medicaid office who led implementation of the private option is leaving his position. Andy Allison has been Arkansas' Medicaid director since 2011. The Department of Human Services announced Friday that Allison would leave, as of June 1 to pursue other opportunities (5/2).

Bangor Daily News: Legislature Overrides 15 Of LePage’s 48 Recent Vetoes
During a return to session that people in the State House refer to as "Veto Day," lawmakers on Thursday overturned 15 of the 48 vetoes issued by Republican Gov. Paul LePage during the past two weeks. ... LePage won an expected double victory when the Legislature sustained his veto of two bills that would have expanded Medicaid under the auspices of the federal Patient Protection and Affordable Care Act, commonly referred to as Obamacare. Democrats have made the effort to expand access to publicly funded health insurance to 70,000 Mainers their top priority for two years, and have passed five bills to do so. LePage has vetoed all five, and GOP lawmakers have stood by his side to sustain each veto. With the issue now dead at least until after this November’s gubernatorial election, one lawmakers said the Medicaid expansion question had finally been put to bed (Moretto, 5/2).

Categories: Health Care

Viewpoints: Battle For Medicaid; GOP's Report On Enrollment Off Base; Need For Kidney Donations

Kaiser Health News - Mon, 05/05/2014 - 9:13am

Los Angeles Times: Medicaid Expansion Is The Final Battle In War Over Obamacare
The final battle of the war over the Affordable Care Act is being waged today over expanding Medicaid. ... The refusal of more than half the states to cover so many of their neediest citizens — the number who have fallen into the "coverage gap" is estimated at 5 million — amazes and frustrates health experts. That's especially so because the federal government covers 100% of the cost of expansion through 2016. After that, the federal share will slowly decline to 90% in 2020 and beyond (Michael Hiltzik, 5/4).

The Wall Street Journal: Standing To Sue Obama
The legal left and media are always last to know, but there are the makings of a correction in how the courts police conflicts between the political branches. President Obama's serial executive power abuses—on health care, immigration, marijuana and much else—may be inspiring a healthy rejoinder. Under the Constitution, Congress is supposed to create and amend laws and the President to faithfully execute them, but Mr. Obama has grabbed inherent Article I powers by suspending or rewriting statutes he opposes. The President has usurped Congress with impunity because he assumes no one has the legal standing to challenge him (5/4). 

The Wall Street Journal: What People Don't Realize About The Affordable Care Act
The Affordable Care Act enrollment numbers released this week illustrate how much more complex the health-care law is than the political debate about it. Many in politics view the ACA through a left or right perspective that sees it only as good or bad. But consider that the law is engineered for variation; it is the exact opposite of a Starbucks or McDonald’s, where you get the same product no matter where you live or what your income is (Drew Altman, 5/2).

The New York Times: Inventing A Failure
Last week, House Republicans released a deliberately misleading report on the status of health reform, crudely rigging the numbers to sustain the illusion of failure in the face of unexpected success. Are you shocked? You aren't, but you should be. Mainstream politicians didn't always try to advance their agenda through lies, damned lies and — in this case — bogus statistics. And the fact that this has become standard operating procedure for a major party bodes ill for America's future (Paul Krugman, 5/4).

The Dallas Morning News: How Has The Massachusetts Health Insurance Law Worked Out?
At Boston Medical Center, the emergency room sees more than 356 of the poorest and most disadvantaged on an average day. Many don't need to be here. They now have Medicaid or health insurance, and their pains, flu and stomach upsets could easily be tended at a doctor's office or outpatient clinic — and at far less cost. "We're still seeing a very high volume," said Dr. Andy Ulrich, vice chairman of the emergency department. "You can’t go to your primary care doctor at 8 p.m. or when you get off work." Eight years ago, as Massachusetts enacted the nation's first sweeping health insurance law, legislators expected newly insured patients to stop using the emergency room as their gateway to medical help. That did not happen. Massachusetts now has the nation’s lowest rate of uninsured — 3.1 percent — and the most expensive health care (Jim Landers, 5/3).

Richmond Times-Dispatch: Beg, Borrow & Steal
The latest twist in the long-running debate over Medicaid expansion in Virginia concerns debt. Republicans say expansion "relies on borrowed federal money." Democrats call that rubbish. After all, they say, Medicaid expansion is part of Obamacare, and Virginians are paying Obamacare taxes, so expansion is paid for. Besides, when you borrow money you have to pay it back, and it's not as if Washington is going to send Virginia a bill. That’s cute — but wrong. In fact, it's wrong in every conceivable way (5/4).

San Jose Mercury News: Impoverished Thinking About Health Care And Poverty
Two weeks ago, my friend finally saw a doctor for diagnosis and treatment of her fever and shortness of breath. Concerned she had pneumonia, I'd been prodding her for days to seek medical attention. But she was uninsured, impoverished and unwilling to accept my help. She instead planned to "hold out" until obtaining health insurance through her state's insurance exchange program that operated in concert with the Affordable Care Act. Although given no guarantee that her application was accepted, she expected to receive coverage by May. Unfortunately, her illness didn't wait that long (Dr. Kate Scannell, 5/2).

Health News Colorado: Survival Skills Needed For Health Care Exchanges When Money Runs Out
We are now at a crossroads in the implementation of Obamacare. The exchange can either continue to promote a fantasy version of what recently happened or it can double down and make real, substantive changes. The recently published feel-good statistics suggest the focus is on pay raises and bonuses for the staff. If the legislative oversight committee and the board buy it lock, stock and barrel, little change will be forthcoming (Francis M. Miller, 5/2). 

On other health issues -

The New York Times: Why People Don't Donate Their Kidneys
The national transplant list just passed a morbid milestone: More than 100,000 people now wait for kidneys. We are at this point largely because even though demand is growing, donations from living and deceased donors have remained flat, between 16,500 and 17,000 annually, for the past decade. ... The problem lies in the requirement that all organs be given altruistically (as a friend did for me in donating her right kidney eight years ago). Federal law is widely interpreted as forbidding donors to receive anything of tangible value in return for their lifesaving deeds (Sally Satel, 5/3).

Los Angeles Times: L.A.'s Jails: Where Not To Treat The Mentally Ill
Los Angeles County supervisors talked for years about how it might make more sense to provide lower-cost healthcare at outpatient clinics instead of sending ambulatory patients to costlier beds at county hospitals. They talked — but did nothing until the mid-1990s, when soaring hospital costs pushed the county close to bankruptcy. The Clinton administration bailed L.A. out, in the process requiring more clinics and fewer hospital admissions. The result was better and more appropriate patient care, smarter spending and, not inconsequentially, fiscal solvency. So if it took near-bankruptcy for the county to finally wise up on healthcare, what is it going to take to get the supervisors to finally move mentally ill offenders from costly and dangerous jail beds to more appropriate, more effective and less expensive community-based treatment? (5/4).

The New York Times: Finally, Some Optimism About Obesity
Earlier this year, we got what seemed like the first good news on obesity rates: A study in JAMA found that there had been a 43 percent drop in the obesity rates of 2- to 5-year-old children in the last decade. But then, last month, that news was contradicted by researchers at the University of North Carolina who used the same data to find that obesity rates had remained flat after all. ... if we compare the fight against obesity to the last public health challenge of similar size — the fight against smoking — it turns out that we are being much more aggressive today (Ezekiel J. Emanuel and Andrew P. Steinmetz, 5/4). 

The New York Times: Are Pap Smears On The Way Out?
Women who want to be screened for cervical cancer have just received a new option — and a new quandary. The venerable Pap smear, which has been the only screening tool to look for cancer in asymptomatic women for many decades, now has a rival, a genetic test that looks for the viruses implicated in causing cervical cancer. Adding a new option seems a positive development. Yet some critics have opposed using the new test as a primary screening tool lest it displace the Pap test, which has been credited with cutting the incidence and death rate from cervical cancer sharply in recent decades (5/4). 

Los Angeles Times: L.A. County Needs To Construct Mental Health Programs, Not Jails
For decades, the county has spent untold amounts of public money to warehouse people with mental illnesses in the Los Angeles County jail. This costly and ineffective approach has resulted in sky-high recidivism rates and increased crime. Now, the Los Angeles County Board of Supervisors is considering a proposal to spend as much as $2.3 billion on a massive jail expansion, with a significant portion of that money going to facilities for mentally ill inmates, who currently make up nearly 20% of the jail population (Terry Smerling, 5/4). 

