Q&A: Linking gait and sleeping with Alzheimer's

Subtle changes in gait and sleeping patterns in older people may be linked to Alzheimer's disease, according to research out today at the Alzheimer's Association International Conference 2012 in Vancouver, Canada. USA TODAY talked to Bill Thies, chief scientific and medical officer for the Alzheimer's Association, about these changes and other warning signs of the disease. Alzheimer's affects 5.4 million people in the USA, numbers that are expected to soar to 16 million by 2050 as Baby Boomers age. The disease is the second most feared, behind cancer.

Q: What are some of the characteristics of how gait might change?

A: Walking becomes slower or more variable. The research presented at the meeting is robust. These links have been suggested before, but this is the first science to support it. In several of the studies, gait changes were noted before cognition changes. One of the studies showed there was no link between walking and memory, but there is a link between walking pace and variability and executive function (a set of mental processes).

Q: If the changes are linked to Alzheimer's disease, what is occurring in the brain to cause the problem?

A: Walking relies on the perfect integration of several areas of the brain. The disease interferes with the communication between different regions of the brain.

Q: How do you know if changes aren't caused by another disease such as Parkinson's or arthritis?

A: That isn't an easy answer, but the current studies ruled out those diseases or found that people who had early stages of Alzheimer's might also have arthritis in a hip or knee as well, or other problems. The important message is to seek a professional's advice if you notice a change in gait. There are a lot of things that are early signs that aren't always diagnostic of Alzheimer's disease but should encourage you to want to get a complete evaluation from a professional.

Q: Can an untrained family member see the changes in gait or is a specialist required to detect it?

A: The changes might be very hard for a loved one to pick up, but even if you suspect a change, then find out what the underlying cause is by going to a specialist.

Q: What effect does sleep have on changes in the brain associated with Alzheimer's?

A: Researchers reported on Monday that cognitive health declines over the long term in some people with sleep problems. A large study done at Brigham and Women's Hospital in Boston, of 15,000 participants ages 70 and older, reported important findings. Sleep duration shorter or longer than the recommended seven hours might have an effect on cognition in older individuals. It's still not clear if sleep change is one of the risk factors or an early sign.

Q: What else did the study note about sleep and cognition problems?

A: Participants who slept five hours or less had lower average cognition than those who slept seven hours a day. Those who slept nine hours a day or more had lower average cognition than those who slept seven hours per day. And too little or too much sleep was cognitively equivalent to aging two years.

Q: What is one of the most common early warning signs of Alzheimer's disease?

A: Loss of interest is an early sign of the disease. I hear it over and over. People will say their husband or wife did something all the time and then over the period of a few months they didn't do it anymore. There could be a number of reasons why they stop doing something they love. But that change in interest and personality should move you toward getting a diagnosis.

Q: If a loved one stops doing something he or she loves, does that mean they have Alzheimer's?

A: Not necessarily. Depression could be another reason, but it is important to find out why they've stopped doing something and take the necessary steps to get them tested. This can happen years before they become demented.

Q: Can you be more specific about some of the things people will stop doing?

A: Very often, there's one person in the household who pays the bills. If you see them struggling to manage the finances, it is time to get a diagnosis. Following recipes and cooking might also be difficult for someone in the early stages of the disease.

Q: How do I find a doctor that can diagnose Alzheimer's?

A: The more practice a doctor has with Alzheimer's, the better he is going to be at diagnosing. Ask the doctor if he is comfortable making a diagnosis. And if he's not, ask him to recommend someone who can do it. It pays to have an early diagnosis.

States Pushing Medicaid Ruling to Cut Rolls Immediately

It’s true that states could, after 2014, reduce their Medicaid rolls without the potential consequences of losing their entire federal share of funding. But some states aren’t waiting until 2014.

The court, which upheld most of the law, struck down penalties for states choosing not to expand Medicaid. A few states are also trying to go farther, arguing that the ruling justifies cuts to their existing programs.

Within hours of the Supreme Court’s ruling on June 28, lawyers in the Maine attorney general’s office began preparing a legal argument to allow health officials to strike more than 20,000 Medicaid recipients from the state’s rolls�including 19- and 20-year-olds�beginning in October to save $10 million by next July.

“We think we’re on solid legal ground,” Attorney General William Schneider said in an interview. “We’re going to reduce eligibility back to the base levels in a couple of areas,” he said. Maine, like some other states eyeing cuts, earlier expanded its Medicaid program beyond national requirements.

Other states, including Wisconsin and Alabama, are expected to follow Maine’s lead, though there is disagreement over whether the high court gave the states such leeway. That could lead to battles between states and the federal government that could drag the health law back to the courts. New Jersey and Indiana also said they were evaluating the decision and did not rule out challenging the requirements.

This looks to me like an expansion of what the Court actually said. The Court’s ruling specifically regarded tying the Medicaid expansion to the initial program funding as unconstitutional. If the cuts contemplated now started before the expansion, that seems to fall under the same maintenance of effort rules that remain in place until 2014. This will take further litigation and a new ruling to figure out.

But it does show that states view the Medicaid program as something to raid, not something to nurture. They want to push the limits of the ruling to make as many cuts as possible. So suggestions that red state governors will not be able to pass up a “good deal” like the Medicaid expansion doesn’t match with this reality.

Meanwhile, given these statistics out of Texas, it’s not clear whether an expansion will really result in an expansion.

The number of Texas doctors willing to accept government-funded health insurance plans for the poor and the elderly is dropping dramatically amid complaints about low pay and red tape, showed a survey by the Texas Medical Association provided to The Associated Press on Sunday before its Monday release.

Only 31 percent of Texas doctors said they were accepting new patients who rely on Medicaid, the health insurance program for the poor and disabled. In 2010, the last time the survey was taken, 42 percent of doctors accepted new Medicaid patients. In 2000, that number was 67 percent.

Texas doesn’t have enough primary-care doctors to serve the size of the state or its rapid population growth. The doctors’ reluctance to take on new Medicaid patients comes at a bad time, since the new federal health care law proposes adding 6 million additional people to the Texas Medicaid rolls with the intent of ensuring every U.S. citizen has access to health insurance. The state ranks last in the nation in terms of percentage of people insured, with 27 percent of Texans without any kind of insurance, according to a March Gallup poll.

Obviously, having health insurance coverage that 31% of doctors will honor is better than having no coverage at all. But geographic distribution matters here. Texas is a big place, and a low-income resident, on the off chance that the state expands its Medicaid coverage, may not be able to find a doctor for many miles. The primary-care doctor problem is central to this debate. States predisposed to reject the expansion will justify it by saying they don’t have the resources to accommodate all these new eligible patients on the Medicaid rolls.

Will Medicaid Bring The Uninsured Out Of The Woodwork?

Win McNamee/Getty Images

Texas Gov. Rick Perry is the latest state executive to say no to an expansion of Medicaid.

Ever since the Supreme Court decided last month that an expansion of Medicaid under the Affordable Care Act should be optional, quite a few Republican governors have been vowing to take a pass.

On Monday, Texas Gov. Rick Perry declared that he won't be expanding Medicaid. He joins other GOP state executives who have rejected offering Medicaid to people with incomes up to 133 percent of the poverty line. This year that's just under $15,000 a year for an individual, or a little over $25,000 for a family of three.

"We're not going to participate in any exchanges," Perry said on Fox News. "We're not going to expand Medicaid. We're just not going to be a part of, again, socializing health care in the state of Texas. And going in direct conflict with our Founding Fathers' wishes and freedom, for that matter."

 

Perry and his colleagues say they're rejecting the health law for mostly ideological reasons. That's because when it comes to Medicaid, the states don't appear to be on the hook for very much money.

