For most of his career, Dr. Stephen Trzeciak was not a big believer in the “touchy-feely” side of medicine. As a specialist in intensive care and chief of medicine at Cooper University Health Care in Camden, N.J., Trzeciak felt most at home in the hard sciences.

Then his new boss, Dr. Anthony Mazzarelli, came to him with a problem: Recent studies had shown an epidemic of burnout among health care providers. As co-president of Cooper, Mazzarelli was in charge of a major medical system and needed to find ways to improve patient care.

He had a mission for Trzeciak — he wanted him to find answers to this question: Can treating patients with medicine and compassion make a measurable difference on the wellbeing of both patients and doctors?

Trzeciak wasn’t convinced. Sure, compassion is good, Trzeciak thought, but he expected to review the existing science and report back the bad news that caring has no quantitative rationale. But Mazzarelli was his colleague and chief, so he dove in.

After considering more than 1,000 scientific abstracts and 250 research papers, Trzeciak and Mazzarelli were surprised to find that the answer was, resoundingly, yes. When health care providers take the time to make human connections that help end suffering, patient outcomes improve and medical costs decrease. Among other benefits, compassion reduces pain, improves healing, lowers blood pressure and helps alleviate depression and anxiety.

In their new book, Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference, Trzeciak and Mazzarelli lay out research showing the benefits of compassion, and how it can be learned. One study they cite shows that when patients received a message of empathy, kindness and support that lasted just 40 seconds their anxiety was measurably reduced.

But compassion doesn’t just benefit its recipients, Trzeciak and Mazzarelli learned. Researchers at the Wharton School of the University of Pennsylvania found that when people spent time doing good for others (by writing an encouraging note to a gravely ill child), it actually changed their perception of time to make them feel they had more of it.

For doctors, this point is crucial. Fifty-six percent say they don’t have time to be empathetic.

“The evidence shows that when you invest time in other people, you actually feel that you have more time, or that you’re not so much in a hurry,” Trzeciak says. “So when 56 percent say they don’t have time in that survey, it’s probably all in their heads.”

The good news is, the same study that found doctors didn’t have time for empathy, also showed that a short training in the neuroscience of empathy made doctors interact with patients in ways patients rated as more empathetic.

Compassion also seems to prevent doctor burnout — a condition that affects almost half of U.S. physicians. Medical schools often warn students not to get too close to patients, because too much exposure to human suffering is likely to lead to exhaustion, Trzeciak says. But the opposite appears to be true: Evidence shows that connecting with patients makes physicians happier and more fulfilled.

“We’ve always heard that burnout crushes compassion. It’s probably more likely that those people with low compassion, those are the ones that are predisposed to burnout,” Trzeciak said. “That human connection — and specifically a compassionate connection — can actually build resilience and resistance to burnout.”

Trzeciak and Mazzarelli hope their evidenced-based arguments will spur medical schools to make compassion part of the curriculum.

For those outside the health care system, acting with compassion can be a kind of therapy as well, the authors say. They cite the phenomenon of the “helper’s high,” the good feeling that comes from helping others, and explain how giving to others benefits the givers’ brains and nervous systems.

“I can say this with confidence,” Trzeciak says. “Other-focused behavior is beneficial to your own mental health.”

For Trzeciak, the research had a personal effect. When he started into the project, he’d been

going through his own existential crisis, triggered by his son’s middle school homework assignment that asked, “What is the most pressing problem of our time?” While he believed his work to that point was meaningful, it was definitely not the most pressing problem of our time.

Along the way, he says, he realized he was feeling burned out after 20 years of practicing medicine. So, armed with data from his book research, he decided to test his own hypothesis.

“The recommended prescription is what I call ‘escapism’ — get away, detach, pull back, go on some nature hikes or whatever but I was not believing it,” Trzeciak explains in a TEDxPenn talk.

Instead, he says, he applied the techniques he’d been studying, including spending at least 40 seconds expressing compassion to patients. “I connected more, not less; cared more, not less; leaned in rather than pulled back. And that was when the fog of burnout began to lift.”

He prescribes the same for anyone, not just health care providers, suffering from mental or emotional exhaustion.

“Look around you and see those in need of compassion and give your 40 seconds of compassion,” he says. “See how it transforms your experience.”

Let’s block ads! (Why?)

Eric Lewis’ plans of expanding his community hospital’s reach have been derailed.

As CEO of Olympic Medical Center, he oversees efforts to provide care to roughly 75,000 people in Clallam County, in the isolated, rural northwestern corner of Washington state.

Last year, Lewis planned to build a primary care clinic in Sequim, a town about 17 miles from the medical center’s main campus of a hospital and clinics in Port Angeles.

