Poll Finds Overwhelming Support For Medicare Paying For End-Of-Life Talks

via Kaiser Health News

constant-63613__180The public overwhelmingly supports Medicare’s plan to pay for end-of-life discussions between doctors and patients, despite GOP objections that such chats would lead to rationed care for the elderly and ill, a poll released Wednesday finds.

Eight of 10 people surveyed by the Kaiser Family Foundation supported the government or insurers paying for planning discussions about the type of care patients preferred in the waning days or weeks of their lives. (KHN is an editorially independent program of the foundation.) These discussions can include whether people would want to be kept alive by artificial means even if they had no chance of regaining consciousness or autonomy and whether they would want their organs to be donated. These preferences can be incorporated into advance directives, or living wills, which are used if someone can no longer communicate.

The Centers for Medicare & Medicaid Services earlier this year proposed paying doctors to have these talks with patients. A final decision is due out soon. The idea had been included in early drafts of the 2010 federal health care law, but Sarah Palin and others opponents of the law labeled the counseling sessions and other provisions “death panels” motivated by desires to save money, and the provision was deleted from the bill.

The notion of helping patients prepare for death has support among many doctors, who sometimes see terminal patients suffer from futile efforts to keep them alive.  Last year, the Institute of Medicine issued a report that encouraged end-of-life discussions beginning as early as 16 years old. The Kaiser poll found that these talks remain infrequent. Only 17 percent of those surveyed said they had had such discussions with their doctor or another health care professional, even though 89 percent believe doctors should engage in such counseling. A third of respondents said they had talked to doctors about another family member’s wishes for how they would want to be cared for at their end.

While none of these proposals calls for the cost of care to weigh on these discussions, the final years of life are indeed expensive for America’s health care system. The Dartmouth Atlas of Health Care has calculated that a third of Medicare spending goes to the care of people with chronic illnesses in their last two years of life. That is likely to increase as the population of those older than 65 increases. An analysis by the Kaiser foundation found that Medicare spending per person more than doubled from age 70 to 96, where it peaked at $16,145 per beneficiary in 2011.

The Kaiser poll found less public support for a cost-containment provision that did make it into the health law. The “Cadillac tax” begins in 2018 and will impose a tax on expensive insurance that employers provide to their workers. Sixty percent oppose the plan, which economists have long favored as a way to discourage lavish coverage and make people aware that extensive use of Medicare services is linked to premiums.

The poll also found that 57 percent of people favor repealing the medical device tax, another piece of the health law that Republicans in Congress are trying to repeal. The tax applies of artificial hips, pacemakers and other devices that doctors implant.

The poll was conducted from Sept. 17 through Sept. 23 with 1,202 adults. The margin of error was +/- 3 percentage points.

Kaiser Health Tracking Poll: September 2015

Yoga Shows Benefits for Arthritis Suffers

Yoga Shows Benefits for Arthritis Suffers

photo: Kevin Dinkel

Yoga may be a safe and effective way to keeping moving for the one in five adults who live with arthritis.

In a randomized trial of people with two common forms of arthritis — knee osteoarthritis and rheumatoid arthritis — those who practiced yoga had about a 20 percent improvement in physical health with similar improvements in pain, energy, mood and carrying out day-to-day activities and tasks.

The study by researchers from Johns Hopkins is believed to be the largest randomized trial to date to examine the effect of yoga on physical and psychological health and quality of life among people with arthritis.

“There’s a real surge of interest in yoga as a complementary therapy, with one in 10 people in the U.S. now practicing yoga to improve their health and fitness,” says Susan J. Bartlett, Ph.D., an adjunct associate professor of medicine at Johns Hopkins and associate professor at McGill University “Yoga may be especially well suited to people with arthritis because it combines physical activity with potent stress management and relaxation techniques, and focuses on respecting limitations that can change from day to day.”

According to the Arthritis Foundation,

  • More than 50 million U.S. adults have doctor-diagnosed arthritis
  • By 2030, an estimated 67 million people will be diagnosed with arthritis.
  • It is the nation’s primary cause of disability
  • Among working age adults (18-64) those with arthritis or a rheumatic condition lose more workdays every year — a combined 172 million– due to illness or injury than adults with any other medical condition.
  • Arthritis and related conditions account for $156 billion annually in lost wages and medical costs, including 44 million outpatient visits and nearly 1 million hospitalizations.

Without proper management, arthritis affects not only mobility, but also overall health and well-being, participation in valued activities, and quality of life. There is no cure for arthritis, but one important way to manage arthritis is to remain active. Yet up to 90 percent of people with arthritis are less active than public health guidelines suggest.

