NPR’s Kelly McEvers talks with Jonathan Whittall, head of humanitarian analysis for Doctors Without Borders, about how bombings of hospitals affect relief organizations in war zones.

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A Pennsylvania’s Geisinger Health is taking a page from retail and treating patients more like customers.

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NPR’s Kelly McEvers talks to Dr. Umair Shah, executive director of public health and environmental services in Harris County, Texas, about what they’re doing to prepare their community for Zika, and how they’re paying for it.

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The nation’s falling teen birth rate saw an even bigger drop over the past decade, with dramatic declines among Hispanic and black teens.

Birth rates are down a whopping 51 percent among Hispanics age 15 to 19 since 2006, and down 44 percent among black teens, according to a survey of census data by the Centers for Disease Control and Prevention. Teen pregnancy rates among whites also fell by a third.

“It’s really a one-two punch,” says study co-author Shanna Cox, associate director for science for the CDC’s Division of Reproductive Health. “Teens are having less sex, and among the teens who are having sex, they’re using more effective methods of birth control.”

The study finds the use of long-acting contraceptives like IUDs and implants jumped from 1 percent of teens a decade ago to 7 percent in 2014. While teen birth rates for minorities are still nearly double that for whites, the CDC finds that disparity has shrunk in many areas.

Still, Cox says the study also shows that teen birth rates can vary widely by place, even by county within the same state, and that there’s a strong connection with socioeconomic factors.

Regardless of race, teen birth rates are higher where unemployment is higher and education and income rates are lower. The CDC and the Department of Health and Human Services have been working with nine communities with some of the highest teen birth rates in the country to develop broad efforts to address all of this.

“So for example, we can work with job skills training,” Cox says. “We can work with sports, community service.” The goal, she says, is “really thinking about ways we can promote teens finishing school, planning for their future and being engaged in their communities.”

The report names other efforts that have been effective in reducing teen birth rates:

Examples of activities included presenting community-specific teen birth data to civic leaders; encouraging health care providers to offer evening and weekend hours and low-cost services to increase access; having teen-focused, culturally appropriate materials available dur­ing health care visits; and implementing evidence-based teen pregnancy prevention programs to reach teens of both sexes both inside and outside of schools (e.g., through Job Corps, alternative schools, churches and community colleges.)

Last year the federal government expanded these kinds of efforts to 84 communities.

The recent decline is part of a longer downward trend in teen birth rates since 1991. But teen pregnancy in the U.S. remains higher than in many other developed countries.

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Need knee replacement surgery? It may be worthwhile to head for Tuscon.

That’s because the average price for a knee replacement in the Arizona city is $21,976, about $38,000 less than it would in Sacramento, Calif. That’s according to a report issued Wednesday by the Health Care Cost Institute.

The report, called the National Chartbook on Health Care Prices, uses claims and payment data from three of the largest insurance companies in the U.S. to analyze how prices for procedures vary from state to state, and city to city.

The takeaway?

Health care prices are crazy.

“There doesn’t seem to be a systematic pattern with respect to what’s high and what’s low,” says David Newman, HCCI’s executive director. Newman is lead author of an article published Wednesday online in the journal Health Affairs that accompanied the release of the Chartbook.

The reports compare average state prices for 242 medical services — from primary doctor visits to coronary angioplasty to a foot x-ray — to the national average price for those services. It shows that states such as Minnesota and Wisconsin have higher than average prices while others, such as Florida and Maryland, were cheaper overall.

Arizona’s health care prices were generally cheaper, about 82 percent of the national average, while next door in New Mexico, care was more expensive, about 25 percent above average.

And prices vary within states, too.

If a Sacramento knee replacement patient doesn’t want to drive the 871 miles to Tuscon, he or she could drive south to Riverside, Calif., and pay $27,000 less. In Florida, the surgery costs $17,000 less in Miami than it does 180 miles north in Palm Bay.

“For every mile that a consumer drives south on I-95, they will save $100,” Newman says.