"The law provided 100 percent coverage for people newly eligible for Medicaid by the federal government, and 90 percent in the out years," says Jeff Goldsmith, a health policy analyst who teaches public health at the University of Virginia.

Compare that to the rest of the Medicaid program, where the federal government pays an average of just under 60 percent.

But it's not just those newly eligible people states are worried about.

Related NPR Stories Texas Gov. Perry Says No To Medicaid Expansion July 9, 2012 Medicaid Expansion: Who's In? Who's Out? July 5, 2012

"Folks don't really understand the struggle states are in," says Dennis Smith, secretary of the Wisconsin Department of Health Services and former head of the federal Medicaid program under President George W. Bush.

Smith says this year his state put more than a billion dollars into its existing Medicaid program. "And that took up literally almost the entire new revenues available to the state � meaning revenues not just for health care, but also intended for education, transportation, law enforcement and everything else," he says.

Even so, Wisconsin had a $600 million budget shortfall. "So states just don't have the dollars, even with those enhanced federal match rates," Smith says.

But what really has many state leaders worried is something called the "woodwork effect." When big parts of the health law go into force in 2014, they worry it will bring out of the woodwork the millions of people who are already eligible for Medicaid but aren't already enrolled.

When some people look to see if they can get health insurance through one of the health exchanges, they may discover a cheaper option. "They will find out that they're actually eligible for Medicaid," says Bruce Lesley, president of First Focus, an advocacy group for children and families.

But many of those people signing up for Medicaid won't be members of the newly eligible expansion group, whose bills will be largely paid by the federal government. They'll be regular old Medicaid beneficiaries, and states will have to pay up to half their costs.

Goldsmith says what has state officials most worried is how easy it will be for these currently eligible but unenrolled Medicaid recipients to sign up.

"It won't be an in-person visit, it won't be a 'bring six forms of ID,' " he says. "There will be an expedited � lubricated, if you will � process to get people onto the rolls, and I think that's the part that's giving state budget officers serious indigestion at this point."

Goldsmith says state officials he's talked to worry that Medicaid, already the largest piece of almost every state budget, could end up dwarfing everything else.

"The health and human services secretary of Louisiana told me that at full implementation, 48 percent of the citizens of his state would be on Medicaid," he says. "And I strongly suspect that [as] you go across the Southern tier of the United States, you'll see a lot of those states in the 30s. A third of their citizens eligible for or potentially enrolled in Medicaid."

HHS

Click on image to read Sebelius' letter to governors.

That has some states looking at cutting back their Medicaid programs even now. Wisconsin's Dennis Smith, who used to run the federal Medicaid program, says he reads the Supreme Court decision as allowing that.

But the Obama administration disagrees. Last night it sent a letter to all the nation's governors, noting that "the Court's decision did not affect other provisions of the law." An administration official confirmed that included the requirement that states maintain current eligibility levels until the year 2014.

Health advocate Lesley, a former Capitol Hill staffer, agrees with the administration. "Our reading of the Supreme Court ruling is [that] the opinion by Justice Roberts ... cites basically a specific section of the law and basically changed the idea that the Medicaid expansion can no longer be a mandatory thing, but now is optional," Lesley says. "However, what it didn't touch on was this idea of requiring states to maintain coverage. So we believe that that is absolutely still in place."

'The key to our success was the integration of the medical and IT teams'

The SIDCA Clinical Station, a solution developed by Everis for the Virgen del Rocío University Hospital in Seville, Spain, was acquired by FLENI after the Spanish hospital ceded them the rights.  In an exclusive interview, the engineer Marcelo Martínez, Systems and Operations manager at FLENI, tells Ehealth Reporter Latin America about the experience.

EHealth Reporter Latin America: Was the clinical department computerized before or after the other departments in the Foundation?

Marcelo Martínez: It was the final step. The systems department started operations in 2000 with two major challenges ahead of it: firstly we needed to start up the data center in the Belgrano office, which required planning and new solutions for every aspect of operations, from the equipment, servers and desks to the formation of the human team. Secondly, we had to install the new Rehabilitation Center at Escobar.

EHRLA: Meanwhile, did the Belgrano office have efficient computer solutions?

MM:  No, we also had to implement an administrative management system because the existing one was obsolete. We had to turn to a jdEdwards which is an ERP that integrates functions including accounting, purchases, payments to suppliers, inventories, etc.

EHRLA: Did you also plan to include the clinical department?

MM: Yes, but we didn’t have much success at the time. We tried to find a solution for an electronic health record by taking a look at what there was on the market, and we signed a contract with a supplier by they didn’t give us what we needed. Then the country started experiencing economic problems, there was the famous ‘corralito’ and we had to cancel the contract in 2003.

EHRLA:  Did you resign yourselves to continuing with administration based on paper and big files?

MM: At the time, what we decided during the administrative phase was to resolve all the billing management internally, so we developed a system called FactHos, which included billing, out- and in- patient management, contract administration, budgets, appointment administration, etc.  

The jdEdwards inventory module solved the logistical problems in the pharmacy, FactHos covered the administrative side, and we had already managed to resolve the computerization of the business-related processes but we still had to computerize the medical department, which was still managed on paper.

EHRLA: Was this difficult to achieve?

MM: Yes, it was quite difficult. We saw many interesting proposals but they were impossible to implement because of the high costs involved or because our Institution wasn’t yet mature enough to get into this area. It’s not the same to open one’s doors with the computer systems already in place, as happened at the Austral Hospital, as to implement them in places where the doctors have been working with paper for years and you have to ask them to change their habits and start working with electronic records. This was a cultural problem we couldn’t ignore.

EHRLA:  But eventually you made doctors part of the solution.

MM: Exactly. In 2010, we had a chat in the hall with a doctor at FLENI, Dr. Roberto Lagos, and he told me about a conversation he had had with one of his colleagues at the Virgen del Rocío hospital in Seville about a solution they used there, and thanks to him we got in contact with the hospital and Doctor Eduardo Vigil Martín in particular.  

They had a functioning electronic health record which we thought would cover all the aspects we wanted to implement. We travelled to Spain to evaluate the software and found that it was suitable.

EHRLA: Did the hospital in Seville show you how it functioned?

MM: Yes, and they were very willing to work with us. This was a great help because there is a big difference between a Powerpoint presentation where everything is beautifully presented and actually going to a hospital where they open their doors to you and you can talk to the people working there; with the doctors and nurses telling you what they find useful to improve their everyday work and what slows them down. The Seville Hospital’s excellent attitude needs to be emphasized; FLENI has also developed a very close medical relationship with them.   

EHRLA: After this experience, what did you subsequently decide?

MM: We could see that implementation would be viable, especially with the interoperability we already had in place. This system has a messaging administration system, InterSystems’ Ensamble product, which made the necessary communication between the systems possible. For example, when an event (an admission, appointment, discharge, etc.) is entered into FactHos, a series of messages is sent to SIDCA in real time, allowing the doctor to carry out treatment using the electronic health record in real time; whilst they are attending the patient.  

EHRLA: When did the new system start functioning?

MM: After the project was approved by our Executive Committee, and the funds were assigned to carry it out, we started the first stage of implementation in June 2011. In record time, by November, we were already producing the institutions’ transversal functions.

EHRLA: What aspects of the process contributed to achieving this goal?

MM: Personally, I think that it was achieved because we formed an excellent team, led by the medical director. It seems fundamental to me to understand that these projects reach further than the systems department, that we support and accompany their development but at the end of the day the tool is for the people who make up the healthcare team and they are the ones who use it. It is important to always bear in mind that the objective must be to facilitate the work to benefit the patient. Luckily everyone at the institution understood this.  