But those plans were put aside, Lewis says, because of a change in federal reimbursements this year. Medicare has opted to pay hospitals that have outpatient facilities “off campus” a lower rate — equivalent to what it pays independent doctors for clinic visits.

Over the past decade, hospitals have been rapidly building outpatient clinics or purchasing existing independent ones. It was a lucrative business strategy because such clinics could charge higher rates, on the premise that they were part of a hospital.

With its new policy, Medicare is essentially saying that an off-campus office is an off-campus office, regardless of whether it’s owned by a hospital, a group of doctors or a solo practitioner.

Taking that position will save Medicare — and possibly patients — money.

The federal insurer bore the brunt of its members’ extra charges, but beneficiaries sometimes picked up part of that expense through deductibles and copayments. Patients with commercial insurance often were blindsided by high bills — going to what seemed to be a normal primary care clinic, only to discover they were charged a hospital facility fee, for example.

Health policy analysts say the new policy represents an important step in rationalizing payments. Part of a strategy called “site neutral” payment, the new policy has its roots in the Obama administration and was part of the Bipartisan Budget Act of 2015.

“You don’t care about where [your treatment is] happening. You care that it’s a safe and inexpensive procedure,” says Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and Management. “And the facility fee just adds to the cost with very little added value.”

The new payment structure may financially hurt some hospitals, he and other experts acknowledge. But making reimbursements more uniform across providers facilitates competition and may lead commercial insurance to follow suit — which could translate to more savings for patients.

This year, the policy’s two-part phase-in cut Medicare payments for clinic visits to outpatient departments by 30%, according to the rule finalized in November. By 2020, the payment rates will be cut by 60% compared with what they were last summer.

The Centers for Medicare & Medicaid Services estimates that the change will save the federal government $380 million this year and patients an average of $7 every time they visit a hospital-owned clinic. Clinic visits are the most commonly charged service for hospital outpatient care under Medicare.

It could also cut down on consolidation in the industry, health care economists say, by closing the loophole that created incentives for hospitals to purchase independent physician practices and charge higher rates for services at taxpayers’ expense.

The American Hospital Association filed a lawsuit late last year alleging that CMS overstepped its authority when setting the new reimbursement schedule. Olympic Medical Center is among the plaintiffs.

The hospital association claims that the new rule infringes on a precedent Congress set with the 2015 budget law. That legislation standardized Medicare payments for clinic visits to physicians’ offices and new hospital outpatient facilities, but allowed most hospital-affiliated departments that existed at that time to continue receiving a higher rate, according to a comment letter from the Medicare Payment Advisory Commission. The group is a nonpartisan agency that advises Congress.

The differential for site-based payments was designed originally to help hospitals offset the higher costs they incur for maintaining the staff and equipment to handle a wide variety of treatments, says Christopher Whaley, an associate policy researcher at the research organization Rand Corp.

But that financial relief became an incentive for hospitals to buy independent practices, says Dr. Ateev Mehrotra, associate professor of health care policy and medicine at Harvard Medical School. Hospitals were able to charge higher prices for services performed at newly acquired clinics.

Mehrotra says the new CMS rule could be a way to slow down the trend.

“This isn’t going to fully put the brakes on it,” he says, “but it could be one push on the brakes here — to kind of push that consolidation down.”

Some health care analysts have urged the government to expand the number of services covered by the site-neutral policy, including paying hospitals’ on-site clinics a rate equivalent to what independent doctors receive.

Hospitals acknowledge that the change implemented by CMS could lead to savings in the health care system, but they say it comes at the cost of patients’ convenient access to medical care. In Washington state, Lewis anticipates a loss of $1.6 million for his hospital.

The lack of a clinic in Sequim means ailing patients there will not be able to get care close to their homes, Lewis says.

“If you’re well-to-do financially, these aren’t big problems,” Lewis adds. “But I think the poorest, elderly, sickest of our society will pay the price of this policy.”

Melinda Hatton, general counsel for the hospital association, agrees. “I think access trumps a couple extra dollars in copays every single time,” she says.

On the other hand, many independent physicians support the change. Marni Jameson Carey, executive director of the Association of Independent Doctors, says she hopes the rule will curb consolidation.

According to a recent report by the consulting firm Avalere, the number of hospital-owned physician practices more than doubled from 35,700 to 80,000 between July 2012 and January 2018. Hospitals own more than 31% of all physician practices, the report found.

Jameson Carey says such mergers can also cause problems for the local economy. When a nonprofit hospital acquires an independent clinic, it effectively removes a tax-paying business from the area. That’s because nonprofit hospitals are exempt from paying certain federal, state and local taxes — in exchange for providing community benefits.