The HCCI data is some of the most detailed and complete information available on health care prices paid by private insurance companies. It includes payment data from Aetna, Humana, UnitedHealthCare. It doesn’t include claims information from The Blue Cross and Blue Shield Association, which is the largest health insurer in the country.

The price variations revealed by HCCI show that the health care market is not following traditional economic and market rules.

“The market just isn’t working,” says Zack Cooper, a professor of health policy and economics at Yale University.

Cooper says in the past, analysts believed that health care costs were rising because people were using too much health care. That analysis was based on Medicare data. However, Medicare pays the same across the country.

The new data show that private-insurance payments vary widely and states that have low Medicare spending, like Minnesota, often have higher prices in the private insurance market.

He says one major factor is the consolidation of hospitals, leading to a lack of competition.

“Where one large hospital dominates the markets, that hospital is able to get higher prices,” he says. “Hospitals have gotten increasingly powerful over time.”

The new data may give insurers and consumers better ammunition to shop around for lower prices or to negotiate better deals.

But that will require people taking a different approach to choosing health care.

People should be willing to travel farther for services, Cooper says. That would put powerful hospital systems in different cities in competition with one another, perhaps putting pressure on prices.

And there are limits on where competition can bloom in health care, says
Sarah Dash, president and co-CEO of the Alliance for Health Reform.

“A woman is going to go to the one OB/GYN that she goes to. She’s not going to run all over town trying to find the cheapest one necessarily,” Dash says.

“Where it’s shoppable, where it’s elective, where it’s not an emergency and where the price is knowable, then there are things that can be done,” she says.

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Accidents happen, and if they are someone else’s fault, you can go to court to try to get compensation for your medical expenses, lost wages and pain and suffering. If you win, though, the pot of gold you receive may be considerably smaller than you expect. Your health plan may claim some — or all — of the award as reimbursement for money it spent on your medical care.

That is completely legal and it happens all the time. But a recent U.S. Supreme Court decision gives consumers ammunition to push back against the health plan.

The basic facts of the case are common: In December 2008, a drunk driver ran a stop sign and hit Robert Montanile, seriously injuring him. Montanile had lumbar spinal fusion surgery and other medical treatment that cost $121,044 and was paid for by his health plan — the National Elevator Industry Health Benefit Plan. Montanile sued the drunk driver and won a settlement of $500,000. He paid his attorneys $263,788 in fees and expenses, leaving him $236,212.

Montanile’s health plan claimed it was entitled to be reimbursed for his medical care.

Contract provisions that allow health plans to reimburse themselves if a member receives a personal injury settlement or jury award are routine; such clauses often assert that the plan should be first in line for money from an award or settlement. The notion is that if the injured person is permitted to keep the money that was paid on his behalf for medical expenses, he’s essentially getting his medical bills paid twice — once by the insurer and then again under the settlement.

Montanile hired another lawyer to negotiate with the health plan. But when those talks reached an impasse, Montanile’s attorney informed the plan’s trustees that if he didn’t hear from them in two weeks he would release the remaining settlement money to Montanile. And when the health plan didn’t respond, that’s what the attorney did.

The health plan later sued Montanile for the money, but he said he had already spent nearly all of it to pay his second lawyer and to care for himself and his daughter. Lower courts ruled that the health plan was entitled to reimburse itself from Montanile’s general assets. The Supreme Court disagreed, ruling 8 to 1 in January that the health plan was entitled to take only the specific pot of money Montanile received in the settlement — or goods that could be traced to it.

The case was remanded back to a lower court, and the National Elevator Industry Health Benefit Plan may yet be able to recover some money from Montanile if it can trace assets to the settlement he received, said Radha Pathak, one of Montanile’s lawyers at Stris and Maher, the Los Angeles-based law firm that represented him in the appellate and Supreme Court cases.

In the simplest sense, the case turned on a lapse in timing. If the health plan had responded to the letter sent by Montanile’s attorney within 14 days, it might have received the funds it was entitled to.

“The clearest message is that if plans want to assert their rights, they need to do it promptly,” said Leslie Anderson, a partner in the Washington Resource Group at benefits consultant Mercer.