USA Today: Budget Squeeze Jeopardizes Search For Cures: Our View
Xiao-Wei Chen is the sort of scientist you'd want to see stay in the United States. Francis Collins, director of the National Institutes of Health, calls him "one of the smartest kids that's come along in a long time." But after 12 years at the University of Michigan, most recently conducting research into how cellular secretions regulate cholesterol, he's returning to China. Some of the reasons why are ominous for U.S. biomedical research. Chen's work ranked him at the very top of a group of scientists being evaluated for research work at NIH, but a budget-caused hiring freeze meant no positions were available. At the same time, Peking University offered him a tenure-track position, funding for his research, good lab space and students to help with his work (5/4). USA Today also provides comments representing an opposing view

WBUR: Mass. Medical Society Chief: Medicare 'Data Dump' Unfair To Docs
Transparency in health care is a worthy goal, but, like any major undertaking, the success of the effort depends on how it’s done. When the Centers for Medicare and Medicaid Services released its list of $64 billion in Medicare payments to individual physicians in 2012, it fell short of its goal in helping consumers understand how care is delivered through Medicare. Provided without context and with little explanation, the payment data had the unintended consequences of creating confusion and misperceptions among patients (Dr. Ronald Dunlap, 5/2).

WBUR: Midnight Friends: How Wired Patients Are Transforming Chronic Illness
Over the years, I’ve watched my cousin Deborah Haber struggle with several chronic, painful medical conditions, including fibromyalgia and a rare incurable disorder called Ehlers-Danlos Syndrome, a connective tissue disease that causes profuse sweating, a high heart rate and insomnia, among its many symptoms. Largely housebound, and managing the life of her 11-year-old daughter, Deborah faces social isolation and persistent pain. But along the way, my cousin has discovered a lifeline that’s lifted her outlook and improved her health. It combines the best qualities of a mother, best friend, therapist and trusted doctor to help her cope: it’s social media (Nell Lake, 5/2).

Categories: Health Care

College Graduation Is A Time To Reassess Health Insurance

Kaiser Health News - Mon, 05/05/2014 - 9:11am

College seniors need to add one item to their "to-do" list as graduation approaches: check out their insurance options, the Los Angeles Times reports. Also, KHN examines California Latinos' interest in getting health care in Mexico--even if they have purchased U.S. insurance.

Los Angeles Times: College Graduates Should Consider Options For Health Insurance 
Devyn Bisson is a 22-year-old Orange resident about to graduate from Chapman University with a degree in film. She knows she'll need to think about health insurance after graduation, but not just yet. "It's the last thing I'm looking at," she says. "I'm way more preoccupied with how I'm going to make money." With graduation looming, college students have many big issues to face in the coming months. They may include signing up for health insurance, and facing deadlines and even fines for laggards (Zamosky, 5/4).

Kaiser Health News: Even With Obamacare, Many Latinos Still Seek Treatment In Mexico
Irma Montalvo signed up for a health plan through California's new insurance exchange last month, getting coverage for the first time in eight years. But when she needed treatment for a painful skin rash, Montalvo didn't go to a doctor near her home in Chula Vista. Instead she drove to Mexico, about 16 miles south. Her doctor, Cecilia Espinoza, diagnosed her with shingles and prescribed medication to relieve pain and head off complications (Gorman, 5/5).

The Fiscal Times examines the legislative language setting up insurance risk corridors and the question of how many enrollees have actually paid their first month's premiums -

The Fiscal Times: A Little-Noticed Glitch Could Derail Obamacare
The Affordable Care Act's risk corridor program has drawn plenty of criticism from Republicans who have dubbed it a "bailout for insurance companies." Sen. Marco Rubio (R-FL) even introduced a bill to entirely scrap the program, which is intended to offset insurance company losses for selling policies on new exchanges. Now, it turns out, a little-known technical flaw in the law's language might do that for him. In a blog post, The Incidental Economist’s Nicholas Bagley points out that the law's vague language regarding the risk corridors may not give the Department of Health and Human Services the legal authority to fund the program (Ehley, 5/2).

The Fiscal Times: Obamacare Update: Lots Of Unanswered Questions
[W]e know that more than 8 million people signed up for health insurance on the state and federal exchanges between October and April 15...This number is significant primarily because it shows demand for the new plans. However, it does not represent how many people will actually have insurance through the exchanges, since people may drop their plans throughout the year. The figure also doesn’t account for how many people have paid their premiums. This data point is huge and will need nailed down in order to find out how many people are actually covered by these plans (Ehley, 5/4).

Categories: Health Care

FBI Turns Attention To Oregon's Health Exchange Troubles

Kaiser Health News - Mon, 05/05/2014 - 9:11am

The Federal Bureau of Investigation is one of many federal agencies taking a long look at the difficulties that plagued Oregon's online insurance marketplace and led state officials to decide to scrap it. Meanwhile, Maryland is working to rebuild its website. News outlets from Colorado and Washington also offer updates.  

The Wall Street Journal: FBI Scrutinizing Health Law Implementation Flaws in Oregon
The Federal Bureau of Investigation is looking into problems that plagued Oregon's implementation of the Affordable Care Act, after the state was forced to scrap its problematic health insurance exchange that was never fully functional, according to people familiar with the investigation (Paletta and Barrett, 5/4). 

The Oregonian: FBI, Inspector General Investigators Probing Cover Oregon Health Insurance Exchange Debacle
The Federal Bureau of Investigation has opened at least a preliminary inquiry into Cover Oregon, part of what could eventually be an alphabet soup of federal agencies delving into the high-profile failure of Oregon's health insurance exchange.  The law enforcement arm of the inspector general of the U.S. Department of Health and Human Services has also launched at least a preliminary inquiry into potential spillover from Cover Oregon into the state's Medicaid-funded Oregon Health Plan, The Oregonian has learned. Meanwhile, both the Government Accountability Office and the U.S. House oversight committee have announced their own investigations (Budnick, 5/2).

The Washington Post: As Md. Rebuilds Its Health Insurance Exchange, Lots Of Pressure And Little Room For Missteps
Maryland is sprinting to rebuild its malfunctioning online health insurance system on a time schedule that leaves no room for error, without the endorsement of the federal government or a clear plan for funding the project. The state has adopted software from Connecticut and hired new consultants. But many of the decision makers who led the first, flawed effort remain in place and — despite criticism — continue to operate largely behind closed doors (Johnson and Flaherty, 5/3).

The Baltimore Sun:  Maryland Wraps Up Late Enrollment On Its Health Exchange
Maryland's health exchange officials say they have contacted all 18,000 people who reported having trouble signing up for insurance through the state's online marketplace before the end of open enrollment in April and added 7,500 people to the rolls. Others enrolled on their own and still more were duplicates, said Alison Walker, a spokeswoman for the exchange (Cohn, 5/2).

The Denver Post:  Colorado Health Care Exchange Faces Financial Challenges
Connect for Health Colorado officials have touted the state's insurance exchange as frugal and having relatively low fees. But after spending at least $100 million in federal funding, the exchange is scrambling to figure out how to sustain itself beyond this year. The exchange may find itself in a difficult position as it seeks solutions in coming months because some members of its own board, along with a vocal group of legislators, oppose fee increases. Its financial outlook may have worsened Friday when the state extended through 2015 health plans that aren't compliant with the Affordable Care Act, which is likely to lower enrollments through the exchange (Kane, 5/5).

The Seattle Times: 4 More Insurers Want To Join State Health Exchange
Four additional companies want to join the competition to sell individual health-insurance plans inside the Washington Healthplanfinder online exchange, and the eight currently selling plans there all propose to return for 2015, according to the Office of the Insurance Commissioner. While the new entries mean 12 companies may be selling plans inside the exchange, 10 propose to offer plans outside the exchange, compared with nine this year (Ostrom, 5/4).

Colorado also makes news with its decision to extend plans not meeting the health law's standards while Georgia's health law opposition enters another phase -

The Denver Post: Colorado Extends Health Plans Not Meeting ACA Standards Through 2015
The Colorado Division of Insurance announced Friday it will allow insurance carriers to continue health plans for individuals and small groups that don't comply with the Affordable Care Act's new rules for minimum coverage through 2015. The insurance division said the decision was based on President Barack Obama's March announcement to extend noncompliant policies issued through the federal exchange. That decision helped defuse a political problem for Democrats in tough re-election battles this fall, and observers said the latest move is likely to do the same in Colorado, which has its own health care exchange (Draper, 5/2).

Health News Colorado: Colorado Allows Canceled Health Plans Through 2015
Colorado will allow about 100,000 people who kept previously canceled health insurance plans to extend them until the end of 2015, but very few health insurance companies are likely to keep selling the plans. Fury last fall over canceled health insurance prompted President Obama to decide that people could keep canceled plans for this year. Then the president made a second exception and said state insurance officials could allow the canceled plans for two additional years. Insurance Commissioner Marguerite Salazar on Friday announced that she will allow people to keep the plans through the end of 2015 — one year less than Obama would have allowed. Salazar said she will decide next year whether to allow another extension through the end of 2016 (McCrimmon, 5/2).