“So, not only do they [hospitals] get the facility fee,” Jameson Carey says, “they don’t have to pay taxes.”

Kaiser Health News is a nonprofit news service and editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

Let’s block ads! (Why?)

One of the biggest corporations on the planet is taking a serious interest in the intersection of artificial intelligence and health.

Google and its sister companies, parts of the holding company Alphabet, are making a huge investment in the field, with potentially big implications for everyone who interacts with Google — which is more than a billion of us.

The push into AI and health is a natural evolution for a company that has developed algorithms that reach deep into our lives through the Web.

“The fundamental underlying technologies of machine learning and artificial intelligence are applicable to all manner of tasks,” says Greg Corrado, a neuroscientist at Google. That’s true, he says, “whether those are tasks in your daily life, like getting directions or sorting through email, or the kinds of tasks that doctors, nurses, clinicians and patients face every day.”

Corrado knows a bit about that. He helped Google develop the algorithm that Gmail uses to suggest replies.

The company also knows the value of being in the health care sphere. “It’s pretty hard to ignore a market that represents about 20 percent of [U.S.] GDP,” says John Moore, an industry analyst at Chilmark Research. “So whether it’s Google or it’s Microsoft or it’s IBM or it’s Apple, everyone is taking a look at what they can do in the health care space.”

Google, which provides financial support to NPR, made a false start into this field a decade ago. The company backed off after a venture called Google Health failed to take root. But now, Google has rebooted its efforts.

Hundreds of employees are working on these health projects, often partnering with other companies and academics. Google doesn’t disclose the size of its investment, but Moore says it’s likely in the billions of dollars.

One of the prime movers is a sister company called Verily, which this year got a billion-dollar boost for its already considerable efforts. Among its projects is software that can diagnose a common cause of blindness called diabetic retinopathy and that is currently in use in India. Verily is also working on tools to monitor blood sugar in people with diabetes, as well as surgical robots that learn from each operation.

“In each of these cases, you can use new technologies and new tools to solve a problem that’s right in front of you,” says cardiologist Jessica Mega, Verily’s chief medical and scientific officer. “In the case of surgical robotics, this idea of learning from one surgery to another becomes really important, because we should be constantly getting better.”

Mega says the rise of artificial intelligence isn’t that big a departure from devices we’re used to, like pacemakers and implantable defibrillators, which jump into action in response to health signals from the body. “So patients are already seeing this intersection between technology and health care,” she says. “It’s just we’re hitting an inflection point.”

That’s because the same kinds of algorithms that are giving rise to self-driving cars can also operate in the health care sphere. It’s all about managing huge amounts of data.

Hospitals have gigabytes of information about the typical patient in the form of electronic health records, scans and sometimes digitized pathology slides. That’s fodder for algorithms to ingest and crunch. And Mega says there’s a potential to wring a lot more useful information out of it.

“There’s this idea that you are healthy until you become sick,” she says, “but there’s really a continuum” between health and disease. If computer algorithms can pick up early signs of a slide toward disease, that could help people avoid getting sick.

But medical data aren’t typically collected for research purposes, so there are gaps. To close those, Verily has partnered with Duke University and Stanford University in an effort called Project Baseline, which seeks to recruit 10,000 volunteers to give tons more data to the company.

Enlarge this image

Judith Washburn and her husband, James Davis, have volunteered to be subjects in Project Baseline, an effort to gather a range of detailed data to characterize and predict how people move from health to illness.

Courtesy of James Davis

hide caption

toggle caption

Courtesy of James Davis

Judith Washburn, a 73-year-old medical librarian and resident of Palo Alto, Calif., signed up after she saw a recruiting ad. “A couple months later, I got a call to go in, and it’s two days of testing, two different weeks and it’s very thorough,” she says.

She had heart scans, blood tests, skin swabs and stress tests — a checkup on steroids, if you pardon the expression. Her husband, James Davis, decided he’d give it a go as well.

“They were having trouble finding African-American participants at the time, so I was pretty much a shoo-in,” he says. “I’m aware of people who donate their bodies to medical science when they die,” he says, “so it’s sort of a way of donating your body while it’s still alive.”

The retired aerospace engineer also got an added benefit. The doctors diagnosed a serious heart condition, and Davis then had triple bypass surgery to treat it.

The couple replies to quarterly questionnaires, a gizmo under their mattress tracks their sleep patterns and they each wear a watch that monitors their hearts. The watches also count their steps — sort of.

“They haven’t quite figured out your exercise yet,” Washburn says. “In fact, I can knit and get steps!”

All this highly personal information goes into the database of a private corporation. Both Washburn and Davis thought about that before signing up but ultimately concluded that’s OK.