But the Supreme Court’s decision also has a significant impact on consumers, who are often fighting an uphill battle in these cases. The court ruling makes it clear that health plans can’t seize an individual’s general assets to pay themselves back for medical expenses. It may also improve consumers’ odds of receiving a larger portion of any settlement or jury award by prompting the plan to respond quickly in negotiations.

In these cases, problems sometimes arise when there’s not enough money to go around. The total — especially after paying legal bills — may not be large enough to cover the injured person’s medical bills as well as the amounts awarded for lost wages and pain and suffering. In those cases, health plans may claim all or a significant portion of the settlement, leaving the injured person who brought the lawsuit with nothing, or at least much less than the amount that was awarded.

Jason Lacey, a partner at Foulston Siefkin in Wichita, Kan., who represents employers in such cases, says he understands how the process may seem unfair to somebody who has been hurt, and then taken on the task of going to court. ” “I took the time to go out and file this lawsuit, and you’re swooping in at last minute and feeding off my efforts,’ ” is how they might feel, Lacey said.

About half of all states have laws that limit or prohibit health plans from reimbursing themselves in this type of case until the consumer has received all that she was awarded, such as lost wages and pain and suffering. But those laws don’t apply to self-insured companies that pay health care claims directly rather than buying insurance.

The Supreme Court’s decision may encourage insurers to sit down and negotiate sooner with the person who was injured about how to divvy up any settlement or jury award in a way that feels fair to both sides, says Matt Wessler, a principal partner at Gupta Wessler in Washington, D.C., who has represented injured consumers in these types of cases.

It was hard in the past for health plan members and their lawyers to suss out whether a health insurer intended to assert a lien in these cases and if so, for how much, Wessler says. Now, after the Montanile decision, the person who won the award may have some leverage.

If health plans don’t notify the worker or his lawyer early in the process that they have an interest in any potential award, Wessler says, “they risk the possibility that by the time they actually get something sorted out the money will be gone.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter:@mandrews110.

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Only Human is a new podcast from WNYC Studios. Hosted by Mary Harris, Only Human tells stories we all can relate to. Because every body has a story. Subscribe to Only Human on iTunes or wherever you like to get your podcasts.

When Lee Herzenberg remembers the day her son Michael was born, she laughs and calls it a “cool birth.” Her obstetrician was a friend, and she describes it almost like a party — “a little bit painful, but that you forget very quickly.” Lee even got a kick out of the fact that a resident learned to do an episiotomy on her.

It was November 1961, and she was at the newly christened Palo Alto-Stanford Hospital Center; her husband, Len, was a biology professor on campus. Like most fathers at the time, he didn’t attend the birth, which meant he wasn’t there when Michael started turning blue.

The nurses whisked the newborn off to the nursery without telling Lee anything was wrong.

It was then that a doctor noticed the characteristic features of Down syndrome: floppy muscles, eyes that slanted upward. They got Michael breathing again, but doctors thought his prognosis was grim. They gave Michael just a few months to live. A daisy chain of physicians was called, and Lee says it was a pediatrics professor who told her husband what had happened. Then Len was dispatched to tell Lee.

She remembers the moment with uncharacteristic emotion. “We hugged each other, and it was a terrible conversation to realize that you’d lost the baby, but the baby was lost,” Lee says now. “We knew immediately what we’d do. We had already made the decision that it was not a good thing to take the baby home, and so we didn’t.”

In the 1960s — an era before neurodiversity movements and early intervention programs — many people still called people with Down syndrome “mongoloids.” Playwright Arthur Miller institutionalized his son, Daniel, in 1966. A few years later, an article in The Atlantic Monthly argued that “a Down’s is not a person.”

Lee and Len Herzenberg had seen friends struggle with the birth of a child with Down syndrome and had even gone with a colleague to an institution, where he dropped off his own infant daughter.

So, they decided Michael would never come home.

But Michael wasn’t absolutely lost to them. Michael’s birth sparked their search for a blood test that has revolutionized prenatal care in this country.