Georgia Health News: Georgia’s Battle With Obamacare Enters New Phase
The most prominent opponent of Obamacare in the Georgia General Assembly says he’s not done fighting the law. Rep. Jason Spencer (R-Woodbine) pushed through the Legislature a Tea Party-supported bill that prohibits the state from running its own insurance exchange. House Bill 943, passed at the tail end of the General Assembly, also forbids state employees to advocate for Medicaid expansion, and halts the “navigator” insurance counseling program at the University of Georgia. The bill was signed into law this week by Republican Gov. Nathan Deal (Miller and Craig, 5/2). 

Categories: Health Care

First Edition: May 5, 2014

Kaiser Health News - Mon, 05/05/2014 - 7:06am

Today's headlines include reports about how President Barack Obama poked fun at the health law during his White House Correspondents' Dinner speech.

Kaiser Health News: Who Should Get Pricey Hepatitis C Drugs?
Kaiser Health News staff writer Julie Appleby, working in collaboration with The Washington Post, reports: “Simple math illustrates the challenge facing U.S. taxpayers, consumers and insurers following the launch late last year of two expensive new drugs to treat hepatitis C. If all 3 million people estimated to be infected with the virus in America are treated at an average cost of $100,000 each, the amount the U.S. spends on prescription drugs would double, from about $300 billion in one year to more than $600 billion” (Appleby, 5/5). Read the story.

Kaiser Health News: Even With Obamacare, Many Latinos Still Seek Treatment In Mexico
Kaiser Health News staff writer Anna Gorman, working in collaboration with USA Today, reports: “Irma Montalvo signed up for a health plan through California's new insurance exchange last month, getting coverage for the first time in eight years. But when she needed treatment for a painful skin rash, Montalvo didn't go to a doctor near her home in Chula Vista. Instead she drove to Mexico, about 16 miles south. Her doctor, Cecilia Espinoza, diagnosed her with shingles and prescribed medication to relieve pain and head off complications” (Gorman, 5/5). Read the story

The Wall Street Journal: Employers Must Notify Laid-Off Workers Of Health-Care Options, New Rule Says
Employers must inform laid-off employees that they are eligible to buy health-care coverage through new online insurance exchanges as an alternative to paying full premiums for their old employer policies, the Obama administration said Friday. Under the Consolidated Omnibus Budget Reconciliation Act of 1985, or Cobra, workers who lose their jobs have long had the option of staying on their company insurance as long as they pay their share of the premium, as well as the share their employer had been paying for them. Since employers often pay the majority of workers' premiums, the cost of continuing coverage often came as a shock to people, although some elected to bear the expense anyway because they needed to continue receiving care (Radnofsky, 5/2).

Los Angeles Times: College Graduates Should Consider Options For Health Insurance 
Devyn Bisson is a 22-year-old Orange resident about to graduate from Chapman University with a degree in film. She knows she'll need to think about health insurance after graduation, but not just yet. "It's the last thing I'm looking at," she says. "I'm way more preoccupied with how I'm going to make money." With graduation looming, college students have many big issues to face in the coming months. They may include signing up for health insurance, and facing deadlines and even fines for laggards (Zamosky, 5/4).

The Wall Street Journal: FBI Scrutinizing Health Law Implementation Flaws in Oregon
The Federal Bureau of Investigation is looking into problems that plagued Oregon's implementation of the Affordable Care Act, after the state was forced to scrap its problematic health insurance exchange that was never fully functional, according to people familiar with the investigation (Paletta and Barrett, 5/4). 

The Washington Post: As Md. Rebuilds Its Health Insurance Exchange, Lots Of Pressure And Little Room For Missteps
Maryland is sprinting to rebuild its malfunctioning online health insurance system on a time schedule that leaves no room for error, without the endorsement of the federal government or a clear plan for funding the project. The state has adopted software from Connecticut and hired new consultants. But many of the decision makers who led the first, flawed effort remain in place and — despite criticism — continue to operate largely behind closed doors (Johnson and Flaherty, 5/3).

The Wall Street Journal: Head Of HHS Office Of Health Reform To Retire 
Michael Hash, a top Department Health and Human Services official overseeing the rollout of the Affordable Care Act, will be retiring, agency staff confirmed on Friday. Mr. Hash, 70 years old, joins a long list of health-care officials leaving the administration in the aftermath of the rollout of the law (Radnofsky, 5/2).

The New York Times: Comedian In Chief’s New Punch Line: Obamacare
Five and a half years into President Obama’s time in office, the jokes are getting a bit stale: Fox News is a “shadowy right-wing organization.” The 47 percent “called Mitt Romney to apologize.” The whole “Kenyan president” bit. Thank goodness for HealthCare.gov. Mr. Obama started his annual remarks at the White House Correspondents’ Association dinner Saturday night with the recognition that the rollout of his health care website could have gone better, admitting that “in 2008, my slogan was ‘Yes, we can!’ In 2013, my slogan was ‘Control-Alt-Delete’” (Shear, 5/3).

The Wall Street Journal: Obama Cracks Jokes At White House Correspondents Dinner 
At the White House Correspondents Dinner on Saturday, President Barack Obama poked fun at the clumsy rollout of his health-care reform plan, relations with Congress and Vice President Joe Biden’s presidential aspirations (Williamson, 5/3).

Politico: Obama Jokes ‘Stellar 2013’ At White House Correspondents' Dinner
Taking the stage, Obama deadpanned that while the launch of Healthcare.gov “could’ve gone better,” it was made into one of the year’s biggest movies - before showing a title screen for the film “Frozen.” At the end of his 20-minute remarks to the crowd of 2,600 in the Hilton ballroom, Obama even brought out former Health and Human Service Secretary Kathleen Sebelius to “fix” a technical problem that he was supposedly having with a video the president pretended he wanted to play for those in attendance at the Hilton (McCalmont, 5/3).

Los Angeles Times: Obama Slings Jokes, Jabs At White House Correspondents' Dinner 
Joel McHale, who stars on NBC's “Community” and hosts “The Soup,” followed Obama with his own roast of the president, 2016 hopefuls and gridlock in Washington. ... McHale's best jokes: ... On Obamacare: “Over 8 million people have signed up for Obamacare, which is impressive, until you realize that Ashley Tisdale has 12 million Twitter followers” (Rothberg, 5/4).

The New York Times: Democratic Group To Return Donations
The Democratic National Committee, faced with the possibility that it had accepted illegal campaign contributions from straw donors, decided Thursday to return sizable donations made last fall in the names of the children of a Florida cardiologist whose lucrative medical practice has caught the attention of Medicare regulators. The doctor, Asad U. Qamar, 50, is a prolific campaign donor who found himself politically sidelined last year once word got out that he had asked his contacts in Congress for help with a federal review of his Medicare payments (Robiles, 5/2).

The Wall Street Journal: Thom Tillis Faces Test In North Carolina Primary
Republicans have criticized Ms. Hagan, who was elected on President Barack Obama's strong coattails in 2008, for consistently supporting Democratic priorities, particularly the Affordable Care Act. Conservative groups already have spent millions attacking her in ads. Mr. Tillis has the support of most party leaders, including Senate Minority Leader Mitch McConnell (R., Ky.), House Speaker John Boehner (R., Ohio) and the head of the Republican campaign arm in the Senate (O’Connor, 5/4). 

USA Today: Health Care Spending Surges In First Quarter
Health care spending rose at the fastest pace since 1980 in the first quarter as the new health insurance law prompted many more Americans to visit doctors and hospitals. But analysts say the sharp increase also reflects other trends that should continue to drive up both medical spending and costs in 2014 after years of slow growth (Davidson, 5/3).

The Wall Street Journal: Medical Code Delay Costing Hospitals Big Bucks
A delay in the implementation of ICD-10, a new health-care coding system, will cost some hospitals hundreds of thousands of dollars, increase complexity for an already-complex system, and increase the risk that something will go wrong when the new coding system eventually kicks in (Boulton, 5/2).

The Wall Street Journal: The Move From Tricare To Medicare
The rules on military service and Social Security are complex because they've changed three times in the past 30 years and could change again. What's important, however, is that you can get both Social Security and military retirement benefits because you paid Social Security and Medicare taxes, just like civilians have (Waters, 5/4).

The Washington Post: Terminal Neglect? How Some Hospices Decline To Treat The Dying
For more than a million patients every year, the burgeoning U.S. hospice industry offers the possibility of a peaceful death, typically at home. But that promise depends upon patients getting the medical attention they need in a crisis, and hundreds of hospices provide very little care to such patients, a Washington Post investigation has found (Whoriskey and Keating, 5/3).