“It depends upon what they’re using it for,” Washburn says. “And if it’s all for research, I’m fine with that.”

Here’s what makes Google’s position unique. Some of the most useful data could be what the company collects while you’re running a Google search, using Gmail or using its Chrome browser.

“As companies like Google and other traditional consumer-oriented companies start moving into this space, it is certainly clear that they bring the capability of taking much of the information they have about us and be able to apply it,” says Reed Tuckson, a well-known academic physician who was recently recruited to advise Verily about Project Baseline.

For example, people’s browsing history can reveal a lot about what they buy, how they exercise and other facets of their lifestyles.

“We now understand that that has a great deal to do with the health decisions that we make,” says Tuckson, who is on a National Academy of Medicine working group that’s exploring artificial intelligence in medicine.

He says Google needs to tread carefully around these privacy issues, but he’s bullish on the technology.

“We should remember that the status quo is not acceptable by itself and that we’ve got to use every tool at our disposal — use them intelligently” to improve the health of Americans, he says. “And I think that’s why it’s exciting.”

Tuckson isn’t the only influential recruit to the effort. Verily recently brought in Dr. Robert Califf, a former Food and Drug Administration commissioner, as well as Vivian Lee, a radiologist who headed the University of Utah’s health care system. Google hired David Feinberg, a physician who ran Geisinger, a major health care provider based in Danville, Pa.

“It seems like it was a bit of a war on talent right now between Amazon and Google and to a certain extent Apple,” says Moore, the analyst. Google needs to build credibility in the medical sphere.

“I think Google is trying to have those people that can basically proof out what Google is doing and stand up and say, ‘Yes, Google can do this,’ ” Moore says.

He also has his eye on what the company’s investment means for the rapidly developing industry around health care and artificial intelligence. “Anyone should take Google very seriously,” he says.

Some big players, like Apple and Microsoft, can hold their own.

“For other AI companies that don’t have those resources, they’re going to have to be very judicious in picking the niches they want to target, niches that are ones that, frankly, Google is not terribly interested in,” Moore says.

Getting the technology to work is just the start.

The health care business is “a very complex ecosystem,” says Dr. Lonny Reisman, a former health insurance executive who now heads HealthReveal, a company that develops algorithms to help doctors choose the appropriate therapy. Google will need to answer many questions as it enters that landscape.

Who will have an incentive to buy software based on artificial intelligence? Will it really save time or money, as advocates often assert? Or is it just the next new driver of health care inflation?

“There are all these competing forces around cost containment,” Reisman says. It’s not easy to balance innovation, access, fairness and health equity, he adds, “so they’ve got a lot on their plate.”

Google’s Corrado says collaborations with academics and the health care industry are key for navigating this territory.

“A big part of the way that research and development should work in this space is by having kind of a long-term portfolio of technologies that you percolate through the academic and scientific community and then you percolate through the clinical community,” Corrado says.

For all the challenges of forging a new path into health care, Google has a potentially enormous advantage in all the data it collects from its billions of users.

Corrado says the company is well aware of the sensitivity of putting that information to use and is thinking about how to approach that without provoking a backlash.

“It has to be something that is driven by the patients’ desire to use their own information to better their wellness,” Corrado says.

In a world where people are increasingly concerned about how their personal data are exploited, that could be even more of a challenge than building the computer algorithms to digest and interpret it all.

You can contact NPR science correspondent Richard Harris at rharris@npr.org.

Let’s block ads! (Why?)

Robin Wallace thought her years of working as a counselor in addiction treatment gave her a decent understanding of the system. She has worked in private and state programs in Massachusetts and with people who were involuntarily committed to treatment.

So in 2017, as her 33-year-old son, Sean Wallace, continued to struggle with heroin use — after years of coping with mental health issues and substance use — she thought she was making the right choice in forcing him into treatment.

“His behavior was erratic,” Robin says. “I think he had some mental health issues that were worsened by his use.”

Now she worries that her decision contributed to Sean’s taking his own life.

The law known as Section 35

Robin had become one of several thousand Massachusetts residents each year who ask the courts to force a loved one into addiction treatment under a state law known as Section 35.

The law allows a family member, physician or police officer to ask the courts to involuntarily commit someone to substance use treatment. Dozens of states have civil commitment laws, but Massachusetts is believed to use it more aggressively than most states.

In the last fiscal year, more than 6,500 Massachusetts residents were ordered into treatment this way.

After a court clinician in Hyannis, Mass., reviewed Robin’s request, a judge agreed that Sean’s substance use was dangerous and ordered him committed to up to 90 days of residential treatment.