I made the mistake of telling one scientist I was reporting about “Len Herzenberg’s lab.” He corrected me instantly: “Len and Lee’s lab.” Because Lee Herzenberg was “leaning in” decades before Sheryl Sandberg coined the phrase. At 81, Lee, a professor of genetics, is still running the lab she and her husband founded more than 50 years ago. Len died in 2013.

The lab is a quirky place, even by Stanford standards. Lee rarely sits on chairs, preferring cushions on the floor. She’s often accompanied by her bichon frise, Gigi. Researchers can often be found working in this basement office well into the night.

But Lee Herzenberg isn’t just quirky. She is one of the few professors at Stanford — possibly the only one — never to have officially graduated from college. Instead, she trained by her husband’s side, auditing courses while he got his Ph.D. at Caltech (women weren’t allowed to attend at the time) and working at his labs at the Pasteur Institute in Paris and the National Institutes of Health.

And the science that’s been done here has changed the course of medicine.

The Herzenbergs are best known as the creators of the modern-day fluorescence-activated flow cytometer, or FACS. It was a machine born out of frustration: Len couldn’t stand squinting down a microscope looking at cells.

Before the FACS, a biologist peering at slides could feel like he was playing a really intense round of “Where’s Waldo,” staring at crowds of all kinds of cells, trying to pinpoint the exact ones he was looking for. Not only was it annoying — Len Herzenberg worried it wasn’t particularly scientific. He wanted a way to find and describe cells that didn’t rely on his worn-out eyes.

The FACS allows you to pour cells in, program the machine to find whatever it is you’re looking for, and then it will spit out a little tube of just those cells alone. And the FACS gives you all kinds of information, too: how big the cells are and how much DNA they have inside.

The FACS was used to diagnose AIDS because the technology can quickly and easily sort out T cells. The FACS was used to find the first stem cells. When Len Herzenberg died, one colleague told The New York Times that “without Len, tens of thousands of people now alive would not be.”

But in the 1970s, the Herzenbergs were still proving the value of this machine. That’s when they started thinking about using it to create a blood test for Down syndrome.

Len had seen research from Finland claiming it was possible to see a fetus’s cells in a mother’s blood. It was hard to believe. But he figured that FACS, with its nearly magical sorting capabilities, could figure it out. So he took on a medical student named Diana Bianchi as a research associate and made sorting out these cells her project.

If they could isolate these cells, he could learn a lot about the developing fetus, including whether the fetus had chromosomal abnormalities.

“They had a very personal reason for doing this, because of their son Michael,” Bianchi says now. “They wanted to have a test that could be offered to any pregnant woman — that would be noninvasive and would allow them to know if a child had Down syndrome. The first step, however, was to show that you could pull out fetal cells.”

Scientists now estimate that for every 200 billion cells in a mother’s bloodstream, about 10 of those are fetal cells. Bianchi was one of the first people to see them.

The New York Times quoted Len saying the work was a “first step” toward a blood test for Down syndrome for all pregnant women. But it would take 30 years for a practical test to become a reality.

As it turned out, Len’s FACS wasn’t the right tool for prenatal diagnosis. There weren’t very many fetal cells to be sorted, and if a pregnant woman already had children, scientists couldn’t be sure if the cells in her blood came from the current fetus or one of her older kids.

But in 2008, Len helped ensure the right tool was found.

A researcher named Stephen Quake had discovered a way to sequence chunks of fetal DNA floating in expectant mothers’ blood. As a member of the National Academy of Sciences, Len made sure the paper was published in the academy’s journal. Another researcher, Dennis Lo, confirmed Quake’s findings. Three years later, the tests were on the market.

Now, at just 10 weeks into a pregnancy, a whole range of things can be revealed with this test. Not just Down syndrome, but a host of other chromosomal abnormalities as well as the sex of the child to be.