The Associated Press: Louisiana: Hospital Plan Rejected
Federal officials have rejected financing plans by Gov. Bobby Jindal’s administration for privatization deals involving six state-run hospitals. The federal Centers for Medicare and Medicaid Services told the state on Friday that the deals do not meet federal Medicaid guidelines (5/2).

The Wall Street Journal: SEIU, California Hospitals In Talks On Cooperative Deal
The nation's biggest health-care union and the California hospital industry are in talks on a deal that could allow the union to boost its ranks by thousands with the cooperation of management, according to documents reviewed by The Wall Street Journal (Trotter and Maher, 5/2).

USA Today: VA Treatment Records Falsified, Probe Finds
A VA investigation of one of its outpatient clinics in Colorado reveals how ingrained delays in medical care may be for an agency struggling to rapidly treat nearly 9 million veterans a year amid allegations that dozens have died because of delays. Clerks at the Department of Veterans Affairs clinic in Fort Collins were instructed last year how to falsify appointment records so it appeared the small staff of doctors was seeing patients within the agency's goal of 14 days, according to the investigation (Zoroya, 5/4).

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Categories: Health Care

Who Should Get Pricey Hepatitis C Drugs?

Kaiser Health News - Mon, 05/05/2014 - 5:01am

Simple math illustrates the challenge facing U.S. taxpayers, consumers and insurers following the launch late last year of two expensive new drugs to treat hepatitis C.

If all 3 million people estimated to be infected with the virus in America are treated at an average cost of $100,000 each, the amount the U.S. spends on prescription drugs would double, from about $300 billion in one year to more than $600 billion. 

That prospect has inspired an unusually blunt public debate:  Should expensive treatments – one new drug costs $1,000 a pill -- be limited only to the sickest patients, or is it appropriate to treat all who want the drugs immediately? And should those in taxpayer-funded programs have the same access?

“These are, at their core, ethical fights,” said Arthur Caplan, director of the division of bioethics at New York University Langone Medical Center.

The issues are especially contentious because the drugs, Sovaldi by Gilead Sciences and Olysio by Janssen Therapeutics, are an advance in treatment and offer a cure for many people; they are not just medicines that ease symptoms or extend life for a few months.

“The more definitive the cure, the closer we are to asking, ‘What’s the value of a human life?’” said Tony Keck, director of Medicaid in South Carolina where the treatments are being covered case by case.

This is not an isolated predicament. Already, specialty drugs account for less than 1 percent of all prescriptions but more than a quarter of spending. Other high-cost specialty medicines in the pipeline include treatments for high cholesterol and diabetes, which affect tens of millions of people.

"This is the tip of the iceberg,” said Steven Pearson, president of the nonprofit Institute for Clinical and Economic Review, which analyzes the effectiveness of new treatments. “We have about a year or two as a country to sort this out” before more specialty drugs hit the market.

Different Groups, Different Guidelines

For now, though, the question is how broadly public and private insurers will make the hepatitis drugs available.

As they draft their guidelines, many are considering recommendations from expert groups.

Early this year, a panel from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America said the new drugs should be the preferred treatments for most of those infected with virus. The 28-member group, a majority of whom received drug industry financing directly or through their research institutions, did not set any criteria for which patients should get the treatment first.

“We just put down the best regimen for the individual,” said Gary Davis, a hepatitis expert and panel co-chairman. “We recognize cost issues are really important, but we are clinicians, not the people who should be addressing that.”

But in April, a panel for the Department of Veterans Affairs— none of whose members reported financial ties with the drug industry —offered a different take:  It suggested doctors use the drugs mostly for patients with advanced liver disease, including those awaiting transplants. The VA panel said most patients at earlier stages of the disease should consider waiting for drugs now in development that may prove superior. Analysts expect those drugs to be available within the next year or two.

Sovaldi and Olysio “should be used because they have a high clinical benefit, but not everyone needs to be treated immediately,” said Rena Fox, a VA panelist and professor of medicine at the University of California at San Francisco.

Recommendations to prioritize treatment for those with advanced liver disease were also made by the California Technology Assessment Forum, a panel sponsored by the Blue Shield of California Foundation that advises insurers, providers and patients.

They noted that drugs expected out as early as this fall may prove superior because they will not require the use of interferon, a drug that can have debilitating side effects.

Even so, Ryan Clary, executive director of the National Viral Hepatitis Roundtable, a patient group, lambastes such limits
as "absolutely, rationing." His group, which receives funding from the drug industry, wants the treatments to be broadly available.

"There are plenty of reasons a person with hepatitis C would like to have the virus out of their body," he said. "To say, 'We want you to hold off until you start to get sick,' is really problematic."

Gilead Defends ‘Fair’ Price

The hepatitis drugs are not the most expensive drugs on the market, but their prices are of concern because of the large number of people infected with the virus.

Sovaldi costs $84,000 for a 12-week treatment, although some patients will need to take the drugs for 24 weeks. Olysio is about $66,000 for a 12-week treatment, but is approved for fewer types of patients. Other drugs must often be used with the two new products, adding to the cost.

Drugmakers defend the pricing, saying the treatments are curative, and can prevent the need for other costly care, such as liver transplants.

“Gilead believes that the price of Sovaldi is fair based on the value it represents to a larger number of patients,” Gilead spokeswoman Michele Rest said.

Demand has been strong so far. On April 22, Gilead reported that Sovaldi sales hit $2.3 billion in the first three months of the year, a record-breaking launch for a drug.

Insurers and consumer advocates hope increased competition will result in lower prices for the next round of hepatitis C drugs expected out later this year and next, but that is by no means guaranteed.

More Hepatitis Patients Expected

No one expects all those infected with the hepatitis C virus to seek treatment: At present, most people with the virus don’t even know they have it, one of the reasons why fewer than 20 percent have sought treatment with the older regimens.

More patients are expected to be diagnosed, however, as health officials urge baby boomers to get tested. The blood-borne virus is spread mainly by intravenous drug use, although many people were unknowingly infected by poorly sterilized medical equipment and blood transfusions before widespread screening of the blood supply began in 1992. 

Policymakers say the cost of treating even half of those infected could raise premiums for everyone with private insurance.

In an earnings call last month, UnitedHealthcare, one of the nation's largest insurers, said it spent $100 million on hepatitis
C treatments in the first quarter of the year, far more than it had expected.

Like many private insurers, United covers the drug broadly, following medical societies' recommendations, although some of its plans may charge patients higher co-payments for the drugs.

Another firm, MedImpact, which oversees pharmacy benefits for tens of thousands of people, saw its spending on hepatitis treatments nearly double this year to $37 million, when compared with the first quarter of 2013.

A Dilemma For Medicaid Programs

Because many of those infected are low-income, in prison or baby boomers, the spending is expected to fall hardest on taxpayer-funded health programs such as Medicaid and Medicare.

This “has the potential to throw a wrench into short-term state budgets,” said Matt Salo, executive director of the National Association of Medicaid Directors.

Medicaid programs, for the most part, are still setting coverage rules, relying on their own panels to review medical studies and recommendations from other groups. In Texas and elsewhere, Medicaid will not cover the drugs at all until those review panels issue guidance.

Other states have completed initial reviews. Florida, for example, placed Sovaldi on its preferred drug list, while Pennsylvania officials will seek public comment on draft rules requiring patients to show some liver damage, get a prescription from a specialist and have their treatment overseen by a case manager to qualify.

In an era of limited resources, the prices pose a particular dilemma for public programs.

“For the price of Sovaldi for one patient, we could provide health insurance through Medicaid for [up to] 26 people for an entire year,” said J. Mario Molina, chief executive of Molina Healthcare with Medicaid plans in 10 states.

“There’s no question it is a very efficacious drug. But it’s just who gets it and when.”

Molina is holding off on offering the drugs in many cases while it seeks answers from state officials about whether they will cover this year’s costs, which were not built into Molina’s contracts. Other Medicaid insurers are seeking similar assurances from state officials.

Is There Harm In Waiting?

Waiting is not unusual for hepatitis patients. In the past, many chose to delay treatment because the available options were problematic. Older regimens were complex to administer, had to be taken for longer periods and were less effective. So there is pent-up demand for the new drugs, although some may still want to wait for interferon-free alternatives. 

Adding to the controversy over the prices of Sovaldi and Olysio, the panel convened by the two medical societies had recommended that some patients who can't take interferon be treated with a combination of those two drugs — nearly doubling the cost. That combination was not approved by the Food and Drug Administration, although doctors can still prescribe it. The combination has been tested on only a small sample of patients.
“There's a big temptation to treat them now," said Fox of the VA panel. "But we have to remain evidence-based."