Another key factor was the work of the resident doctors, who are young and used to computer tools. They rapidly realized that their use would make their work easier as they take care of patients, optimizing their use of time and making it possible to access SIDCA from anywhere they are in the institution.

EHRLA: Did you have external help?

MM: Yes, absolutely. During the implementation process we were accompanied by Everis España, the company that developed the SIDCA solution which the Junta de Andalucía shared with us. The person who actively collaborated with the implementation and supported SIDCA, defining the parameters for the health record to follow, was Doctor Eduardo Vigil Martín. We also sought out professionals from Everis Argentina who could contribute and assume local costs and continue the evolutionary development. So we managed to build a local working team, with the support of Everis España, which spends its working day at FLENI and is collaborating with the adaption, modifications and new developments. Using the SIDCA sources we were able to develop the system according to our particularities and needs.

EHRLA: And is it now fully operational?

MM: Not at the moment, because we haven’t implemented it to its full potential. What we did was to define 11 functions, also called sheets, and prioritized the ones that are transversal to the care of in-patients or the development of the surgery. We still have to examine the issues specific to the different specialties. For example, the development of sheets for strokes, multiple sclerosis, cognitive neurology, clinical pain, etc.   

SIDCA is already integrated with FactHos via ESB, our Laboratory (Omega), Pathology Systems and our RIS/PACS (Carestream), as these are generators of information complementary to Electronic Health Records.

EHRLA: What benefits do you hope to achieve in the long term?

MM:  The most interesting part of this system is the ability to exploit information, administration and knowledge. SIDCA, as well as generating clinical documentation and electronic health records, has a Warehouse module which allows, via the codification of information with international codes such as ICD 9, the generation of a rich database for information and research. The good thing is that this product is unlimited in scope, making it possible to integrate any solution you can imagine. 

 

This story originally appeared at E-Health ReporterLatin America.

ACR launches EHR-enabled medical imaging platform

RESTON, VA – Officials at the American College of Radiology (ACR) announced Wednesday that the associations national standard for medical imaging protocols - dubbed the ACR Appropriateness Criteria (AC) - is newly accessible in an EHR-enabled Web services platform.

The technologically-enhanced platform will ensure safe, effective and appropriate use of medical imaging, as the AC will now possess the capability of integration with computerized physician ordering and electronic health record (EHR) systems, officials say.

The ACR has selected the Matthews, N.C.-based National Decision Support Company (NDSC) to provide the technical platform, support and licensing of the AC under the appellation ACR Select.

NDSC will provide EHR vendors with a direct method for healthcare organizations to easily integrate and use the AC guidelines in daily practice.

The ACR AC is a comprehensive clinical decision support database with more than 130 topics and 614 variant conditions that provide evidence-based guidance for the appropriate utilization of all medical imaging procedures. More than 300 volunteer physicians, representing over 20 radiology and non-radiology specialty organizations, participate on the ACR AC expert panels, continuously updating these guidelines, and providing real-time access, via ACR Select, to the latest medical imaging procedure guidance.

"ACR Select will have a substantial impact on the healthcare community by bridging the gap between medical providers and the ACR AC guidelines," said Paul H. Ellenbogen, MD, chair of the ACR board of chancellors. "The commitment from major EHR technology providers to integrate these standards is a testament to the importance of promoting appropriate medical imaging use."

Although Medicare imaging use has waned since 2008 and imaging continues to be the physician service experiencing the least amount of growth among privately insured Americans according to the Health Care Cost Institute, officials say opportunities still remain to ensure appropriate ordering of scans and maximize the value of these lifesaving tools. 

By integrating ACR AC with EHR technology, physicians are able to order the right imaging examination at the appropriate time. ACR officials say EHR technology platforms can improve quality, reduce unnecessary scans and lower imaging costs. 

"We are very excited about our relationship with the ACR," said Michael Mardini, CEO, NDSC. "Through ACR Select, we're able to electronically deliver ACR AC in its complete form and uphold the promise of making imaging safe, effective and accessible to those who need it."

This new partnership between the ACR and NDSC delivers on the promise of appropriate medical imaging, which experts say reduces the number of invasive surgeries, unnecessary hospital admissions, shortens length-of-stay and contributes to improved patient care. 

'Most Wired' hospitals named for 2012

CHICAGO – The 2012 installment of the "Health Care’s Most Wired" survey finds hospitals nationwide leveraging health information technology in new and envelope-pushing ways.

As they deploy IT to improve care and address inefficiencies, hospitals are also concerned with protecting patient data, optimizing patient flow and improving staff communications, according to Hospitals & Health Networks, which polled some 1,570 hospitals for the survey, conducted in partnership with McKesson, the College of Healthcare Information Management Executives (CHIME) and the American Hospital Association.

Among other key findings from the study:

93 percent of Most Wired hospitals employ intrusion detection systems to protect patient privacy and security of patient data, in comparison to 77 percent of the total respondents; 74 percent of Most Wired hospitals and 57 percent of all surveyed hospitals use automated patient flow systems;90 percent of Most Wired hospitals and 73 percent of all surveyed use performance improvement scorecards to help reduce inefficiencies;100 percent of Most Wired hospitals check drug interactions and drug allergies when medications are ordered as a major step in reducing medication errors.

“As shown by these survey results, hospitals continue to demonstrate how IT not only can be used to improve patient care and safety but it is also a means to improve efficiency,” says Rich Umbdenstock, president and CEO of the American Hospital Association.

“Equipping caregivers with the information needed to drive quality, safety and efficiency will continue to be an imperative as the challenges facing health systems grow increasingly complex,” added Pat Blake, president, McKesson Technology Solutions. “The effective use of health IT, including actionable analytics and connectivity, can be a strategic lever as hospitals and health systems work to drive better outcomes while managing capacity, reducing costs, and coordinating care across multiple settings and caregivers.”

Almost half of the Most Wired hospitals reported using social media for community outreach and crisis communication, compared to just one-third of total respondents.  More than 25 percent offer care management messages and chats with physicians.

The survey was conducted between Jan. 15 and March 15, and asked hospitals and health systems nationwide to answer questions regarding their IT initiatives. Respondents completed 662 surveys, representing 1,570 hospitals, or roughly 27 percent of all U.S. hospitals.

See the list of Most Wired winners on the next page.
 

NAACP boos for Romney only the beginning

Presidential candidate Mitt Romney appears amused during 15 seconds of booing that followed his comment that he would "eliminate every non-essential expensive program I can find ... that includes ObamaCare ..." Romney made the comment Wednesday during his speech at the NAACP National Convention.

Mitt Romney received some boos this week during his appearance before the NAACP. Boos were loudest when he spoke of his desire to repeal the Affordable Care Act (ACA). Given that the President won 94 percent of the African-American vote, it's not surprising that NAACP members don't welcome rhetorical attacks on the president's signature domestic policy achievement, especially when a Republican candidate expressly deploys the sobriquet "ObamaCare."

Still, that audience had particular reasons for concern regarding health care and health reform. Health care and health outcome disparities have long been a civil rights concern. Moreover, the politics of race and ethnicity have historically cast long shadows over health reform.

Minority communities desperately need ACA

Twenty-one percent of African-Americans are uninsured, compared with 11 percent among non-Hispanic whites. Swathes of black America from Chicago's south side to the Mississippi delta have much to gain from ACA. Expanded delivery of health services provides an important source of employment within these same communities. Twenty-seven percent of African-Americans receive Medicaid. Quite correctly, millions of African-Americans regard proposed measures such as the bloc granting of Medicaid or the House Republican budget as serious threats to programs that they themselves, or a neighbor, or a relative, rely upon every day to meet basic needs.