Until this test, doctors had to rely on amniocentesis, an invasive procedure that involves inserting a needle in the womb to sample amniotic fluid, or biopsying the placenta, to tell them with any reliability whether a fetus had a chromosomal abnormality. These tests aren’t just uncomfortable; they come with a risk of miscarriage. By some estimates, in the past five years the number of these procedures performed in this country has plummeted by more than 50 percent.

To some parents, this knowledge can be alarming. Advocates in Ohio are trying to pass a law preventing abortions if Down syndrome is the reason (North Dakota and Indiana have already passed similar laws).

Lee Herzenberg is honest about what she would have done if she’d known early on in her pregnancy that Michael had Down syndrome.

“I’d say if I had the choice of not pushing Michael into this life — if I at that time would know I was carrying a Down syndrome child — I would have aborted the child,” she says. “I see no reason Michael has to live the life he leads. The fact that we’ve made it very happy for him or that he’s made it very happy for us — all of that is adapting to a situation, but I don’t think it’s fair or proper.”

But Lee is alarmed that these tests are now being used to determine the sex of unborn babies. She worries about parents choosing to abort girls.

Diana Bianchi, that medical student from the Herzenberg lab, is now a professor at Tufts, where she founded the Mother Infant Research Institute. She’s still working in prenatal testing. In fact, perfecting these tests has become her life’s work.

But her focus has shifted. Now that she can detect Down syndrome so early, she wants to treat it early, too — in the womb. Because finding this chromosomal abnormality at 10 weeks means there’s a window of opportunity: The brain changes associated with Down syndrome don’t occur until a month or so later. Theoretically, you could treat a fetus before some brain changes occur at all.

Bianchi’s work is still early. She’s experimenting with mice, giving them existing drugs in utero to see if she can forestall brain damage.

There’s an often-quoted statistic, that 90 percent of parents who find out that their fetus has Down syndrome will abort. But that statistic is from a study done in the United Kingdom. In the U.S., far fewer women terminate.

“We have to unpack this connection between prenatal testing and abortion,” she says. “We have good data to suggest that approximately 40 plus percent of women who know their fetus has Down syndrome continue their pregnancy. There are many women who speak very highly of the fact that this allows them to prepare.”

The Down syndrome baby who kicked off the search for this blood test is now a 54-year-old man. He lives in a squat house in Redwood City, Calif., just a 30-minute drive from his birth mother’s home.

For years, Michael lived with a local woman named Barbara Jennings, who raised a number of children with developmental challenges. The Herzenbergs’ pediatrician helped them find her when Michael was a newborn. The Herzenbergs would visit Michael every month or so, but they never felt they should bring him home. When Barbara died, Michael moved to this group home.

It’s hard to know how much Michael understands when I speak to him, though he has learned to read and use a cellphone. And he’s stubborn. A lot like his mother, actually. “Michael has the hardest head in the whole world,” says Janet Thomas, the caretaker who runs this house. “He does whatever he wants to do. He does not care whatever you say. He’s going to do whatever it is he wants to do — that’s Michael.”

I asked Lee if she ever regretted not raising Michael, and she said no. “It was a decision that was selfish, if you like, because we had things we wanted to do. In retrospect, a lot of things would never have gotten done. There would be no FACS had we decided to do this. Because it would have been a very intensive kind of upbringing.”

As for Michael, he clearly loves his mother, no matter what she decided. In Michael’s room, there are photos on almost every surface, with snapshots of his biological and adopted families. In the corner is a huge poster of his father, celebrating when he won the Kyoto Prize for his contributions to biotechnology. And deep in one album, there’s a picture of Len and Lee together. The caption reads: “Michael’s Other Mom + Dad.”

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To wrap up our series on public health in Baltimore, Audie Cornish met up with Baltimore City Health Commissioner Leana Wen in Freddie Gray’s neighborhood of Sandtown-Winchester. The health department recently opened a new outpost of its violence prevention program Safe Streets there, employing ex-offenders to mediate conflicts before they erupt in violence.

Wen spoke about pushing a public health agenda in a city that has long struggled with poverty, violence and addiction. She also talked about what she, as an emergency physician, has learned in her first stint in government. Here are interview highlights, edited for length and clarity.