Sean had begged his mother in court that day not to go that route. He was being sent to a program, he told her, where he would be locked up and not allowed to continue taking the medication that was helping him with his addiction — methadone.

“I thought he misunderstood,” says Robin. “Because I couldn’t conceive that there would be an opioid treatment program that would not provide medication-assisted treatment.”

It turns out Sean was right. Although many providers say medication is the gold standard in addiction treatment, Sean was sent to a program in a state prison in Plymouth, Mass., that does not provide the medicine.

When we spoke with Sean in 2017 — shortly after he’d spent about a month committed, he said that the conditions were inhumane and that he was often placed in segregation, or “the hole” — though he had not committed any crime.

“I was punished for not eating,” Sean told us. “That’s how I ended up in the hole. If you refuse your tray, they consider it a behavioral issue. I didn’t know that — I was just sick.”

He spiraled to suicide

Sean also said in that interview that he was having trouble adjusting to life after his time in the Plymouth prison.

“I just feel different,” he said. “I have a lot more anxiety. I feel scared. I feel like I’m going to wake up and be back there.”

Less than a year after that interview, Sean killed himself. His mother says that after that stint in civil commitment, Sean could no longer hold a job. He ended up in a psychiatric hospital and was later jailed on charges of trying to break into a house. Robin believes being locked up for addiction treatment contributed to his suicide.

“I think that his trauma was very much triggered by him being in the cell” at the local jail, she says. “And he just felt like he couldn’t take it anymore.”

The sheriff wouldn’t comment, but documents at the local jail confirm that Sean tried to take his own life there; he later died from those injuries.

Sean’s longtime partner, Heather McDermott, says he was never the same after his civil commitment.

“He was like a big, sad, depressed tumor that I was trying to bring back to life,” McDermott says. “We had a home. I can’t even believe we got here, and then — then he died.”

Massachusetts is one of a few states that use prisons and jails to involuntarily commit men to addiction treatment — and Massachusetts uses the approach more than most states do.

In an emailed statement, the Massachusetts Department of Correction said that its mission is to promote public safety by providing a secure treatment environment. And there is so much demand for involuntary treatment for addiction in Massachusetts that 100 more beds opened in another jail last year.

Hampden County Sheriff Nick Cocchi says that many traditional treatment centers aren’t willing to take patients who don’t want to be there and that, with a declining inmate population, jails have room for these men.

“This is a very dangerous, acutely sick and — I would say — not so well-behaved population,” Cocchi says.

Many states are going down the same road as Massachusetts — strengthening their civil commitment laws to hold people against their will so they will get treatment. And some researchers, such as Leo Beletsky of Northeastern University, say more families are choosing to have loved ones locked up because it’s the only way to get immediate help.

“Limiting someone’s civil rights should be the last resort and only reserved for those cases that are truly dire,” he says.

Denise Bohan believes involuntary commitment saved her 33-year-old son’s life. Families are desperate, she says, and can’t reason with a loved one in the throes of addiction.

“This is a last resort,” Bohan says. “It’s not something you do, like, just on a whim. This is a desperate act of just trying to save your child’s life.”

Several Massachusetts officials are signaling that the law may change so that correctional facilities will not be used for men committed to involuntary addiction treatment — primarily because addiction is now widely considered a disease that requires medical treatment.

Already, a class action lawsuit against the state has been filed, charging gender discrimination — because Massachusetts stopped sending involuntarily committed women to prisons in 2016, in response to a different lawsuit.

A longer version of this story originally appeared in WBUR’s CommonHealth. Deborah Becker is a senior correspondent and host at WBUR. Her reporting focuses on mental health, criminal justice and education.

Let’s block ads! (Why?)

Former Vice President Joe Biden told a rally in Dorchester, Mass., Thursday that the 31,000 Stop & Shop workers on strike in New England are part of a movement to “take back this country.”

“I know you’re used to hearing political speeches, and I’m a politician. I get it,” said Biden, who is mulling over a White House bid in 2020. “But this is way beyond that, guys. This is way beyond that. This is wrong. This is morally wrong, what’s going on around this country. And I have had enough of it. I’m sick of it, and so are you.”

Biden, a Democrat, was quick to support members of the United Food & Commercial Workers union when they walked off the job last week.

Thursday’s appearance in Boston gave Biden face time with a key Democratic constituency — blue-state union members — on the home turf of potential primary rival Sen. Elizabeth Warren, who already has entered the presidential race.

“Probably it’s more benefiting him than us,” said Peter Amati, a longtime florist at the Stop & Shop in Milford, Mass. “This is the right place.”

Warren joined picketing Stop & Shop workers in Somerville, Mass., last Friday, saying, “Unions built America’s middle class, and unions will rebuild America’s middle class.”