Arguments for "repeal and replace" raise other unfortunate resonances within the African-American community, too. Many conservative governors have announced that they will not participate in the Affordable Care Act's Medicaid expansion, and that they will not establish a state health insurance exchange.

South Carolina is one of these states. As an Obama campaign volunteer in 2007, one of my first assignments was to help test a new computerized phone system. For reasons that remain baffling, I was assigned a long list of African-American voters in rural South Carolina. I talked with many people who wanted to discuss health care. Many had low incomes, were in relatively poor health, and needed real help.

One older gentleman told me about the multiple chronic conditions both he and his wife were struggling with. He told me about their hefty medical bills. He was on board for Obama. Having grown up under Jim Crow, he couldn't quite believe an African-American was a serious candidate for the presidency. But also, with simple honesty, he asked, "If Senator Obama wins, will he help me?" The man had stacks of bills he couldn't pay.

His question was a punch in the gut, because I had some inkling of the tough fight required to bring him that help. I stammered something about how Obama ��if he were elected president � would fight every day for people like him. Inside, I worried that this man's enthusiasm would turn out to be misplaced.

Painful messages for those already hurting

When health reform passed, a promise was kept to that man and many others, Yet in all likelihood he is still waiting for real help. Indeed things have gotten worse. South Carolina has imposed or proposed punishing cuts in dental and vision care, adult day care and personal care services, hospice, even meals on wheels. Following the Supreme Court decision, Governor Haley declared that the state will not participate in expanded Medicaid coverage made possible under health reform, issuing a statement saying:

We are not going to jam more South Carolinians into a broken program, a program that stifles innovation, discourages personal responsibility, and encourages fraud, abuse and overuse of services � and that, by the way, costs us billions of dollars.

Based on the financial numbers, this makes little sense. The federal government is offering to pay roughly 95 percent of the costs. When one considers matters such as uncompensated care, South Carolina apparently saves money by embracing health reform. There is an unmistakably nasty undertone that goes beyond money to insinuations that people on Medicaid are irresponsible welfare recipients who waste public resources.

Texas Governor Rick Perry wrote an even tougher letter to HHS Secretary Sebelius:

[P] lease relay this message to the President: I oppose both the expansion of Medicaid as provided in the Patient Protection and Affordable Care Act and the creation of a so-called "state" insurance exchange, because both represent brazen intrusions into the sovereignty of our state.

I stand proudly with the growing chorus of governors who reject the PPACA power grab. Thank God and our nation's founders that we have the right to do so.

Whatever the finer points of fiscal federalism, one could hardly craft a message more alienating to African-Americans than the rejection of an African-American president's signature achievement based on a rhetoric of states' rights. Fifty years ago, governors in these same states opposed Medicare and Medicaid. They (rightly) feared that these programs would magnify the federal government's power to desegregate medical facilities. It took about seven years for southern states to fully participate in Medicaid.

Obviously, times have changed. These conservative governors are not racist supporters of Jim Crow. Still, when they reject favorable deals to operate programs of such significance to low-income minority communities, they doubly damage their party's brand in minority communities. First, they alienate surprising numbers of people who specifically need or value these services. These politicians earn wider enmity by calling to mind some ugly memories. Romney has political problems within the African-American community that have nothing to do with health reform. This is a problem, nonetheless. There were deeper reasons for the booing.

NAACP boos for Romney only the beginning

Presidential candidate Mitt Romney appears amused during 15 seconds of booing that followed his comment that he would "eliminate every non-essential expensive program I can find ... that includes ObamaCare ..." Romney made the comment Wednesday during his speech at the NAACP National Convention.

Mitt Romney received some boos this week during his appearance before the NAACP. Boos were loudest when he spoke of his desire to repeal the Affordable Care Act (ACA). Given that the President won 94 percent of the African-American vote, it's not surprising that NAACP members don't welcome rhetorical attacks on the president's signature domestic policy achievement, especially when a Republican candidate expressly deploys the sobriquet "ObamaCare."

Still, that audience had particular reasons for concern regarding health care and health reform. Health care and health outcome disparities have long been a civil rights concern. Moreover, the politics of race and ethnicity have historically cast long shadows over health reform.

Minority communities desperately need ACA

Twenty-one percent of African-Americans are uninsured, compared with 11 percent among non-Hispanic whites. Swathes of black America from Chicago's south side to the Mississippi delta have much to gain from ACA. Expanded delivery of health services provides an important source of employment within these same communities. Twenty-seven percent of African-Americans receive Medicaid. Quite correctly, millions of African-Americans regard proposed measures such as the bloc granting of Medicaid or the House Republican budget as serious threats to programs that they themselves, or a neighbor, or a relative, rely upon every day to meet basic needs.

Arguments for "repeal and replace" raise other unfortunate resonances within the African-American community, too. Many conservative governors have announced that they will not participate in the Affordable Care Act's Medicaid expansion, and that they will not establish a state health insurance exchange.

South Carolina is one of these states. As an Obama campaign volunteer in 2007, one of my first assignments was to help test a new computerized phone system. For reasons that remain baffling, I was assigned a long list of African-American voters in rural South Carolina. I talked with many people who wanted to discuss health care. Many had low incomes, were in relatively poor health, and needed real help.

One older gentleman told me about the multiple chronic conditions both he and his wife were struggling with. He told me about their hefty medical bills. He was on board for Obama. Having grown up under Jim Crow, he couldn't quite believe an African-American was a serious candidate for the presidency. But also, with simple honesty, he asked, "If Senator Obama wins, will he help me?" The man had stacks of bills he couldn't pay.

His question was a punch in the gut, because I had some inkling of the tough fight required to bring him that help. I stammered something about how Obama ��if he were elected president � would fight every day for people like him. Inside, I worried that this man's enthusiasm would turn out to be misplaced.

Painful messages for those already hurting

When health reform passed, a promise was kept to that man and many others, Yet in all likelihood he is still waiting for real help. Indeed things have gotten worse. South Carolina has imposed or proposed punishing cuts in dental and vision care, adult day care and personal care services, hospice, even meals on wheels. Following the Supreme Court decision, Governor Haley declared that the state will not participate in expanded Medicaid coverage made possible under health reform, issuing a statement saying:

We are not going to jam more South Carolinians into a broken program, a program that stifles innovation, discourages personal responsibility, and encourages fraud, abuse and overuse of services � and that, by the way, costs us billions of dollars.

Based on the financial numbers, this makes little sense. The federal government is offering to pay roughly 95 percent of the costs. When one considers matters such as uncompensated care, South Carolina apparently saves money by embracing health reform. There is an unmistakably nasty undertone that goes beyond money to insinuations that people on Medicaid are irresponsible welfare recipients who waste public resources.

Texas Governor Rick Perry wrote an even tougher letter to HHS Secretary Sebelius:

[P] lease relay this message to the President: I oppose both the expansion of Medicaid as provided in the Patient Protection and Affordable Care Act and the creation of a so-called "state" insurance exchange, because both represent brazen intrusions into the sovereignty of our state.

I stand proudly with the growing chorus of governors who reject the PPACA power grab. Thank God and our nation's founders that we have the right to do so.

Whatever the finer points of fiscal federalism, one could hardly craft a message more alienating to African-Americans than the rejection of an African-American president's signature achievement based on a rhetoric of states' rights. Fifty years ago, governors in these same states opposed Medicare and Medicaid. They (rightly) feared that these programs would magnify the federal government's power to desegregate medical facilities. It took about seven years for southern states to fully participate in Medicaid.

Obviously, times have changed. These conservative governors are not racist supporters of Jim Crow. Still, when they reject favorable deals to operate programs of such significance to low-income minority communities, they doubly damage their party's brand in minority communities. First, they alienate surprising numbers of people who specifically need or value these services. These politicians earn wider enmity by calling to mind some ugly memories. Romney has political problems within the African-American community that have nothing to do with health reform. This is a problem, nonetheless. There were deeper reasons for the booing.