Study participants were randomly assigned to either a wait list or eight weeks of twice-weekly yoga classes, plus a weekly practice session at home. Participants’ physical and mental wellbeing was assessed before and after the yoga session by researchers who did not know which group the participants had been assigned to.

Compared with the control group, those doing yoga reported a 20 percent improvement in pain, energy levels, mood and physical function, including their ability to complete physical tasks at work and home. Walking speed also improved to a smaller extent, though there was little difference between the groups in tests of balance and upper body strength. Improvements in those who completed yoga was still apparent nine months later.

Instructors were experienced yoga therapists with additional training to modify poses to accommodate individual abilities. Participants were screened by their doctors prior to joining the study, and continued to take their regular arthritis medication during the study.

Check out this video from WebMD with yoga poses for rheumatoid arthritis sufferers.

Hopkins researchers have developed a checklist to make it easier for health practitioners to safely recommend yoga to their patients. People with arthritis who are considering yoga should “talk with their doctors about which specific joints are of concern, and about modifications to poses,” suggested Clifton O. Bingham III, M.D., associate professor of medicine at Johns Hopkins University School of Medicine and director of the Johns Hopkins Arthritis Center. “Find a teacher who asks the right questions about limitations and works closely with you as an individual. Start with gentle yoga classes. Practice acceptance of where you are and what your body can do on any given day.”

Results were published in the April issue of the Journal of Rheumatology.


Advocates Say Mental Health ‘Parity’ Law Is Not Fulfilling Its Promise

Advocates Say Mental Health ‘Parity’ Law Is Not Fulfilling Its Promise

From time to time, I share articles that I believe warrant additional attention.  This is one of them.

by Jenny Gold, Kaiser Health News

When Michael Kamins opened the letter from his insurer, he was enraged.

His 20-year old son recently had been hospitalized twice with bipolar disorder and rescued from the brink of suicide, he said. Now, the insurer said he had improved and it was no longer medically necessary for the young man to see his psychiatrist two times a week.  The company would pay for two visits per month.

“There was steam coming out of my ears,” Kamins recalled, his face reddening at the memory of that day in June 2012.  “This is my kid’s life!“

Michael Kamins sits in his son’s room at his house in West Hollywood, California on Thursday, April 30, 2015 (Photo by Heidi de Marco/KHN).
Michael Kamins sits with the family dog in his son’s room at his house in West Hollywood, California in April. (Photo by Heidi de Marco/KHN)

His son again became suicidal and violent, causing him to be rehospitalized eight months later, said Kamins, a marketing professor at the State University of New York, Stony Brook.  Kamins is suing the insurer, OptumHealth Behavioral Solutions, which disputes his version of events and denies that it left the young man without sufficient care.

Seven years after Congress passed a landmark law banning discrimination in the treatment of mentally ill people, many families and their advocates complain it stubbornly persists, largely because insurers are subverting the law in subtle ways and the government is not aggressively enforcing it.

The so-called parity law, which was intended to equalize coverage of mental and other medical conditions, has gone a long way toward eliminating obvious discrepancies in insurance coverage. Research shows, for instance, that most insurers have dropped annual limits on the therapy visits that they will cover. Higher copayments and separate mental health deductibles have become less of a problem.

But many insurers have continued to limit treatment through other strategies that are harder to track, according to researchers, attorneys and other critics.  Among the more murky areas is “medical necessity” review – in which insurers decide whether a patient requires a certain treatment and at what frequency.

Kamins is among a small group of people around the country to file lawsuits alleging federal or state parity laws were violated when patients with mental illness were held to a stricter “medical necessity” standard than those with other medical conditions.

“Medical necessity’ is the insurers’ last hurrah,” said Meiram Bendat, Kamins’ attorney, who filed the lawsuit in New York State court

Bendat, who is seeking class-action status in the Kamins case and has filed other parity suits in New York, Illinois and California, said attorneys are acting because the government won’t.

Enforcement of parity laws is lax, he said, and companies are getting away with skirting their requirements.

In fact, only a handful of states have dug into whether insurers are complying with parity laws. And in the seven years since the federal law was passed, the U.S. government has not taken a single public enforcement action against an insurer or employer for violating the law.

Attorney and psychologist Meiram Bendat at his home in West Hollywood, California, on April 30, 2015.  Bendat focuses on mental health cases and has filed several cases alleging violations of parity law (Photo by Heidi de Marco/KHN).
Attorney and psychologist Meiram Bendat at his home in West Hollywood, California, in April. Bendat focuses on mental health cases and has filed several cases alleging violations of parity law. (Photo by Heidi de Marco/KHN)

Clare Krusing, a spokesperson for America’s Health Insurance Plans, the industry’s main trade group, said it is “a misperception” that enforcement has been weak. Insurers are working closely with federal and state governments, she said, and “have taken tremendous steps to implement these changes and requirements in a way that is affordable to patients.”