With a slow-progressing disease, waiting until those studies are completed — or until there are other interferon-free regimens — might be a good option for such patients, Fox said.

For every 100 patients chronically infected with the virus, 60 to 70 will develop liver disease, according to projections cited in a report prepared for the California Technology Assessment Forum. Over 20 years or more, an expected 5 to 20 will develop cirrhosis, which is irreversible scarring of the liver. One to five of those would die of cirrhosis or liver cancer. 

Asking Patients To Delay Treatment

Experts note that it’s highly unusual to ask patients to wait for a treatment already on the market.

“When you think of diabetes, high blood pressure, cancer or other conditions, there aren’t many where there is a serious discussion of whether or not treatment should be given”— and usually that’s because of a safety issue, said David Thomas, another member of the medical societies’ panel.

“There’s no safety issue, so ‘Does it cost too much’ is the only question left,” said Thomas, director of the infectious diseases division at Johns Hopkins University School of Medicine.

Speaking for himself, rather than the panel, he said that cost questions need to be debated “with all the vested parties at the table, not just the doctor sitting down with a patient.”

Yet doctors are increasingly being asked to think about cost — at the risk of a loss of trust by their patients, said NYU’S Caplan.

“That’s a shot directly across the bow of the traditional notion that my physician is my advocate, that they look out for me … and don’t worry about the national debt or the fact that Medicare will go broke in 20 years,” he said. “They worry about me.”

The Blue Shield of California Foundation helps fund KHN coverage in California.

Categories: Health Care

Even With Obamacare, Many Latinos Still Seek Treatment In Mexico

Kaiser Health News - Mon, 05/05/2014 - 5:01am

TIJUANA, Mexico – Irma Montalvo signed up for a health plan through California's new insurance exchange last month, getting coverage for the first time in eight years.

But when she needed treatment for a painful skin rash, Montalvo didn't go to a doctor near her home in Chula Vista. Instead she drove to Mexico, about 16 miles south. Her doctor, Cecilia Espinoza, diagnosed her with shingles and prescribed medication to relieve pain and head off complications.

Irma Montalvo, a U.S. citizen, prefers to travel to Mexico to meet with her doctor, Cecilia Espinoza, even though she signed up for a health plan through Covered California (Photo by Heidi de Marco/KHN).

Montalvo, 64, said she comes to Tijuana in part because it costs just $15 to see the doctor. She can't use her insurance for care outside California but it's still cheaper because she doesn’t have to worry about a deductible. More important, she said, is that she feels comfortable with Espinoza.

"She listens to me," said Montalvo, a U.S. citizen who was born in Mexico, said in Spanish. "I come here feeling really bad, and three days later I am better."

Mexican immigrants living in California, Arizona, Texas and New Mexico have long sought health care in border cities like Tijuana, Mexicali and Nogales. The Affordable Care Act won't change that, experts said, even though it has expanded coverage to millions of people, including many Latinos.

Naturalized citizens and legal residents are expected to continue traveling for check-ups, minor surgeries and dental care, drawn to treatment that is less expensive and a medical culture that is less hurried. Doctors speak their language and patients often can get appointments without long waits.

In fact, it's possible even more U.S. residents may seek care with Mexican doctors, said David Hayes-Bautista, director of the Center for the Study of Latino Health and Culture at the UCLA School of Medicine.  Many Latinos in the United States live in areas with a huge undersupply of providers, and as new coverage increases the demand for care, waits for appointments could grow longer and more frustrating, he said.

"If you don't have access to care, going to Tijuana may seem like a reasonable alternative," he said.

Some of these patients now going to Mexico remain uninsured, or work for employers in the U.S. offering insurance plans that pay for medical care in Mexico. Others have signed up for Obamacare to cover emergencies or avoid a fine – but face high deductibles and out-of-pocket expenses.

Irma Montalvo, 62, was diagnosed with shingles and says she doesn’t mind the trip to Tijuana to be treated because she trusts her doctor (Photo by Heidi de Marco/KHN).

"Even with insurance, it can sometimes be cheaper in Mexico," said Steven Wallace, who is  associate director the UCLA center and has studied why Mexican immigrants seek care in Mexico.

The majority of these patients are Mexican immigrants with green cards or U.S. citizenship who can travel freely across the border. One 2009 study by Wallace found that nearly half a million Mexican immigrants living in California receive medical, dental or prescription services every year south of the border.

Lorena Villanueva, who cleans houses in Riverside County, Calif., came to Tijuana on a recent day because of a flare up of allergies that gave her a sore throat and a rash on both arms. Villanueva bought a plan through  Covered California for about $150 a month. Joining a plan that her husband has through his work as a car salesman was too expensive.

"To be honest, I like to come here better even if I have insurance," she said. "Over there it's wasting money and wasting time."

The Obamacare plan, she said, is just for emergencies. For most everything else, Villanueva said she will continue driving the 70 miles to Tijuana. "It's a long drive … but for me, it's worth it," she said.

The medical office where she sees her doctor is in an eight-story, modern building just steps from the border and across the street from a bus station. Two flags – one American and one Mexican – fly above the building owned by SIMNSA, a cross-border health plan.

Just outside, security guards monitor who enters and a line of taxis waits to give patients rides. Inside, the clinic is bustling with people seeking to get their eyes checked, lab results read, cavities filled, hearts examined, allergies treated and children immunized.

SIMNSA was the first Mexican HMO to be licensed as a health care service plan in California with a network that extends through the border cities of Tijuana, Tecate and Mexicali (Photo by Heidi de Marco/KHN).

Licensed in California and overseen by the state's Department of Managed Health Care, SIMNSA offers health insurance to employees of American companies in San Diego and Imperial counties. The employer plan offers the essential benefits required under the ACA, administrators said.

Patients not on the SIMNSA employer plan can walk in to the clinic and pay out-of-pocket. Or, like Montalvo, they can pay a small membership fee allowing them to see an internist for $15 and a specialist for $25.

SIMNSA provides primary and specialty care, physical therapy, spa services and a pharmacy. "It's a one-stop shop," said Christina Suggett, chief operating officer.

Suggett said appointments typically last 30 minutes or more and the doctors don't rely heavily on nurses or medical assistants – a contrast to often more rushed encounters in the United States. Physicians develop long-term relationships with their patients, who return again and again, often bringing family members along.

Ophthalmologist Josue Delgado has been seeing Alberto Luna, 49, for several years. Luna lives just over the border in National City and has a SIMNSA policy through his job at a hotel in San Diego. Luna said he never has to wait to see Delgado and that the doctor treats him like a friend.

"We know each other by first name," Delgado said of Luna.

On this day, Luna was seeking follow-up treatment for a  complication of his diabetes -- bleeding in his eye. Delgado explained it  was causing blurry vision and wasn't healing. The doctor gave Luna a note for his boss so he could spend a few more weeks at home before returning to work. "Make sure you rest," Delgado told his patient, shaking his hand.

Xochitl Castaneda, director of the health initiative of the Americas at U.C. Berkeley's School of Public Health, said Mexican clinics offer something not always found in the U.S. "In Spanish, we say calidad and calidez, quality and warmth," she said. "When you are sick, you need medical support. You also need emotional support. That is something that Mexican physicians give."

The question of quality is not settled. Experts say that some hospitals, doctors and clinics are comparable to the U.S. but that quality varies widely. Some studies find that patient satisfaction with Mexican providers is generally good while others find the care needs improvement.

It is that warmth that brings Montalvo back to Tijuana, despite her new Covered California plan. After checking Montalvo's rash, Espinoza told her to continue the medication and come back in a few weeks. She also told her to call – night or day – if she had any questions. 

"You are responding perfectly" to the medication, Espinoza told Montalvo. "I'm happy."

Montalvo smiled at her doctor before heading down to the pharmacy. "Que dios le bendiga," Montalvo told her. "May God bless you."

Categories: Health Care

Younger Muscles And Minds: Protein Turns Clock Back In Mice

CommonHealth (WBUR) - Sun, 05/04/2014 - 3:32pm

Nonagenarian Olga Kotelko, left, on her way to victory in her age group in the 100-meter dash at Sacramento State in July 2011. Pat Peterson, right, won a younger age group. (Ken Stone/masterstrack.com, with permission)

Just about a year ago, Harvard stem cell scientists reported promising news for elderly heart failure patients: In mice, they found, a protein called Growth Differentiation Factor 11 could undo heart damage wrought by aging.

But was it just a heart thing? Or might GDF11 apply more broadly to other ways that we get older but not better?