Biden’s message was similar, though he delivered it without the Dunkin’ doughnuts that Warren brought along.

Stop & Shop workers went on strike to protest the company’s proposed changes to wages and benefits. Labor contracts for five UFCW chapters in Massachusetts, Connecticut and Rhode Island expired Feb. 23, and the two sides have been unable to agree to new terms despite meeting with a federal mediator.

Stop & Shop, a subsidiary of the Dutch conglomerate Ahold Delhaize, is asking workers to contribute more to their health insurance premiums. The company says workers currently pay an average of 8.2% of the cost of single coverage and 6.6% of the cost of family coverage. Those contributions are well below national averages, according to the Kaiser Family Foundation’s 2018 Employer Health Benefit Survey.

Stop & Shop also wants to reduce pensions for some workers, arguing that the company is an industry outlier and therefore at a competitive disadvantage. Stop & Shop wants to freeze its monthly pension-fund contribution for new full-time workers. Pension payments for part-time workers hired after Feb. 23, 2014, would stop increasing under the company’s proposal.

In addition, Stop & Shop wants to freeze the 50% hourly bonus paid to part-time workers on Sundays. New part-time hires would receive smaller bonuses: an extra $1 per hour for the first year of employment and $2 per hour after that.

The eight-day strike has shuttered some Stop & Shop stores and slowed business at others, as the company offers reduced hours and limited food selections.

Picketers are going without pay and say they don’t expect much financial assistance from the union. Paul Batista, a butcher at the Stop & Shop on Everett Street in Allston, Mass., told WBUR this week that the union won’t begin to make up for lost wages until the strike hits the two-week mark, and checks will be just $100 per week for full-time workers and $50 per week for part-timers.

Batista added that May 1 is an important date for striking Stop & Shop workers: That’s when company-sponsored health insurance will lapse, he said.

Strikers can apply for unemployment benefits but might not receive them. According to the Massachusetts Executive Office of Labor and Workforce Development, “employees participating in a labor dispute (i.e., strike) that results in a substantial curtailment of the employer’s business do not qualify for benefits.”

Let’s block ads! (Why?)

In 2017, Susan learned that she carries a genetic mutation that may elevate her lifetime risk of developing breast cancer to 72 percent.

Her doctor explained that individuals who have this mutation in the BRCA2 gene have choices in treatment. Some people opt for a preventive double mastectomy. But Susan could instead choose to undergo increased cancer screenings, which, for her, would mean an annual mammogram and annual MRI scan.

Because she had just had her first child, Susan chose increased surveillance — that meant she’d be able to preserve her ability to breastfeed.

Both Susan and her husband, who make their home in Broomall, Pa., have insurance provided through their respective employers to help pay for medical treatment. But there’s an expensive hitch: These annual scans she’d need would be pricey, and their companies offered only high-deductible health plans.

Susan’s annual deductible for her plan (which covers her and her child) is $6,000 annually. (NPR has agreed to use only Susan’s first name because she worries any publicity might jeopardize her job.)

“I’ve worked at my employer for 17 years,” she says. “When I first started, there was no paycheck deduction for health insurance and my copay was only $5. But in 2011, my employer switched to only providing high-deductible insurance plans.”

Susan went in for her first mammogram and MRI in February 2017. Her out-of-pocket cost for the MRI was more than $2,000. The bill for her mammogram was $1,088 (although she was eventually able to appeal and have the charges for the mammogram reduced to $191).

As a result of the high bill, Susan decided to put off her 2018 annual screenings until she had dealt with paying off the bills from 2017.

Susan’s story of delaying care because she’s underinsured is not an outlier. A study published last month in Health Affairs examined claims data from a large national insurer for 316,244 women whose employers switched insurance coverage from low-deductible health plans (i.e., deductibles of $500 or less) to high-deductible health plans (i.e., deductibles of $1,000 or more) between 2004 and 2014.

The study group consisted of women who were in low-deductible plans for one year, then switched to a high-deductible plan for an additional one month to four years. The control group consisted of women who remained in low-deductible plans.

In particular, the researchers looked at the relative effects of such plans on women who have low incomes versus those with higher incomes.

Women with low incomes who had high-deductible insurance plans waited an average of 1.6 months longer for diagnostic breast imaging, 2.7 months for first biopsy, 6.6 months for first early-stage breast cancer diagnosis and 8.7 months for first chemotherapy, compared with low-income women with low-deductible plans.

In some cases, delays of that length might lead to poorer health outcomes, says J. Frank Wharam, an internist and specialist in insurance and population health, who led the study. More research needs to be done to confirm that, he says.