On her goal to make Baltimore a model for the country

We have gotten significant national recognition for some of our programs, including our programs to respond to the opioid overdose epidemic. I had the opportunity to testify in front of the U.S. Senate and House and was invited to speak with President Obama about Baltimore’s work. I do believe that because of the way we’ve focused on addiction as a disease, that that’s changing the conversation in our city and actually, is leading the way around the country. People are beginning to see Baltimore not as [the HBO drama] The Wire and heroin overdose, but actually as a model for recovery and resilience.

On what she wants to tackle next

The unrest [after Freddie Gray] paradoxically opened the door for us to address trauma, which is a natural segue to talk about mental health and the bigger picture of emotional wellbeing. People finally felt like they could talk about the trauma they’ve experience for so many years. It’s the trauma of police brutality. It’s the trauma of discriminatory practices. It’s the trauma even of being poor. We now want to convene a city-wide group to address this issue, which is very difficult because ultimately, the trauma work has to be done at the community level.

On her optimism, despite the challenges Baltimore faces

I’m not blind to the problems that exist. But I also realize these problems have been in the making for decades. We’re not going to be able to make a huge difference overnight. But there are things we can do along the way to demonstrate to our community that we hear you, and this is what we do in the meantime. We cannot solve the issue of addiction overnight, but we can reduce overdose deaths, and we have passed a Good Samaritan law [to protect people who help overdose victims] and we are introducing programs where individuals caught with drugs are not going to be incarcerated but actually, are going to be offered drug treatment. So we’re showing that things can be done, and that we’re taking small steps. And actually, our community gets it. If we just came to the community and said we’re going to solve all of our crime problems overnight, they’re not going to buy it. But if we say we know the success of Safe Streets , it’s been demonstrated in four sites across our city, now we’re going to open a fifth site in Sandtown, you can feel the energy and the optimism. And maybe that’s why I’m so optimistic.

On what she’s learned from the job since she began in January 2015

I was never in the political world, and I’m not from Baltimore. So coming here, everyone was new. It’s been a really steep learning curve.

The things I’ve learned over the year have been a lot about myself, and who I am as a manager, who I am with navigating complicated politics and situations, but also what motivates me. And I’ve learned that I like a fight. I don’t want to be in a situation where things are going well. I don’t feel like I have anything to do in that case. In the ER, it’s the patient dying in front of me. It’s someone who is gravely ill, and my fight is the fight to save their life.

I see the same thing in Baltimore. There are so many problems. There are so many fights I can have every single day. It’s the fight to get health on every agenda, to change legislation, to change public perception and mindset, to reduce stigma, to introduce new programs in a time of severe fiscal constraints. I like a fight, and I’m good at it, and that is what motivates me.

I’m learning now just how powerful that voice can be — to say, I’m not here as a politician. I’m here as a doctor and as a scientist. I’m here to give voice to all these issues that we’ve seen that are unfair — housing politics, policing policies, drug policies. And I’m saying from a health perspective how these policies have destroyed our community, and this is what we’re doing about it now.

Dr. Leana Wen has been a contributor to Shots since 2013. You can read her account of why she decided to become Baltimore’s health commissioner here.

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Budget woes at the University of California, Berkeley could force the shutdown of a program many people are unaware of — its medical program.

The Joint Medical Program, part of Berkeley’s School of Public Health, is small. Just 16 students a year are admitted. Under a university budget restructuring process initiated in February by Berkeley’s Chancellor Nicholas Dirks, the School of Public Health must cut expenses by roughly 3 percent — or about $900,000.

One of the items on the list to meet that target is closure of the Joint Medical Program. Losing 16 new doctors a year may not sound dramatic, but this particular population is unusual in medicine. While most medical students head into lucrative specialties, the majority of this program’s graduates go into primary care.

John Balmes, acting director of the program, says California needs these doctors. The state, he says, “is 43rd in the nation in terms of primary care physicians.” And with the Affordable Care Act increasing the number of insured Californians, “We need more primary care physicians, not less.”