New research finds that the protein has similarly rejuvenating effects on brains and muscles — though again, only in mice, so it will be years before we’ll know whether humans might see similar benefits. But GDF11 does circulate in the human bloodstream as it does in the mouse, so it’s not totally outlandish to imagine that we might someday pop pills to increase our circulating GDF11 to stay stronger, smarter and generally healthier as we age. And already, researchers are discussing the need to seek potential benefits for patients with Alzheimer’s and other degenerative diseases.

Upcoming papers in the journal Science found that when given GDF11, some older mice — the equivalent of roughly 70-year-old humans — became able to run as long and smell as well as young mice.

The Harvard press release quotes Doug Melton, chair of the university’s Department of Stem Cell and Regenerative Biology, as saying he couldn’t “recall a more exciting finding to come from stem cell science and clever experiments. This should give us all hope for a healthier future. We all wonder why we were stronger and mentally more agile when young, and these two unusually exciting papers actually point to a possible answer:  the higher levels of the protein GDF11 we have when young. There seems to be little question that, at least in animals, GDF11 has an amazing capacity to restore aging muscle and brain function.”

I spoke with Harvard stem cell biologist Amy Wagers, a leader in the GDF11 research, about what it means. Our conversation, edited:

I imagine our headline shouldn’t say ‘Fountain of Youth discovered.’ How do you prefer the effects of GDF11 to be described?

I like ‘healthy aging.’ It’s really important to say that we don’t have any idea whether GDF11 might affect lifespan at all, but it does seem to improve or enhance healthy function in multiple different tissues.

What’s our best understanding at this point of what GDF11 does biologically?

I would say our understanding is still in its infancy. What we know is that GDF11 is a protein that is produced and present in the bloodstream at high levels when you’re young and it goes away as you get older. When you add it back to older animals, there are beneficial effects on a number of different tissues.

At the organismal level, we know that it enhanced muscle repair capacity and skeletal muscle structure so that physical function is improved. We know that in the brain it increases the production of neural stem cells and functioning of the olfactory system. And we know in the heart it reverses cardiac hypertrophy.

At the cellular level, again, we’re really just starting to piece this together, but we have seen that exposure to GDF11 in muscle stem cells actually allows them to repair some damage that seems to accumulate in their genetic material, and it also then allows them to differentiate, to mature into the muscle cells that are needed for the muscle tissue to function more effectively. It also seems to improve the cell’s ability to generate energy and to improve the machinery that does quality control for proteins in the cell.

We haven’t been able yet to put in order which effects are first and which other effects might be dependent on the first, or whether they’re all independent effects of exposure to GDF11, but that’s something we’re working very hard to understand. It’s also important to understand so when we design trials [of potential drugs], we know what to look for, to say ‘This is working or not working.’

Are ‘skeletal muscles’ what we normally think of as muscles? And how much did the mice improve, in human terms?

Yes, what you normally think of as muscle, or the ones you consume when you eat a steak. In terms of the improvement, probably, the best way to describe it is that we tested them for physical functioning in two different types of experiments. One was figuring out how hard they could pull on a bar, something akin to a pull-up. The older mice that received GDF11 were the same age as controls but they could pull with about 50 percent more strength than the mice that didn’t get it.

And the other test was endurance — we put the mice on a treadmill to see how long they could run, up to 90 minutes, before they got exhausted and gave up. Mice love to run. Older mice usually give up much earlier than the 90-minute trial, but in the animals treated with GDF11, they varied but some of them could run as long as the control mice could.

So it’s like a 70-year-old running as far as a 30-year-old can…So what connects all these dots, between heart and brain and muscle? Is there some common thread or pathway?

I think that is one of the most exciting aspects of this. We’ve known for a relatively long time that something in young blood improves many different tissues in older animals — brain, muscle, spinal cord. It could have been a different substance that was talking to each one of these tissues. What these new papers add to the story is that in fact, it’s the same molecule that’s talking to very different tissues with different responses to aging, with different mechanisms for maintaining themselves and for repairing after injury. So it says there’s actually some coordination between them, and it helps us understand a little bit about aging and why there might be synchrony between the emergence of aging-related dysfunction in various tissues that seem quite different.

The other exciting aspect of this is that it tells us it’s actually feasible now to start thinking about therapeutic strategies that might be targeting the root causes of these age-related dysfunctions and might be beneficial for multiple tissues.

It sounds like it could be a kind of a central key to why we may get worse in some ways as we get older?

I think our experiments so far are suggestive of that but we haven’t yet fully tested whether having high levels of GDF11 is essential for staying young. We’ve added it back in older animals and seen it improve how they function but we haven’t taken it away from younger animals.

It’s not a given that it’s a youth maintenance factor as well as a restoring factor in old age. But we’ve generated the mice we’ll need to test that, and that will tell us about whether determining someone’s level of GDF11 would be informative or not.

I imagine we could do that tomorrow if we wanted, test people’s GDF11 levels.

But we need to know what it means.

What are your next steps?

We’re very interested in the therapeutic translation of this work. So there are some things we need to understand. We need to understand why GDF11 goes away with age: because the cells that make it are dying or changing? Or because the cells that make it just stop making as much? Or because there’s some sort of inhibitor that’s destroying it? That’s very important for figuring out the best way we would up-regulate this pathway in the clinical sense.

We’d also like to know whether other tissues are affected by GDF11 in age.

Which ones?

All of them. My lab’s priority is the blood system, and there are known effects of the protein in red blood cell production. We think the source of GDF11 may be in the blood system. Also, I don’t want to leave anyone with the impression that GDF11 is ‘it.’ We actually think from our ongoing experiments there are probably other factors that can have similar effects. So we want to use GDF11 to help us piece together the larger network of factors in the blood that could have effects on aging and function.

Is there a name for those factors?

I’ve used ‘rejuvenation factors.’ Though another thing we don’t know is whether the improved function that we cause with GDF11 in animals is identical to young function. Or is it a ‘pseudo-youth’ stage? One could argue that on a therapeutic level maybe it doesn’t matter, but for trying to understand the normal process of aging it does matter.

According to the press release, the research groups are talking with a venture capital group to get funding to prepare for human clinical trials.

We’re talking through how to move forward, and have been working with other people who’ve worked on similar pathways. It will take a few years.

A perhaps frivolous question: Earlier work found that blood from younger mice improved function in older mice. So I’m wondering why we older humans aren’t already vampires? That is, wouldn’t I want younger blood to help me stay more youthful?

It’s a fair question. There are, obviously, a lot of substances in blood, and everyone has slightly different level of any substance in blood. If you don’t know what the active component of blood is that’s causing these effects, there’s no way to track whether you’ve given enough or too much. The more we can stay close to regulating one or a handful of specific pathways and know exactly what they do, the less chance of side effects. My view is that I really would want to understand how this works, so that we can design the most optimal method, really monitor the dosage, monitor the effects.

But have past experiments found healthful effects of infusing old humans with younger humans’ blood?

I suppose there’s lore about this that has existed for hundreds of years, but as far as a controlled clinical trial, I’m not aware of one.

Further reading:

The New York Times: Young blood may hold key to reversing aging

USA Today: Blood of young mice boosts brains, muscles of older ones

Science: Young blood renews old mice

Categories: Health Care

My Baby’s Head Is Flat! Study: Expensive Helmet Likely Won’t Help

CommonHealth (WBUR) - Fri, 05/02/2014 - 1:11pm

Miles, a patient at Boston Children’s Hospital, wearing his corrective helmet (Photo: Katherine C. Cohen/BCH)

When my son was an infant, we followed modern medical wisdom and always put him to sleep facing upward. Within a few weeks, he developed a noticeably flat plane on one side of the back of his soft, bald little head.

“Deformational plagiocephaly” is the technical term, and it’s a widespread condition that has risen sharply since public health campaigns to put babies to sleep on their backs began in the 1990s. It affects at least one-fifth of American babies and possibly closer to half. My own overwrought, sleep-deprived diagnosis sounded more like, “Oh, no, my baby’s head is going flat!”

We brought him to specialists who raised the prospect that he might need to wear a helmet virtually non-stop for a few months, to protect his flat spot from pressure and help it round back out.

A helmet? All day and night? But there was no actual danger from his moderate head-flattening, no known risk except perhaps of future ridicule. In the end, we tried a custom-carved foam “head cup” and special “positioner” pillows to help vary which side he slept on. And we consoled ourselves that he just wouldn’t be able to become a skinhead when he grew up, which was surely just as well.

It’s the kind of parental decision you can second-guess yourself about forever. (There’s no sign of any flatness nine years later beneath his full head of hair, but what happens if he goes bald?) So I found welcome reassurance in a study just out in the journal BMJ on “Helmet therapy in infants with positional skull deformation.”