Interestingly, women with high incomes who relied on high-deductible health plans were not immune to such delays — they experienced lags of 0.7 months for first breast imaging, 1.9 months for first biopsy, 5.4 months for first early-stage breast cancer diagnosis and 5.7 months for first chemotherapy, compared with high-income women with low-deductible plans.

The researchers also found that having a high-deductible health plan was linked to delays in care whether the women lived in metropolitan areas or not and whether they lived in neighborhoods that were predominantly white or predominantly nonwhite.

“In general, we are finding that the effects of modern high-deductible plans on access to care are sometimes predictable but often surprising,” Wharam explains.

“In addition to well-recognized factors that can influence how quickly a patient is diagnosed and treated — such as income and education levels — other aspects of her life likely play a role too,” he says, such as her familiarity with her disease and insurance benefits, her previous experience interacting with an insurer, her tolerance of risk and her familiarity and ease with the health care system and its jargon.

Other recent studies have noted similar delays in diagnosis and treatment for complications from diabetes, cardiovascular illness and other conditions. And a report from the Kaiser Family Foundation in 2017 found that 43 percent of adults with health insurance reported difficulties in meeting their deductible — up from 37 percent in 2015.

Dr. Veena Shankaran is co-director of the Hutchinson Institute for Cancer Outcomes Research at Seattle’s Fred Hutchinson Cancer Research Center, where her work focuses on studying financial challenges experienced by cancer patients. Though not involved in the Health Affairs study, Shankaran says the findings don’t surprise her.

“We’re seeing that high-deductible plans are really the epitome of the access-to-care problem,” she says. “People don’t have the liquid cash to meet their deductible, so you see delays in care or even avoiding treatment altogether.”

According to data from the Centers for Disease Control and Prevention, from 2007 through 2017, enrollment in high-deductible health plans that are linked to a health savings account increased from 4.2 percent to 18.9 percent among adults 18 to 64 who had job-based coverage, while enrollment in high-deductible health plans without an HSA increased from 10.6 percent to 24.5 percent in that same age group.

Meanwhile, enrollment in more traditional workplace plans decreased.

The Patient Access Network Foundation, a nonprofit in Washington, D.C., assists underinsured patients who have life-threatening chronic or rare diseases get access to medications and treatment by assisting with out-of-pocket costs. Dan Klein, the organization’s president and chief executive officer, says he has noticed an uptick in the number of patients seeking PAN’s help.

“One thing that worries me,” Klein says, “is that Congress is very focused on lowering prescription drug prices. That’s a good goal, but it’s meaningless in an environment where patients still can’t access care or medications because of their deductibles.”

Susan resumed screenings this year. She says she did look into patient-assistance programs, such as the one offered by Right Action for Women, which helps individuals at high risk for breast cancer get access to MRI screenings. But she did not meet the criteria.

In preparation for her next scan, she has established a flexible spending arrangement at work and a health savings account so she can pay for at least some of her medical expenses from tax-free income. And she has been setting up payment plans with her health care providers. Still, concern over how she and her husband will pay for looming tests and treatment preoccupy the couple.

“After that first MRI bill, I wanted to give up,” Susan says. “Because, in addition to dealing with the BRCA diagnosis, the insurance bills were overwhelming.

“I sometimes think about opting for surgery as a way to deal with my mutation,” she adds. “But then I get nervous — because I’m afraid of the resulting bill from the hospital.”

Erika Stallings is an attorney and freelance writer based in New York City. Her work focuses on health care disparities, with a focus on breast cancer and genetics. Her work has appeared in HuffPost, New York Magazine, Jezebel and O, The Oprah Magazine. Find her on Twitter: @quidditch424.

Let’s block ads! (Why?)

Workplace wellness programs — efforts to get workers to lose weight, eat better, stress less and sleep more — are an $8 billion industry in the U.S.

Most large employers offer some type of wellness program, with growth fueled by incentives in the federal Affordable Care Act.

But no one has been sure they work. Various studies over the years have provided conflicting results, with some showing savings and health improvements while others say the efforts fall short.

Many studies, however, faced a number of limitations, such as failing to have a comparison group, or figuring out whether people who sign up for such wellness programs are somehow healthier or more motivated than those who do not.

Researchers from the University of Chicago and Harvard may have overcome some of these obstacles with one of the first large-scale studies to be peer-reviewed and employ a randomized controlled trial design. They published their findings Tuesday in the medical journal JAMA.

The scientists randomly assigned 20 BJ’s Wholesale Club outlets to offer a wellness program to all employees, then compared results with 140 stores that did not.

The big-box retailer employed nearly 33,000 workers across all 160 clubs during the test.