In 2014, just 12 percent of medical students nationally went into primary care residencies. By contrast, more than half of the graduates of the Berkeley program have gone into primary care. It’s unclear exactly why so many students go into primary care. One clue lies in the program’s unusual approach to curriculum.

The program, established in 1971, prides itself on avoiding lecture halls and instead focusing on what it calls “problem-based learning,” where students review cases as a group. In addition, the medical program is one of few nationally, says second-year student Josh Pepper, that is housed within a school of public health, and that gives a broader focus to patients’ lives.

“We’re constantly having to question how things like socioeconomic status, insurance, housing and culture and addiction play a role in patients’ health outcomes,” Pepper said.

It gives a more holistic perspective, he says. “We develop a whole skill set you don’t normally get at a traditional medical school.” Pepper has helped launch an online petition in support of the program.

It’s called a joint medical program because students do three years at Berkeley’s School of Public Health, during which they do an original research project. They then go to the medical school at the University of California, San Francisco for two years of clinical rotation. They graduate with a master’s in science and an M.D.

A report earlier this year commissioned by the California Primary Care Association detailed the shortfall in primary care providers in California. The state’s ratio of primary care physicians in its Medicaid program, called Medi-Cal, is roughly half the federal recommendation, it said. By 2030, the analysis predicted a shortage of more than 8,000 primary care doctors.

“Certainly with the shortage we are facing, we should not eliminate any existing programs that we know have successful track records into funneling people into primary care,” says Carmela Castellano-Garcia, president of the California Primary Care Association. “We cannot afford that at this time.”

All of Cal’s professional schools, including the School of Public Health, must trim expenses by the same rate, says Dan Mogulof, a spokesman for the university, and it’s up to the schools themselves to determine how to meet the target.

Linda Anderberg, director of communications for the School of Public Health, said it is considering several options to achieve the budget cuts. “The school does not want to lose the program,” she says.

She stressed that no decisions have been made and that the process would be completed during the summer. Most of the cuts would not go into effect until 2018, she said.

Meanwhile, staff and students are speaking out to try to save the program.

“If I had to go to medical school all over again, I’d want to do it in the Joint Medical Program,” says acting director Balmes. He says there’s an advantage to being in a small, supportive environment.

“I think that translates into very fine doctors, because they’re good human beings as well as good doctors,” he says.

This story was produced by member station KQED’s blog State of Health.

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You’ve probably heard of the credentials M.D. and R.N., and maybe N.P. The people using those letters are doctors, registered nurses and nurse practitioners. But what about PSC.D or D.PSc? Those letters refer to someone who practices pastoral medicine – or “Bible-based” health care.

It’s a relatively new title being used by some alternative health practitioners. The Texas-based Pastoral Medical Association gives out “pastoral provider licenses” in all 50 states and 30 countries. Some providers call themselves doctors of pastoral medicine. But these licenses are not medical degrees. That has watchdog organizations concerned that some patients may not understand what this certification really means.

That includes patients like 60-year-old Mark Sarchioto, who lives just outside Dallas. Sarchioto has crippling neuropathy and has been searching for a treatment for decades. One leg is numb, and as he shifts from his walker to the couch, he holds out his left hand.

“It feels like somebody is puncturing it with needles,” he says. “Right now it’s cold and I can’t keep it warm.”

In 2013, he and his wife, Joan Sarchioto, heard an ad for a breakthrough therapy for neuropathy at HealthCore Center in Richardson, Texas. They jumped at the chance for a free evaluation. But it didn’t take long to realize the free evaluation was going to cost them.

“We get in and the [medical assistant] or whoever takes the vitals and they go, ‘We need to go take your X-rays and there’s an evaluation fee of $35.’ And I said, ‘But I thought this was free,’ ” Joan Sarchioto says. “When they start ordering tests, I know what’s BS — and I know what’s not.”

The founder of HealthCore Center is Karl Jawhari. He is a chiropractor, but says he practices “functional medicine” under his license from the Pastoral Medical Association.