Firefighters Prevail In Fight for Health Insurance

Courtesy of John Lauer/AP

Firefighter John Lauer, seen at the scene of a wildfire in Montana, led a campaign for health coverage of seasonal firefighters and their families.

It all started around a kitchen table in Custer, South Dakota. John Lauer, a 27-year-old seasonal firefighter for an elite U.S. Forest Service wildland fire team, sat down with some colleagues to write a petition.

Lauer is one of thousands of firefighters who spend their summers protecting homes, businesses and forests across the country. Lauer loves the work, but he hated seeing his talented and experienced colleagues leave because the job didn't offer health insurance.

"It's a very difficult thing to walk away from this line of work, because you simply can't afford it," he says. "You know, you can't have a family and do this. And, if you do, you're kinda rolling the dice and hoping nobody gets sick."

 

Lauer has seen two firefighters on his crew roll the dice and lose in recent years. Constance Van Kley is married to one of them. When she got pregnant five years ago, she skipped some of her prenatal care because she didn't want to rack up medical bills. But then their son was born seven weeks early. "By the time he got home, we were about $70,000 in debt," she says.

When another crew member got hit with huge bills related to his child's birth again this year, Lauer felt like he had to do something. He and some colleagues started a petition.

They posted it online and then went out to fight fires. Within a couple of months 125,000 people had signed it.

The response grabbed the attention of Rep. Diana DeGette, a Democrat from Denver. She drafted a bill that would give seasonal federal firefighters the same health insurance benefits full-timers at federal land management agencies receive. DeGette says it's pretty common for seasonal firefighters to put in a whole year's worth of work in a six-month fire season.

"Some of these firefighters have as many as 850 hours of overtime every fire season," she says. "And they have so many health risks, because they're out there on the front lines."

Just hours after the bill was introduced Tuesday, President Obama took action himself. He ordered federal agencies to start offering seasonal firefighters the same health benefits year-round federal employees get.

The president's move is "surreal," Lauer says.

"This has been an issue that's been out there so long and nothing's ever happened on it. I think a lot of folks just thought this is the way it's going to be forever. It's changing the game for them."

More than 10,000 seasonal firefighters are on the job this season. The president has not yet offered an estimate of how much it will cost to extend healthcare benefits to them.

This story is part of a partnership with NPR, Colorado Public Radio and Kaiser Health News.

Medicaid Expansion: Who's In? Who's Out?

Courtesy of the Center for American Progress

In the week since the Supreme Court upheld almost all of President Obama's health care law, some of the biggest action has been on the Medicaid front, where the administration definitely lost.

Until last week, the Affordable Care Act was expected to drive an expansion of Medicaid to the tune of about 17 million more people being covered over the next 10 years.

The Affordable Care Act, as written, would have required states to provide Medicaid coverage to adults, whether they have children or not, with incomes up to 133 percent of the federal poverty level.

Now that expansion is optional, and it's unclear how many uninsured people will ultimately gain coverage under the law.

 

Medicaid is paid for with a mix of state and federal funds. So a big expansion could get expensive for states, even though the federal government would kick in a lot of the extra dough.

"It's going to cost Florida $1.9 billion a year," Florida Republican Gov. Rick Scott said on CNBC's Squawk Box Monday. He said Florida wouldn't go along with it.

Scott's claim is too high, according to an independent analysis by Politifact, which put the cost of the additional Medicaid coverage at a little over $500 million a year. And most of those costs wouldn't pop up until 2020.

But five states, including Florida, have said they're out as of Thursday morning, according to The Daily Briefing from the Advisory Board Co.

Lots of states now offer Medicaid only to adults with children, and the income cutoff is generally much less generous, too.

The law says the feds could withhold all federal Medicaid funds from states that didn't comply. But the high court ruled that hammer was just too extreme.

A majority held:

"The threatened loss of over 10 percent of a State's overall budget is economic dragooning that leaves the States with no real option but to acquiesce in the Medicaid expansion."

So the states can skip of the expansion and only miss out on those federal funds that would have gone toward it.

The interactive chart from the Center for American Progress, embedded above with its permission, shows what's at stake. Hover over a state to see how many people could be affected.

As Julie Rovner reported last week, many low-income people who don't qualify for Medicaid now won't be eligible to for the next best alternative, a tax credit to subsidize the purchase of health insurance through a state exchanges.

Rovner is taking another look at how the Medicaid choices are unfolding. Stay tuned.

Healthcare Advocates: Time To Bury the Hatchet

Health insurance executives breathed a sigh of relief when the Supreme Court upheld their favorite part of the Affordable Care Act (the part that is one of the least popular among the rest of us)�the individual mandate. And then, I�m confident, moments after they exhaled, they were on a conference call with their army of lobbyists and PR people to approve a strategy, developed months ago, to gut the provisions that the rest of us do like. These are the parts of the law that require insurers to provide coverage to millions they have long shunned like lepers, and that make the most egregious but profitable industry practices a thing of the past, like canceling our policies when we get sick.

Part of their strategy will be a propaganda campaign to persuade us that the consumer protections in the law are not in our best interest. �The new health care reform law includes a number of provisions that will increase the cost of health care coverage,� warned America�s Health Insurance Plans (AHIP), the industry�s largest PR and lobbying group, after the ruling. The provisions in question are the ones that help finance the expansion of coverage, make premiums more affordable for older Americans and outlaw benefit plans that provide inadequate coverage. AHIP�s real concern, of course, is that such measures will negatively impact insurers� profit margins.

The strategy will also encourage the industry�s political and media allies to keep referring to �Obamacare� as a �government takeover� of healthcare. This fabrication has been widely accepted as truth�one reason the Affordable Care Act polls so poorly.

Finally, the strategy will seek to exploit the hostility many on the left feel toward the ACA�and the deep divisions among progressives over whether it really is a step in the right direction. Insurance executives are counting on single-payer progressives to stay so disillusioned with the law and those responsible for it that they will boycott the November election, helping the industry�s Republican friends to take back Washington.

I�m sure that conference call took place because I was a regular participant in many like it while serving as head of communications for Humana and, later, Cigna, two of the country�s largest insurers. Right up until the day I walked out the door in 2008, I was working with my peers at other companies on such a strategy to influence public opinion. One of the reasons I quit�and became a vocal critic of the industry I served for two decades�was that I didn�t have the stomach to be a part of yet another deception-based effort to undermine reform. During my career I helped implement the industry�s game plan to defeat the Clinton reform proposal. A few years later I helped lead a behind-the-scenes fearmongering campaign, fronted by the National Federation of Independent Business but planned and financed by the insurance industry, to make sure Congress never passed a Patient�s Bill of Rights. Congress never did (although the Affordable Care Act does contain some of those �rights�).

One of the things that differentiates insurance company executives from many healthcare reform advocates, I�ve learned, is that the former never approach any high-stakes political game without a well-planned strategy, one that seeks to take advantage of their opponents� weaknesses and divisions. It�s true that without reform advocates, President Obama wouldn�t have had a bill to sign into law. But in other battles, we in the industry found that advocates could almost never seem to craft a well-planned strategy or sustainable coalition. One reason we don�t have universal coverage in the United States today is the failure of these same advocates to recognize the need for a strategy�and the need to compromise.