Ensuring that mental health and other medical treatments are exactly on par is challenging, she said.

“A treatment plan for diabetes or a chronic heart disease is very different from a treatment plan for a patient that’s seeking care for depression or another mental illness,” she said. “It’s not a math formula.”

But Henry Harbin, former CEO of Magellan Health, a managed behavioral health care company, said insurers are taking advantage of minimal oversight.

“They can micromanage care down to almost nothing,” said Harbin, who also served as Maryland’s mental health director before becoming a consultant. “The enforcement in this area is a joke.”

Great Expectations

When it passed in 2008, the federal mental health parity law was seen as a major achievement for Americans with mental illnesses.

Though some states already had their own parity laws on the books, there were serious gaps in the protections they offered. This law was to force insurers across the country to provide the same access to treatment as they do for cancer, diabetes and other conditions.

At the time, Sen. Edward Kennedy called the law “historic,” and praised his colleagues for finally ending “the  senseless discrimination in health insurance coverage that plagues persons living with mental illness.”

But enforcement was not assigned to any one agency. Instead, it fell to the departments of Labor, Health and Human Services and Treasury, as well as state insurance commissioners.

The Department of Labor, which is responsible for monitoring health insurance offered by large employers, set up a complaint line for consumers.  Still, advocates say, most consumers don’t know they have new rights, and those that do often don’t know where to turn.

“It gets very complicated for the average person,” said Carol McDaid, who runs the Parity Implementation Coalition, an advocacy group created to make sure parity laws were properly enforced.

“They’re already in a [mental health] crisis, looking for help, and they don’t know if they should write and complain to their state insurance commissioner, the Department of Labor, the health department. It gets very difficult.”

Since 2010, just 867 of the 1.5 million total health insurance inquiries made to the Department of Labor had to do with the parity law, most of which were not complaints, a spokesman for the department said in May. A total of 140 cases of alleged parity law violations were found, and they were resolved through “voluntary compliance,” in which the employer agreed to pay for the patient’s services, the spokesman said. He said that the investigators also requested that the insurers change their broader policies, when appropriate.

Separately, HHS found 196 possible violations of parity law by insurers from September 2013 through September 2014, a spokeswoman said. In each case, she said, plans voluntarily made changes or told the agency they believed their plan was in compliance with the law.

No action by a federal agency, however, resulted in a lawsuit, fine or public announcement.

“Our problem is that these investigations are all kept secret,” McDaid said. That means the decisions have no effect on what other employers or insurers do, and consumers don’t learn what to look out for, she said.

Former congressman Patrick Kennedy, one of the authors of the parity law, said timing was partly to blame for the administration’s sparse enforcement record.

Michael Kamins says there were several physical confrontations with his bipolar son in his bedroom growing up (Photo by Heidi de Marco/KHN).
Michael Kamins says there were several physical confrontations with his bipolar son in his bedroom growing up. (Photo by Heidi de Marco/KHN)

“Parity got kicked down the track until the Obama administration could get the Affordable Care Act on track,” he said. It took five years for the government to issue final rules explaining exactly what insurers had to do to comply.

Enforcing laws against insurance companies, he added, was also a delicate undertaking.

“Insurance companies were part of the coalition that helped bring the ACA to life, and the administration feels an enormous debt of gratitude,” he said. “It’s a challenge politically to then step on the toes of those that brought them to the dance.”

Meanwhile, research points to some continuing inequities in coverage.

Data compiled on health plans in 2010, the first year of the national parity law’s implementation, found that insurers frequently reviewed mental health treatment more strictly than other care. For instance, they more often required “preauthorization” for doctor visits or made patients “fail first” at one level of care before getting approval for another.

A study this year from the Johns Hopkins Bloomberg School of Public Health found that a quarter of the plans sold on two state Obamacare exchanges appeared to violate the federal parity law in various ways, including requiring higher cost-sharing for mental health. The states, one large and one small, were not named.

In a 2015 survey by the National Alliance on Mental Illness, an advocacy group for mentally ill people and their families, patients said they were denied payment because treatment was deemed “not medically necessary” twice as often for mental health as for other medical conditions.

Without strong government enforcement, patients and families say they are left to their own devices.

But demonstrating that an insurer has violated parity rules requires a detailed analysis of a plan’s mental health and medical benefits.  And though the law requires that insurers disclose those documents, critics say they often are not complying.