The paper is small but it’s the first randomized, controlled study — the gold standard in medical research — of helmets for plagiocephaly in babies. And it found that, at least in 84 babies without other risk factors, the helmets don’t help. The babies tended to improve with or without helmets. From the press release:

There was no meaningful difference in skull shape at the age of two years between children treated with therapy helmet and those who received no active treatment. Both groups showed similar improvements although only a quarter made a full recovery to a normal head shape, according to the team of researchers based in The Netherlands.

The results are especially underwhelming when you consider that the helmets, made of firm foam in a hard plastic shell, can cost as much as several thousand dollars, even in Great Britain, where the national health system doesn’t tend to pay for them.

The findings can also seem a bit daunting when you consider that once the flat-headedness developed in babies, only about a quarter of them fully “normalized,” helmet or not.

Dr. Carolyn Rogers-Vizena, a craniofacial surgeon in the department of plastic and oral surgery at Boston Children’s Hospital, emphasizes this point: By no means should concerns about head flatness dissuade parents from putting babies to sleep on their backs, which is known to protect against Sudden Infant Death Syndrome. Back-sleeping alone should not be blamed, she added; babies who develop flat heads usually have other risk factors that lessen mobility, including neck tightness, prematurity or developmental delays.

Also, the study offers useful new knowledge but it’s only one small study, she said, “it’s certainly not the be-all and end-all.”

Because the study is the first of its kind and has not yet been reproduced by other researchers, “it won’t yet dramatically change my practice,” Dr. Rogers-Vizena said. “But it gives me something new to tell parents when we’re counseling them, and hopefully bigger, higher-powered studies will come out so we can get a sense of who’s an appropriate candidate for a helmet and who’s not.”

The study excluded many babies who would be typical patients for Dr. Rogers-Vizena, those with more severe cases or the neck tightness known as torticollis.

Still, it could offer some solace to parents agonizing over the helmet decision, as I did.

“There’s a huge amount of parental anxiety around deformational plagiocephaly,” Dr. Rogers-Vizena said, “and I think there’s often a lot of guilt, because parents feel, ‘I did this — I didn’t pick him up enough or he was in the wrong position in utero.’ And hopefully this will alleviate some of that anxiety and say, ‘You don’t have to be super-aggressive’” about getting plagiocephaly treated, and “parents shouldn’t feel like they’re being negligent by not helmeting.”

(Note: Helmet makers are questioning the study’s findings, The New York Times reports, saying that a helmet’s benefits all depend on the right fit.)

Ideally, of course, you head off head problems before they happen. In an editorial that accompanies the paper, Brent R. Collett of the Seattle Children’s Research Institute writes in part that the findings highlight the importance of preventing plagiocephaly — whether through public messages about “tummy time” or other means.

A striking 2011 French paper found that prevention is highly possible if new parents are actively educated to help their babies move more freely. Only 13 percent of babies in the study whose parents got preventive education developed plagiocephaly, compared to 31 percent in a control group. (Also striking, from the abstract:  ”For each supplementary hour of immobility during the third and fourth months of life, the risk of Deformational Plagiocephaly at four months doubled.”)

The French study used a brochure headlined “For baby’s sake, let’s do things differently from day one” and “Give baby room to move!” It included statements like “I only use my baby’s car seat when traveling” and “If baby always turns his/her head to the same side, I attract baby’s attention on the other side” whether “by talking to or looking at baby at every contact” or “with a toy or brightly colored material close by.”

Here’s more on prevention from the orthotics company Boston Brace’s page on plagiocephaly:

Repositioning: An infant’s skull is incredibly flexible in its growing stages prior to cranial maturity. This makes it vulnerable to risks of flattening while placed against any surface for long periods of time.

To avoid this, some medical experts recommend a technique called “repositioning,” which simply means alternating the infant’s position to evenly distribute the gravitational pressures on a growing skull.

Suggested means of repositioning include encouraging infants to respond to toys and stimuli equally on both right and left sides. If flattening becomes apparent on a certain area of the infant’s head, parents should encourage a position in which the flattened portion of their child’s head is not in contact with any surface. Also recommended is to have an infant spend time on their stomach, which must be supervised for safety reasons.

Dr. Rogers-Vizena says there are also many products on the market to help prevent or alleviate plagiocephaly, from donut-shaped pillows to other head supporters and even hats, but there hasn’t been enough research for her to be able to recommend any of them.

Readers, any anecdotal evidence to share?

Categories: Health Care

Mass. Medical Society Chief: Medicare ‘Data Dump’ Unfair To Docs

CommonHealth (WBUR) - Fri, 05/02/2014 - 12:01pm

Earlier this month, the federal government released a great torrent of data about Medicare payments to individual doctors — tens of billions of dollars to over 880,000 health providers. Media coverage tended to highlight a small number of doctors who received big shares of the Medicare money, though it also included cautions that there could be good reasons for high payments.

Like many other national and state medical societies, the Massachusetts Medical Society opposed the release of raw data without explanation. Here, Dr. Ronald Dunlap, current president of the MMS, argues that the data may be sowing confusion and doing more harm than good.

By Dr. Ronald Dunlap
Guest contributor

Transparency in health care is a worthy goal, but, like any major undertaking, the success of the effort depends on how it’s done.

When the Centers for Medicare and Medicaid Services released its list of $64 billion in Medicare payments to individual physicians in 2012, it fell short of its goal in helping consumers understand how care is delivered through Medicare.

Dr. Ronald Dunlap, president of the Massachusetts Medical Society. (Courtesy MMS)

Provided without context and with little explanation, the payment data had the unintended consequences of creating confusion and misperceptions among patients. Here are a few examples why:

• The oncologists receiving some of the highest payments are in private practice, and the data did not note that reimbursements to these physicians include the costs of drugs and treatments as well as payments for physician services. (Oncologists employed by hospitals are not reimbursed for drugs; those are billed to their hospitals.)

• Eye physicians also received high payments, attributable to caring for a growing elderly population with vision impairments like macular degeneration, a condition requiring treatment with expensive drugs.

• In some cases, the number of reported services was misleading, and physicians had no way to review or correct erroneous information. One primary care physician in Michigan was credited with more than $7.5 million in payments. That physician, however, directs a Medicare project that includes 1,600 physicians, who each receive small payments every month. Similarly, a pathologist in New Jersey was listed as receiving $12.6 million, but those payments were spread among nearly 30 doctors.

• The data also omits information about a physician’s patient population, the level of their diseases or conditions, or how long treatments lasted. Nor do the payments reflect the quality of care provided or the demographics of the individual medical practices. A physician with a larger population of patients over 65, for example, will naturally have higher Medicare reimbursements.

Payments to physicians are just one part of health care spending, a complicated and highly variable undertaking that includes a number of variables: the cost of drugs, hospital services, imaging costs, overhead expenses, as well as provider salaries. Also to be figured in: cost controls set by the federal and state governments, added scrutiny by insurers and employers, the creation of new models of care like accountable care organizations, and thousands of billing codes that providers must use to file claims add to the complexity.

Physicians must also account for what is perhaps the biggest variable of all: the patient. No two are exactly alike. Each may have different conditions, requiring different levels, lengths, and intensities of treatment.

The release of Medicare payments may have benefits in preventing and discovering fraud and abuse and identifying outliers. Let’s hope so. But simply dumping data and offering a searchable database without adequate clarification and interpretation doesn’t increase understanding of the subject. It only provides false impressions that can unfairly label physicians.

Any future numbers from The Center for Medicare and Medicaid Services or other sources should come with adequate descriptions for a more accurate accounting.

Ronald Dunlap, a cardiologist in Weymouth, Mass., is 2013-2014 president of the Massachusetts Medical Society, the statewide professional association of physicians with 24,000 members.

Categories: Health Care

Midnight Friends: How Wired Patients Are Transforming Chronic Illness

CommonHealth (WBUR) - Fri, 05/02/2014 - 10:03am

(mic_000/Flickr)

By Nell Lake
Guest contributor

Over the years, I’ve watched my cousin Deborah Haber struggle with several chronic, painful medical conditions, including fibromyalgia and a rare incurable disorder called Ehlers-Danlos Syndrome, a connective tissue disease that causes profuse sweating, a high heart rate and insomnia, among its many symptoms.

Largely housebound, and managing the life of her 11-year-old daughter, Deborah faces social isolation and persistent pain.

But along the way, my cousin has discovered a lifeline that’s lifted her outlook and improved her health. It combines the best qualities of a mother, best friend, therapist and trusted doctor to help her cope: it’s social media.