The wellness program consisted of asking participating workers to fill out a health risk questionnaire, have some medical tests, such as blood pressure and blood glucose, and take up to eight classes on topics such as nutrition and exercise.

After 18 months, it turned out that, yes, workers participating in the wellness programs self-reported healthier behavior than those not enrolled, such as exercising more or managing their weight better.

But the efforts did not result in differences in health measures, such as improved blood sugar or glucose levels, how much employers spent on health care or how often employees missed work. Their job performance and how long they stuck around in their jobs also seemed unaffected, the researchers say.

“The optimistic interpretation is there is no way we can get improvements in health or more efficient spending if we don’t first have changes in health behavior,” says Katherine Baicker, dean of the Harris School of Public Policy at the University of Chicago, and one of the study’s authors. (Dr. Zirui Song, an assistant professor of health policy and medicine at Harvard Medical School, was its co-author.)

“But if employers are offering these programs in hopes that health spending and absenteeism will go down, this study should give them pause,” Baicker says.

The study comes amid widespread interest in wellness programs.

The Kaiser Family Foundation’s annual survey of employers found that 53 percent of small firms and 82 percent of large firms offer a program in at least one of these areas: smoking cessation, weight management, and behavioral or lifestyle change. (Kaiser Health News is an editorially independent program of the foundation.)

Some programs are simple, offering gift cards or other small incentives to fill out a health risk assessment; take a lunch-and-learn class; or join a gym or walking group. Others are far more invasive, asking employees to report on a variety of health-related questions and roll up their sleeves for blood tests.

A few employers offer financial incentives to workers who actually reduce their risk factors — lowering high blood pressure, for example, or reducing levels of bad cholesterol — or who make concerted efforts to participate in programs that might help them reduce these risk factors over time.

The Affordable Care Act allowed employers to offer financial incentives worth up to 30 percent of the cost of health insurance — that led some employers to entice workers with what could amount to hundreds or even thousands of dollars in discounted insurance premiums or reduced deductibles.

Such large financial incentives led to court challenges about whether those programs are truly voluntary. The result of such cases is still unclear — a judge has asked the Equal Employment Opportunity Commission to revise the rules governing the programs, but those revisions are not expected to be published this year.

In the study reported in JAMA, the incentives were modest. Participants got small-dollar gift cards for taking wellness courses on topics such as nutrition, exercise, disease management and stress control. Total potential incentives averaged $250. About 35 percent of eligible employees at the 20 participating sites completed at least one module.

Results from those workers — including attendance and tenure data, their self-reported health assessment and results from lab blood tests — were specifically compared with similar reports from 20 primary comparison sites where workers were not offered the wellness gift cards and classes. Overall employment and health spending data from all worksites were included in the study.

Wellness program vendors say details matter when considering whether efforts will be successful.

Jim Pshock, founder and CEO of Bravo Wellness, says the incentives offered to BJ’s workers might not have been large enough to spur the kinds of big changes needed to affect health outcomes.

Amounts “of less than $400 generally incentivize things people were going to do anyway,” Pshock says. “It’s simply too small to get them to do things they weren’t already excited about.”

An accompanying editorial in JAMA notes that “traditional, broad-based programs like the one analyzed by Song and Baicker may lack the necessary intensity, duration, and focus on particular employee segments to generate significant effects over a short time horizon.”

In other words, don’t give up entirely on wellness efforts, but consider “more targeted approaches” that focus on specific workers who have higher risks, or on “health behaviors [that] may yield larger health and economic benefits,” the editorial suggests.

It could be, the study acknowledges, that 18 months isn’t enough time to track such savings. So, Baicker and Song also plan to publish three-year results once they are finalized.

Still, similar findings were recently reported by the University of Illinois, where individuals were randomly selected to be offered wellness programs. This study, published in 2018 by the National Bureau of Economic Research, concluded that the workplace wellness program did not reduce health care costs or change health behaviors.

In one interesting point, that study found that wellness-program participants were likely already healthier and more motivated, “thus a primary benefit of these programs to employers may be their potential to attract and retain healthy workers with low medical spending,” the authors write.

Everyone involved in studying or conducting wellness agrees on one thing: Changing behavior, and getting people motivated to participate at all, can be difficult.

Steven Aldana, CEO of WellSteps, a wellness program vendor, says that for the efforts to be successful, they must cut across many areas — from the food served in company cafeterias to including spouses or significant others in helping people quit smoking, eat better or exercise more.

“Behavior is more complicated than simply taking a few wellness modules,” Aldana said. “It’s a lifestyle matrix or pattern you have to adopt.”

Kaiser Health News is an editorially independent, nonprofit program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

Let’s block ads! (Why?)