The Parity Implementation Coalition in Washington D.C., has received hundreds of consumer complaints to its helpline, but McDaid said virtually none of the health plans have been willing to release the necessary documents to demonstrate that there has been a parity violation, she said.

Krusing of the insurers’ association insisted that documents are being made available to patients and providers.  “Plans are committed to being transparent about their coverage decisions,” she said. Decisions to deny treatment, she said, are based on ensuring that patients receive care based on the best medical evidence.

“We are still at a point in the health system where patients face wide variation in the type of care they’re receiving,” she said. “Oftentimes we see tests and procedures done that are costly and unnecessary for the type of care that they’re seeking or even help or benefit their condition.”

The federal government is considering whether to tighten disclosure rules for insurers. In the meantime, some consumers, including the Kamins family, are turning to the courts.

Debating What’s ‘Medically Necessary’

Kamins’ son had always been a star, according to his father, who holds his power of attorney and asked that the young man’s first name be withheld for privacy reasons.

As a boy, he was a quiet but quick-witted jokester, who graduated fifth in his high school class in 2010, Kamins said.

A few months after heading to an Ivy League college, however, he was overcome by depression, his father said.  His grades slipped. He began experimenting with drugs. Then, in the spring of 2011, he tried to kill himself, according to Kamins and the lawsuit.

His parents brought him home to Los Angeles, where the family lives while Kamins commutes back and forth to New York.  The family has insurance through Kamins’ job.

But Kamins said OptumHealth Behavioral Solutions would not cover inpatient care before his son had tried an outpatient program that focused on drug addiction.

That marked the first of several violations of parity law, according to Kamins’ lawsuit, which seeks a change in Optum’s policy and reimbursement for benefits denied, plus attorneys’ fees.  By requiring  the young man to “fail first” at a lower level of care before paying for more expensive residential treatment, Optum, a subsidiary of UnitedHealth Group, had created an illegal obstacle to mental health treatment, the lawsuit alleges.

“Imagine someone going to a hospital and being told you can’t get open-heart surgery in the midst of a heart attack because you haven’t tried aspirin or nitroglycerin first. That’s the absurdity of it,” said Bendat, Kamins’ lawyer. “It’s just a way to discourage higher levels of care that we would never tolerate in the non-psychiatric context.”

After the addiction program, Optum paid for the young man to see a psychiatrist a few times a week. His father said he began showing signs of improvement and seemed on track to return to school back East.

But in June 2012 — four months after the young man was hospitalized during a manic episode —  the insurer’s letter arrived saying it was no longer “medically necessary” for him to see his psychiatrist so frequently.

That fall, the suit alleges, Kamins’ son tried to return to his Ivy League school. He found a psychiatrist and began going twice a month as he had been authorized to do in the letter, Bendat said.  Kamins said he tapped into his retirement fund to pay for extra visits, but his son spiraled downward.

In court documents, Optum alleges that Kamins’ son actually was entitled to more frequent visits with a new mental health provider, suggesting that the limitation on visits applied only to the psychiatrist he had been seeing in California. The insurer argues that his subsequent hospitalization in February had nothing to do with limitations put on visits in California.

In a written statement, Optum officials said they “take the mental health needs of each of our members very seriously, and we are committed to helping them get care that has shown to be most effective in helping people overcome and live better with mental and emotional challenges.”

Kamins said that was not his experience.

 “The irony in all this is that Optum fights tooth and nail to dole out care for my son. But had they allowed him upfront to get the care he needed, he might not have ended up back in the hospital, which they had to pay for,” he said.

As for Kamins’ son, he returned to college in the fall of 2013. The next year, his father’s employer contracted with a new insurer, which Kamins said gave the young man greater access to care and helped him stabilize.

Now 23, he is scheduled to graduate next year.

Kaiser Health News (KHN) is a nonprofit national health policy news service. 

Does Diabetes Increase Risk of Cognitive Decline?

Does Diabetes Increase Risk of Cognitive Decline?

1436321382_featured.jpegThere is mounting evidence that Type 2 diabetes may be associated with cognitive decline in older adults.

A new study in the July 8 online issue of Neurology found that people with Type 2 diabetes had worse regulation of blood flow to the brain over a two-year period when compared to those without the disease. This was associated with lower scores on tests of cognition skills and their ability to perform their daily activities.

“Normal blood flow regulation allows the brain to redistribute blood to areas of the brain that have increased activity while performing certain tasks,” said study author Vera Novak, MD, PhD, of Harvard Medical School in Boston in a statement. “People with Type 2 diabetes have impaired blood flow regulation. Our results suggest that diabetes and high blood sugar impose a chronic negative effect on cognitive and decision-making skills.”