Deborah, 39, used to lie awake at night with “agonizing, shooting nerve pain,” feeling helpless and alone. She began going online, where she found others who were also awake and in pain; they became her midnight friends. “When you cannot sleep,” she says, “and you know your kid’s going to be up in a couple of hours, and you’re going to have to get her to school on time,” even if you’re exhausted — “knowing that you are not alone is a life-saver.”

With a rare and painful chronic condition, Deborah Haber found a lifeline: social media (Courtesy)

Early on in her social media journey, Deborah mostly used Twitter. It was through people she met there that she learned about Ehlers-Danlos syndrome. She talked with her doctor, who did her own research and sent Haber to a specialist, who diagnosed the rare congenital disease. Deborah’s online activity, then, led directly to the diagnosis, which led to “far better care.”

Clearly, Deborah’s not alone: she’s part of a large and growing group of people with chronic illness in the U.S. who are using the Internet and other online technology to take charge of and improve their own health. This goes far beyond Googling your child’s weird rash: these millions of “empowered patients” are joining social-media communities, consulting online health databases, learning and sharing knowledge about drug side effects, crowdsourcing research studies, electronically monitoring their health and becoming health care activists who share what they’ve learned with their doctors.

Online patients with chronic illness use social media to improve both mental and physical health and to better connect with an understanding community, says Jennifer Covich Bordenick, chief executive officer of eHealth Initiative, which published a study earlier this year on patients’ social media patterns.

“It’s really incredible, if you look at what social media is allowing patients…to do right now,” she says. “It’s providing tremendous access to support, information, and it’s connecting people in a way that they haven’t been able to do before. … People with chronic illness are more motivated. … There’s an urgency there.”

And their numbers are swelling: chronic disease in the U.S. has been steadily increasing for decades: 45 percent of U.S. adults now have at least one chronic condition and that figure is projected to reach 50 percent by 2030.

These wired, actively engaged patients can potentially improve the management of chronic diseases and lead to better health outcomes, says Dr. Joseph Kvedar, a dermatologist and the founding director of the Center for Connected Health at Partners Healthcare System in Boston. Paying attention in this manner matters, Kvedar says. Even “people who are active enough to go and read about their condition on the Internet,” he says, “are people who pay more attention to their condition — and the more attention you pay to it the better you do.”

The difference, for sufferers of chronic illness, is that they will cope with their conditions for the rest of their lives. It’s not “a battle where you gear up and you fight, and you’re thrilled that you’ve beaten an illness, and everyone rallies around you. It’s something that goes for years and years,” says Erin Kotecki Vest, who has lupus, an autoimmune disorder.

For people like my cousin, the Internet becomes part of health management — for life. “My health and the Internet are completely and inextricably entwined,” she says.

Serious And Social

According to a Pew Research Center report from 2013, Internet users with chronic conditions are more likely than other online adults to search the Web for information about medical problems, treatments and drugs; to look at reviews about drugs and other treatments; and read or watch other people’s personal stories about their illnesses. They’re also more likely than other online users to monitor their health by tracking their weight, diet, exercise, blood pressure and other health indicators.

Kotecki Vest, a former broadcast journalist and later the political director for BlogHer, had to stop working after her lupus diagnosis. Because of her compromised immune system, she avoids leaving the house. “My immune system is so low that picking up my children at school is a danger,” she says. “So I keep my sanity with Facebook and Twitter and Instagram and blogs and Pinterest and wherever else we” — her online community — “can all get together.”

She belongs to a chronic-illness Facebook group, a lupus group and many others. She enjoys virtual laughs with people online, even watches TV with them, sharing reactions via Twitter.

Like so many others with chronic illnesses, Kotecki Vest says the primary benefit of her time online has been friendship, emotional support, a sense of community. But like others, she has also gained important health information from her social-media activity. Recently, she’d been troubled by unfamiliar symptoms — sort of like hot flashes, she says, with sweating and chills. Online she found a woman describing similar experiences. The woman had recently started taking CellCept, an immunosuppressive drug. Kotecki Vest was taking the drug, too. They chatted via Facebook and Twitter, discovered the link between the drug and their common symptoms, and brought the information to their respective doctors. Both were told that the sweating and chills were side effects of the drug, although uncommon ones.

Receiving the information, Kotecki Vest told me she felt better able to persevere through discomfort and to continue taking a drug she and her doctor considered important.

Only now are doctors beginning to quantify how social media might actually help improve health. Kvedar says he’s awaiting final results of a study, sponsored by Partners HealthCare, that is following two groups of children who have asthma. One group is participating in a private Facebook page designed to provide them with information and support. The control group is receiving their usual care. Kvedar says he sees initial signs that the children on Facebook are managing their asthma better than those who are not in the social media group.

From Engagement To Activism

In the spring of 2008, 58-year-old Carolyn Thomas had been feeling “awful,” with pain at the center of her chest and down her left arm, nausea, sweating — classic symptoms of a heart attack. Thomas took herself to the emergency department at her local hospital in Victoria, Canada. An emergency physician listened to her symptoms and ordered tests. The results came back normal. The ER doctor told Thomas that she likely had acid reflux.

Thomas left the hospital feeling embarrassed: She figured she’d made a big deal out of nothing. For the following two weeks, however, she didn’t feel better. Eventually, she says, she could walk no more than five steps without needing to rest. Certain that acid reflux couldn’t explain this, she drove back to the same hospital, the same emergency department — still believing that she wasn’t having a heart attack, but sure that something else was wrong.

Carolyn Thomas went from suffering heart-disease patient to savvy health activist with an assist from social media. (Courtesy)

This time doctors found that Thomas’s left anterior descending coronary artery was almost entirely blocked. Thomas was having a heart attack. She was rushed to surgery.

Back home, Thomas felt “stunned, shocked and angry.” Her first impulse was to go online. She searched for “women and heart attacks” through Google and discovered the Mayo Clinic’s website. From there she learned about the “WomenHeart Science and Leadership Symposium for Women with Heart Disease,” an annual training program for female heart-attack survivors. “It’s sort of like cardiology boot camp,” she says. The program trains women to become educators of other women in their home communities: Thomas applied and was invited to attend.

She emerged from the symposium feeling empowered, with more credibility, she says, and motivation to help others. Within a year of her heart attack, Thomas had become a heart-disease activist and now runs a blog to help educate other women about the disease, raise women’s awareness of their risks and underscore the fact that women’s heart disease is so often misdiagnosed and undertreated.

Feeling Better And Possibly Lowering Costs

A recent report in the Journal of the American Medical Association found that 84 percent of U.S. health care costs go to care of adults with chronic conditions — two thirds of that money to people under 65. Encouraging greater patient engagement through technology can help lower these costs, says Kvedar, citing a program called Connected Cardiac Care which found that among patients participating in remote health monitoring, hospital readmission rates were reduced by 51 percent.

The greatest potential benefits of patient engagement, it seems to me, are to patients themselves through improved health, solace, a sense of control and less isolation.

Here are some tips I’ve gathered from digitally savvy patients — they’re not prescriptive, rather, just a few subjective nuggets of guidance:

• Provide credible information to your doctor. Avoid bringing folk medicine and/or advice that hasn’t been tested by medical research. If you do bring ideas for alternative medicine to your doctor, be humble and curious, not dogmatic.

• Work for a partnership with your doctor and, as my cousin says, “try to find a balance between going in there convinced that you’re right” and being open to your physician’s reaching a different conclusion.

• Change doctors if necessary. If he or she is not open to your participating in your care, find another physician. It’s got to be someone you truly trust.

• Google with caution. Asking “Dr. Google” about your condition might be scary — and wrong. Better, perhaps, to visit reputable sites like the Mayo Clinic’s consumer site, which will give you a reasonable, informed perspective to start with.

• Do your research about online communities before joining. Some online patient support groups are sponsored by drug companies and aim at promoting their products rather than offering unbiased support.

• Check with your doctor. The chances are good that the information offered in online communities is correct: A study in the British Medical Journal found that only 10 of 4,600 posts in a sample of online patient groups were false or misleading. And of these, seven were identified by other site participants and corrected within an average of four hours and 33 minutes. Still, it’s wise to consult with a physician who knows you before following online advice.

More helpful websites for people with chronic illnesses:

Association of Cancer Online Resources

Centers for Disease Control and Prevention

e-patient

DiabeticConnect

Healing Well

U.S. Department of Health and Human Services

Inspire

Medline

My Health Teams

Participatory Medicine

PatientsLikeMe

PubMed

Smart Patients

Treatment Diaries

Nell Lake, a journalist and magazine writer, wrote the new book, “The Caregivers: A Support Group’s Stories of Slow Loss, Courage And Love” in which she chronicles the lives of family caregivers over two years. She lives in Western Mass.

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