Senator Ted Kennedy, who fought so hard for universal coverage, learned a tough lesson on compromise when Richard Nixon was president. Worried that Kennedy and other liberal Democrats might be able to get enough votes in Congress to pass a single-payer bill, Nixon proposed an alternative plan that would have required employers to provide health insurance to their workers. It also would have had the government finance coverage for low-income Americans who didn�t have a job. Kennedy refused to negotiate seriously, thinking he could get his own reform plan enacted the next time a Democrat�maybe even himself�occupied the White House. He condemned Nixon�s plan as a windfall for insurance companies. (Sound familiar?)

Kennedy said years later that his refusal to bargain with Nixon was the biggest regret of his career. He had underestimated the ability of the insurance industry, the American Medical Association and other entrenched special interests to join forces and forge a strategy to ensure that, even after the Democrats took back the White House in 1976 and solidified their control of both houses of Congress, single-payer legislation would go nowhere. This experience was one of the reasons he supported reform legislation nearly forty years later that he knew would fall short of achieving universal coverage and that would be condemned by many die-hard single-payer supporters as, yes, a windfall for insurance companies.

Among today�s die-hards (many of whom are good friends)are members of Physicians for a National Health Program and Healthcare-NOW! They are still furious at the president and the Democrats for their baffling decision not to give single-payer legislation a decent hearing and for compromising too early and too often, in their view, with the special interests. Many are no longer on speaking terms with the staff of Health Care for America Now, the umbrella organization for unions and advocacy organizations, which didn�t join their calls to kill the bill when the public option was stripped out. They believed, as Kennedy did years earlier, that more could be gained by starting over. Many still do and could be seen alongside the Tea Partiers on the steps of the Supreme Court, demanding the entire law be struck down.

These divisions are playing right into the hands of my former colleagues. Progressives must bury the hatchet and get down to the business of developing a strategy to move forward. The two factions actually see eye-to-eye on many things, including the fact that the law does much good but does not get us close enough to universal coverage, and that Obama and Congressional Democrats made strategic and tactical blunders throughout the reform debate. Now they must recognize that their true opponents are the people I used to work for�not one another.

FDA regulators face daunting task as health apps multiply

Want to monitor your blood pressure and sugar level? Eat healthier meals? Screen yourself for depression? Find out if you need glasses? Now you can do it all with apps on your smartphone.

In fact, there are 40,000 medical applications available for download on smartphones and tablets � and the market is still in its infancy. But that growth is in the cross hairs of new regulatory efforts from the Food and Drug Administration.

Medical apps offer the opportunity to monitor health and encourage patient wellness on a moment-to-moment basis, instead of only during the occasional visit to the doctor's office. Some even replace devices used in hospitals and doctor's offices, such as glucometers and the high-quality microscopes used by dermatologists to examine skin irregularities.

"There's a lot of enthusiasm now for the ability to use design and to use consumer technology to help improve people's health at the ground level," says Andrew Rosenthal of Massive Health, a mobile health app company in San Francisco.

But so far, the market has been unregulated; for both doctors and patients. It is difficult to know which apps actually live up to their health claims or provide accurate information.

Last year, the FDA began to lay down the law. The agency released a first draft of guidelines that require mobile apps developers making medical claims to apply for FDA approval for those applications, the same way that new medical devices must be proved safe and effective before they can be sold. But that process can be both time-consuming and expensive.

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Some app developers are bristling at the thought of a rigid regulatory structure, which they fear will stifle innovation in an industry known for rapid growth and flexibility.

"The FDA's current regulatory process was created when the floppy disk was around" � ancient history in the tech world, warns Joel White, executive director of the Health IT Now Coalition, which includes the computer chip maker Intel, pharmacy benefits manager Medco, Verizon, Aetna and the U.S. Chamber of Commerce.

According to the Government Accountability Office, the FDA takes about six months to approve a medical device that is similar to an existing product and 20 months to approve a brand new device. That's simply too slow, White says.

Top Paid Medical Apps for iPhones (from the iTunes store)

1. Pill Identifier ($0.99)

Developer: Drugs.com

Pill Identifier allows you to identify more than 10,000 different over-the-counter and prescription pills based on their appearance. Search by imprint, size, shape or color.

2. Pregnancy ++ ($2.99)

Developer: Health & Parenting Ltd.

Pregnancy ++ tracks the course of your pregnancy, including your weight, diet and exercise. It also includes HD fetal pictures, a kick counter and a contraction counter.

3. Baby Connect (Activity Logger) ($4.99)

Developer: Seacloud Software

Baby Connect tracks your baby�s everyday activities (including feeding, sleep, growth, health and vaccines) and creates graphical reports and trending charts. The information can be shared between parents, nannies and other child care providers.

4. Instant ECG: An Electrocardiogram Rhythms Interpretation Guide ($0.99)

Developer: iAnesthesia LLC

Instant ECG is an app for health care professionals, which teaches the basics of reading electrocardiograms (ECG). The app offers video demonstrations of 30 different arrhythmias to teach and then test a provider�s ability to diagnose irregularities.

5. MedCalc (medical calculator) ($0.99)

Developer: Mathias Tschopp and Pascal Pfiffner

MedCalc gives health care professionals access to more than 200 different diagnostic formulas, scores, scales and classifications that help measure a person�s health.

6. Pill Reminder by Drugs.com ($0.99)

Developer: Drugs.com

The Pill Reminder App keeps track of all of your medications, vitamins and supplements. Set up reminders to take your meds or refill a prescription, and check for drug interactions, dosage information and possible side effects.

7. Anatomy 3D: Organs ($1.99)

Developer: Real Bodywork

Anatomy 3D: Organs teaches users about structure and function of internal organs using 3D models, videos, audio lectures, diagrams, quizzes and a glossary.

8. Diagnosaurus DDx ($1.99)

Developer: Unbound Medicine, Inc.

Diagnosaurus DDX helps health care providers accurately diagnose patients quickly at the bedside. Providers can search over 1,000 differential diagnoses by organ system, symptom and disease, and use a special feature to consider alternative diagnoses when multiple conditions are possible.

9. Everyday First Aid ($0.99)

Developer: Portable Monster LLC

Everyday First Aid offers users information on how to handle an emergency. The medical information is based on guidelines from the American Red Cross and other health organization, and tells you how to handle situations including choking, wound cleaning, jellyfish stings, tick bites and heart attacks with illustrated training guides.

10. Drugs & Bugs ($5.99)

Developer: Haymarket Media

Drugs & Bugs is an app for medical students and health care professionals who care for patients with infectious diseases. It provides information on more than 100 antibiotics and nearly 200 bacterial pathogens, and allows providers to compare the effectiveness of various drugs.

"We're seeing mobile apps updated and created on a daily basis," he adds. "The life cycle is dramatically different."

It's also expensive: The cost of getting FDA approval for a standard medical device is about $24 million to $75 million, according to a Stanford University report.

The health app market currently is worth about $718 million and is expected to double by the end of the year, according to Research2Guidance, a global mobile research group.

Alain Labrique, who directs a global initiativeat Johns Hopkins University dedicated to mobile health technology, says that although the FDA guidelines could delay some tech development, they are an important consumer safeguard.

Labrique argues that many apps are "a lot of hype and very little evidence." While apps offer an exciting new opportunity in health care, "We also want to protect the public and be sure that medical claims are supported by data assessment and some comparison to a gold standard."

In particular, he warns that commercial interests and "the tendency to capitalize on the next big things" may lead app developers to overstate what their products can accomplish. "Making sure the public's best interests are met is not always the most expedient process."

The FDA expects to release final guidelines on mobile health apps this year, but some app developers aren't waiting. Many companies have started the formal application process, and the FDA has already approved a handful of apps.

White says that many app developers are not opposed to regulation, but they believe that the FDA process doesn't fit the industry. He suggested that the government set up a new regulatory framework for mobile health � something like the National Transportation Safety Board� to accommodate the speed, flexibility and innovation of this new marketplace.