HealthCore Center advertises natural weight loss, help for hypothyroidism and diabetes programs – and on its website it touts its employees as doctors of pastoral medicine. Jawhari’s office walls are lined with framed certificates, and there’s a Bible on his desk.

“We’ve seen people with an array of issues: thyroid issues, diabetes, blood pressure, cholesterol,” Jawhari says. “We work with a lot of people to reduce their weight and so forth and we’ve had great success with that.”

Jawhari hasn’t always had success with state regulators. Last August, he was fined $2,500 by the Texas Board of Chiropractic Examiners for deceptive advertising. In June, the Texas Medical Board – which licenses, regulates and disciplines physicians, physician assistants and other practitioners – issued a cease and desist order demanding that Jawhari stop offering to treat conditions beyond his chiropractic training.

He says he’s done that.

There may be people who take advantage of the pastoral license, he says, but he’s not one of them.

“I’ve heard of a few people that are practicing that aren’t even doctors,” he says. “It’s up to the consumer to do due diligence and figure out is this practitioner — does this doctor know what he’s doing?”

In recent years, the Texas Medical Board has sent about a dozen cease and desist orders to people using the pastoral medicine certification. Some hawk dubious supplements like colloidal silver, promise extreme weight loss, treat thyroid disorders and discourage vaccine use.

The Texas Medical Board has just become aware of the term pastoral medicine in the last couple of years, says Mari Robinson, the board’s president.

“Folks are purporting to treat and diagnose illness using that term,” she says. “It’s not a degree; it’s not a license.”

At least not a license recognized by the Texas Medical Board. NPR reached out to several other people in North Texas who have licenses from the Pastoral Medical Association. None agreed to talk.

Many of the practitioners who highlight their pastoral medical degrees have slick websites touting patient success stories.

Robinson says anyone in the United States who wants to create a website can do so, but it is illegal to diagnose what is wrong with someone, treat them, or offer to treat them without the appropriate training and licensing.

The Pastoral Medical Association didn’t respond to several attempts to connect by phone. It did send an e-mailed statement explaining it was founded by a group of Christians concerned with the increase in chronic illness. The association says it seeks to protect “the Almighty’s Health Care workers.”

According to the Association’s website, to obtain a license, applicants must pass “rigid standards” that the group wouldn’t share. Members also have to pay processing and annual fees that can range from a few hundred dollars to a few thousand.

So, why might someone join?

People may feel they are more marketable if they get some credentials, says Stephen Barrett, a retired psychiatrist and founder of the consumer protection site quackwatch.org.

“There are lots of credentials you can buy, and this is just one of many.”

Barrett says the Pastoral Medical Association functions like a private club. Patients sign confidentiality agreements, pay out-of-pocket and are prohibited from suing if they’re unhappy with the care they receive. Any disputes are handled by an ecclesiastical tribunal.

“They’re claiming that ‘Any advice we give you is pastoral in nature,’ ” Barrett says. “In other words, ‘If I give you health advice that’s not health advice, that’s pastoral advice.’ “

These practices do have supporters. Toni McElhaney of Plano, Texas, found out about HealthCore through a flier advertising a free thyroid seminar. She’d been taking medication for hypothyroidism but still felt exhausted.

She says she paid $300 for initial testing and $4,500 for a six-month treatment plan. None of her treatment is covered by health insurance.

McElhaney thinks the heavy metal detox, special diet and herbal supplements helped her lose weight and gain energy. So, does it matter to her that the woman she sees isn’t actually a licensed doctor or nurse?

“No,” she says. “It doesn’t matter to me. I feel like she knows her stuff and I have responded better to her treatment than I would have just going to an endocrinologist alone.”

Sometimes traditional medicine doesn’t have all the answers, and navigating what’s legit in the world of alternative medicine can be tough. The key, according to Mari Robinson of the Texas Medical Board, is to really understand the qualifications of the person you are seeing. Just because someone puts doctor in front of their name doesn’t mean they are medically qualified.

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