The study involved 40 people with an average age of 66. Of those, 19 had Type 2 diabetes and 21 did not have diabetes. Those with diabetes had been treated for the disease for an average of 13 years. The participants were tested at the beginning of the study and again two years later. Tests included cognition and memory tests, MRI scans of the brain to look at brain volume and blood flow, and blood tests to measure control of blood sugar and inflammation.

Blood flow regulation in the brain decreased by 65 percent in people with diabetes. Those with lower ability to regulate blood flow at the beginning of the study had greater declines in a measure of how well they could complete daily activities such as bathing and cooking.

Higher levels of inflammation were also associated with greater decreases in blood flow regulation, even if people had good control of their diabetes and blood pressure, Novak said.

On a test of learning and memory, the scores of the people with diabetes decreased by 12 percent, from 46 points to 41 points over the two years of the study, while the scores of those without diabetes stayed the same, at 55 points. Blood flow regulation in the brain was decreased by 65 percent in people with diabetes.

“Early detection and monitoring of blood flow regulation may be an important predictor of accelerated changes in cognitive and decision-making skills,” Novak said.

Two of every three people with diabetes have high blood pressure, according to the American Diabetes Association. They are at 1.5 times higher risk of stroke and are more likely to suffer a heart attack, heart disease, kidney disease or eye problems.

Although this was a small study, its results were in line with those of previous studies, including a University of Pennsylvania investigation which found that that diabetes may actually accelerate brain aging by as much as two years. Researchers determined that those who have had the disease longer (15+ years) had less gray matter than those more recently diagnosed (four years or less).

The CDC estimates that 29 million people in the U.S. have Type 2 diabetes — including about 8 million who are unaware of their condition. Diabetes risk increases with age; more than one-quarter of those over 65 (about 10.9 million) have diabetes.

As the U.S. population continues to grow older, prevalence of chronic conditions like diabetes and its associated complications — including, apparently, cognitive impairment — will severely strain health care delivery, the long term care system, and place further stress on families caregivers.

Many chronic diseases are preventable. So put down those new Oreo thins and go take a walk.

Why good people do bad things

Why good people do bad things

eve-fateHonest behavior is much like sticking to a diet. When facing an ethical dilemma, being aware of the temptation before it happens and thinking about the long-term consequences of misbehaving could help more people do the right thing, according to a new study.

The study, “Anticipating and Resisting the Temptation to Behave Unethically,”  was recently published in the Personality and Social Psychology Bulletin. It is the first study to test how the two separate factors of identifying an ethical conflict and preemptively exercising self-control interact in shaping ethical decision-making.

In a series of experiments that included common ethical dilemmas, such as calling in sick to work and negotiating a home sale, researchers from the University of Chicago Booth School of Business and Rutgers Business School found that two factors together promoted ethical behavior: Participants who identified a potential ethical dilemma as connected to other similar incidents and who also anticipated the temptation to act unethically were more likely to behave honestly than participants who did not.

“Unethical behavior is rampant across various domains ranging from business and politics to education and sports,” said study author Ayelet Fishbach, professor of business and marketing at U Chicago. “Organizations seeking to improve ethical behavior can do so by helping people recognize the cumulative impact of unethical acts and by providing warning cues for upcoming temptation.”

In one experiment, business school students were divided into pairs as brokers for the buyer and seller of a historic New York brownstone. The dilemma: The seller wanted to preserve the property while the buyer wanted to demolish it and build a hotel. The brokers for the seller were told to only sell to a buyer who would save the brownstone, while the brokers for the buyer were told to conceal the buyer’s plan to develop a hotel.

Before the negotiations began, half of the students were asked to recall a time when they cheated or bent the rules to get ahead. Only 45 percent of those students thinking about their ethics ahead of time behaved unethically in the negotiations, while more than two-thirds, or 67 percent, of the students who weren’t reminded of an ethical temptation in advance, lied in the negotiations in order to close the deal.

In another experiment involving workplace scenarios, participants were less likely to say it is okay to steal office supplies, call into work sick when they aren’t really ill, or intentionally work slowly to avoid additional tasks, if they anticipated an ethical dilemma through a writing exercise in advance and if they considered a series of six ethical dilemmas all at once.

In other words, people are more likely to engage in unethical behavior if they believe the act is an isolated incident and if they don’t think about it ahead of time.

The results of the experiments have the potential to help policy makers, educators and employers devise strategies to encourage people to behave ethically. For example, a manager could control costs by emailing employees before a work trip to warn them against the temptation to inflate expenses. The notice could be even more effective if the manager reminded employees that the urge to exaggerate expenses is a temptation they will encounter repeatedly in the future.