Orrin Franko, 29, is part of a new breed of doctor-innovators in the mobile health industry. He's an orthopedic surgery resident at the University of California San Diego and runs a website called TopOrthoApps.com, where he reviews orthopedic apps for doctors and patients. He is also developing several of his own.

Recently, he invented a plastic attachment that works with an app that allows iPhones to measure the curve of the spine to test for scoliosis. It mimics a medical device called a Scioliometer, which is used in nearly every hospital across the country. The Scoliometer costs about $100 and was cleared by the FDA in 1983; the iPhone app costs 99 cents and Franko says his plastic attachment could be sold for about $10.

But he also knows that his device will have to be approved by the FDA, requiring a significant capital investment. He's planning to apply, he says, but with so many new apps coming on the market "there's no way the FDA is going to keep up."

Instead, he predicts, app developers with products that are not strictly medical, such as a healthy eating app, may avoid making medical claims in their marketing in order to skip the FDA process and will rely on good user reviews instead to generate publicity.

While the FDA sorts the process out with developers, Franko isn't wasting any time. In January, he helped launch the peer-reviewed Journal of Mobile Technology in Medicine to help doctors make sense of the bonanza of medical apps.

Franko's goal is to make sure doctors and patients know what they're getting as quickly as possible. "These apps already exist," he says, "and people are using them in hospitals to make medical decisions, but no one knows if they're actually doing what they claim to be doing."

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Health coverage for ex-prisoners: a quiet but important benefit of health reform

"If I'm trying to sell health reform, the smiling waitress with two kids, the laid-off steel worker, and the 7th grader with cancer work better on the campaign posters. Yet for many reasons � some obvious, some not � the health and well-being of ex-prisoners has a disproportionate impact on us all." - Harold Pollack

I began my public health career on a Yale postdoctoral fellowship. One of my formative experiences there was to accompany colleagues on the Community Health Care Van, a needle exchange-based mobile clinic for street drug users. I helped people complete basic paperwork.

A weathered middle-aged guy stepped onto the van. When I asked what brought him there, he pulled back his shirt to reveal a chalky-white oozing crater in his shoulder. That festering infection was my rude introduction to the life realities of injection drug users.

Most of these women and men suffered greatly. Most were uninsured. Facing complex illnesses, addiction, and severe life challenges, many nonetheless consumed enormous health system resources as they cycled through correctional facilities, became emergency department frequent-fliers, and required heavy use of other safety-net services.

We demonstrated that Community Health Care Van services reduced patients' emergency department use. We could have done more for these patients and their loved ones if we could have provided reliable primary care, appropriate drug treatment, and other services requiring insurance coverage.

This won't matter politically, but the Affordable Care Act will quietly improve public health by expanding coverage for hundreds of thousands of ex-prisoners and others under the control of the criminal justice system. Most of these men and women are on parole or probation. A nice Health Affairs paper by Alison Evans Cuellar and Jehanzeb Cheema runs the numbers. Roughly half of the 700,000 people released every year from correctional institutions will gain coverage or improved care under health reform.

Why we should care about ex-cons

Yeah I know. Ex-prisoners aren't the most cute and cuddly people who need insurance coverage. If I'm trying to sell health reform, the smiling waitress with two kids, the laid-off steel worker, and the 7th grader with cancer work better on the campaign posters. Yet for many reasons � some obvious, some not � the health and well-being of ex-prisoners has a disproportionate impact on us all.

For one thing, a large percentage of Americans with HIV/AIDS, tuberculosis, hepatitis C, and other infectious diseases pass through the gates of our jails and prisons every year. Engaging these men and women into care � and keeping them safe and healthy � yields huge public health benefits.

Many ex-prisoners suffer from severe mental illness. As states and localities implement punishing cuts to the medical safety net, frightening numbers of people have limited access to appropriate care, sometimes with tragic results.

There's suggestive evidence that ex-prisoners with health insurance may be less likely to continue prior drug use. They are also less likely to re-offend. Many ex-prisoners have serious drug problems. Absent insurance coverage, many find themselves on long waiting lists for treatment programs. Many women with drug problems require access to reproductive health services to avoid unintended pregnancies.

Nowhere to turn

Right now, many ex-offenders are ineligible for public insurance coverage. The panhandler at the train station with a heroin problem is simply poor. He isn't a vet. He isn't a mom. Addiction and substance abuse are not qualifying conditions for federal disability programs. If he has a history of violent or drug felonies, he may be barred from important aid programs. If he was enrolled in Medicaid prior to incarceration, he might well have been automatically disenrolled upon entry to jail or prison.

The Affordable Care Act improves this situation. Most important, poor people qualify for Medicaid even if they don't match the specific categories of various assistance programs. If your income falls below 133 percent of the federal poverty line, you are eligible. This is a boon for poor people. It is also a boon for mental health and drug treatment centers, and other safety-net providers. These facilities now have a reliable source of payment for their indigent patients. Many ex-prisoners will also benefit from affordability credits and protections provided under the new state health insurance exchanges.

Much practical work remains to be done. Many prisoners serve their time in relative health. They then disappear until they get rearrested or face some crisis that requires costly care. Many offenders lead chaotic lives. Some are homeless or have no fixed address. They aren't always fastidious if they are asked to return three times to the welfare office with different forms. Enrollment and retention procedures for both Medicaid and for the new exchanges must be carefully designed in light of these realities, to ensure that ex-prisoners are actually covered.

I'll bet less than one percent of the American public has thought about this difficult � often thankless � activity on behalf of an easily despised population. It's still important to protect public health and to relieve suffering. It's another reason to support health care reform.

Homeland Security zeroes in on medical device vulnerabilities

WASHINGTON – Even as they promise better health and easier care delivery, wireless medical devices (MDs) carry significant security risks. And the situation is only getting trickier as more and more devices come with commercial operating systems that are both Internet-connected and susceptible to attack.

That’s according to a bulletin circulated by the U.S. Department of Homeland Security (DHS) this week, which explains that part of the problem is that the FDA cannot regulate who uses medical devices or how they are used – including, most notably, how they're connected to networks.

Devices include implantable medical devices, external medical devices, portable computers such as iPads, tablets, and smartphones – all of which are creating what DHS referred to as an “expanding attack surface.”

[See also: Breaches epidemic despite efforts at compliance, says Kroll.]

“Instant connectivity of these devices to the Internet or a Health Information System (HIS) that could be compromised if not protected with the latest anti-virus and spyware,” the DHS bulletin explained. “MDs like smartphones and tablets are mini-computers with instant access to the Internet or linked directly to a hospital’s network. The device or the network could be infected with malware designed to steal medical information.”

To that end, DHS breaks out five main points of entry for wireless mobile devices:

Insider: The most common ways employees steal data involved network transfer, be that email, remote access, or file transfer.Malware: These include keystroke loggers and Trojans, tailored to harvest easily accessible data once inside the network.Spearphishing: This highly-customized technique involves an email-based attack carrying malicious attack disguised as coming from a legitimate source, and seeking specific information.Web: DHS lists silent redirection, obfuscated Javascript and search engine optimization poisoning among ways to penetrate a network then, ultimately, access an organization’s data.Lost equipment: A significant problem because it happens so frequently, even a smartphone in the wrong hands can be a gateway into a health entity’s network and records. And the more that patient information is stored electronically, the greater the number of people potentially affected when equipment is lost or stolen.

[See also: The Challenge of Encrypting BYOD Devices.]

DHS described a presentation at last year’s Black Hat conference in which a security researcher, himself diabetic, demonstrated how to disrupt and jam an implanted insulin pump without the user being any the wiser. What’s more, some medical devices contain personal information that could be stolen and sold for illegal uses – as do electronic medical records when stored on unencrypted devices.

In the bulletin, DHS holds up the Department of Veterans Affairs as an example of how to mitigate wireless MD risk – one that federal agencies as well as private health entities could learn from.The VA, of course, has been blazing a mobile devices trail.

After more than 180 cyber attacks on VA MDs, the agency isolated such devices from its main network by creating a Virtual Local Area Network (VLAN) replete with access control lists that enable only authorized users to access the main network, thereby protecting clinical data because those same devices are effectively disconnected from other areas of VA’s network.

“Healthcare and Public Health Sector IT Administrators need to address the gap between security and mobile device use,” wrote DHS officials. “Areas of concern include unmanaged mobile device access, authentication of users requesting access to a hospital’s web server, how to secure mobile devices with health information, unsecured wireless connectivity or cellular networks and protection against unauthorized breach of lost and/or stolen devices."

6 reasons today's health IT systems don't integrate well

Although the healthcare community has been clamoring for integration of its IT systems for decades, the industry is still in a rather elementary stage when it comes to useful and practical systems integration, according to Shahid Shah, software analyst and author of the blog The Healthcare IT Guy.

"Our problem in the industry is not that engineers don’t know how to create the right technology solutions or that somehow we have a big governance problem," he said. "[Although] those are certainly issues in certain settings, the real cross-industry issue is much bigger – our approach to integration is decades old [and] opaque, and [it] rewards closed systems."

Shah outlines six reasons today's health IT systems don't integrate well.

1. They don’t support shared identities. These shared identities include single sign-on (SSO) and industry-neutral authentication and authorization, said Shah. "Most health IT systems create their own custom logins and identities for its users, including roles, permissions, access controls, etc., stored in an opaque part of their own proprietary database," he said, adding that ONC should mandate all future EHRs use "industry-neutral" and well-supported identity management technologies, so each system has, at least, the ability to share identities. "Without identity sharing and exchange, there can be no easy and secure application capabilities, no matter how good the formats are," he said.

2. They're too focused on "structured data integration." Instead, said Shah, systems should be focused on practical app integration in the early phases of a project. "In the early days of data collection and dissemination, it's not important to share structured data at detailed, machine-computable levels first, [but it's more] important that different applications have immediate access to portions of data they don't already manage." Once app integration is in good shape, he continued, then it's time to focus on structured data integration, and all the governance and analytics associated with it. "When we do structured data integration too early, we often waste time because we don't understand the use cases well enough, so we can't iterate to best-case solutions," he said. "We're driven to worst-case implementations."

[See also: 5 technologies every hospital should be using.]

3. They're more "push" data-focused versus "pull" data-focused. "A common question we ask at the beginning of every integration project is, 'What data can you send me?'" said Shah. "This is called the 'push' model, where the system that contains the data is responsible for sending to all those that are interested." Future EHRs need to implement syndicated ATOM-like feeds, which could contain HL7 or other formats, for all their data, so they can share and allow anyone who wants it to "subscribe" to the data, continued Shah.  In turn, this is known as the "pull" model, or when data holders simply allow secure, authenticated subscriptions to their data without worrying about direct coupling with other apps. "If our future EHRs became completely decoupled secure publishers and subscribers of the data, many of our integration problems would go away like they did for others using modern Internet approaches," said Shah. 

4. They're more focused on "heavyweight, industry-specific formats" instead of "lightweight, or micro formats." According to Shah, appointment scheduling in the "health IT ecosystem" is a major source of "health IT integration pain," he said. "If EHRs just used industry standard iCal/ICS publishing and subscribing, we could solve 80 percent of appointment schedule integration instantly." Shah continued and said to think about how an iPad can sync with an Outlook/Exchange server at work. "It's not magic – it's a basic, industry-neutral and appropriately securable standard, widely used and widely supported." Another example, he said, is the use of HL7 ADTs for patient profile exchanges, instead of more common and better-support standard like SAML. "If you've ever used your Google account/profile to log into another app on another website, you're using SAML," said Shah. "Again, no magic – it works millions of time a day with 'good enough' security and user-controlled privacy."

5. Data emitted are not tagged using semantic markup, so they're not shareable by default. "Even when we do have full data governance, we do our structured data integration and then we present information on the screen," said Shah. "We don't tag data with proper semantic markup, when it's basically free to do." Future EHRs, he continued, should generate Resource Description Framework-in-attributes (RDFa), using industry neutral schemas for common information, such as personal data. "Using RDFa as a start, EHRs can then start publishing full RDF in the future, so it's easier to discover where certain kinds of meta data can be found, without requiring massive registries and other old-style opaque techniques," he said. "None of this is technically challenging, insecure, or difficult to implement, if we really care about integration and are not just giving it lip service." 

[See also: 5 stages of EHR maturity and patient collaboration.]

6. They don't produce common output in a security- and integration-friendly way. Shah said future EHRs should start to use industry-neutral CSS frameworks, such as Twitter's Bootstrap, which is both free and open source. "When using Javascript, EHRs should use common, lightweight, and integration-friendly libraries, like jQuery, and not Javascript frameworks that take over the app and view port, and prevent easy discovery and integration." When you omit Javescript Object Notation (JSON) from your APIs, Shah continued, offer both JSON and JSONP, so secure integration can occur more easily. "All of these techniques … are commonly accepted, secure Web practices and need to make their way into our EHRs," he said. 

Healthcare for My Neighbors?

Our medical and medical insurance ethos sadly is that sick people are good for business. That health care should be a money making machine is the mentality of a nation tricked into believing for-profit health care and medical insurance are superior to national health care as practiced in every other industrialized nation. In contrast the ethos of national healthcare is to keep people healthy in order to save buckets of money. It works. Every nation with national health care delivers health care for all at a fraction of the cost Americans pay. The incentives of public health care are opposite to those of a for-profit system.

I am a WWII veteran. My response to conservatives who are certain government can�t do anything right is that I am grateful for VA health care and for Medicare, both run by �the government� and paid for in the same way we pay for public education and the fire department, i.e., through public taxation.

�In the box� thinking places profit over the health of the nation. It prevents Americans from having full medical insurance from day one. Unlike citizens of every other industrialized nation, Americans must wait until old age to get 80% rather than total coverage as in other nations.

We are the only industrialized nation in the world in which parents are forced to advertise in the local newspaper that an account has been set up at a local bank to accept donations to pay for treatment of a child with life threatening cancer. No Canadian, French, or English parent would need to �pass the hat� or to ask for charity in order to save the life of a child. In other nations it is never �charity�, but �healthcare with dignity.�

We are the only nation where private insurance companies can restrict services to a particular state forcing clients to travel thousands of miles for treatment, or dictate where a client can get a blood transfusion, or deny payment for a bone marrow donor search.

�Why should I pay for the health care of my neighbors?� is the outraged cry of conservatives. With national healthcare the answers are: (1) My neighbors pay for mine. (2) It is the ethical thing to do. (3) costs are half or less than half of what we pay now and would cover everyone.

Every other advanced nation pays a fraction of what the U.S. does. Canadians pay $3,000 per capita to cover everyone while the U.S. pays $7,000 per capita and leaves out 47 million plus an equal number of at risk underinsured souls. European nations pay a third of what we do with better outcomes.

A National health care system would make us feel good about ourselves. At last we could say with pride to the world, �We are willing to pay for the healthcare of our neighbors just like everyone else.�

Live in Oklahoma and want to get involved? Ron du Bois is one of the founders of Oklahomans for Universal Health Care and the convener of Stillwater Speaks Health Care Committee. Please contact Ron at (405) 377-2524 or duboisr@sbcglobal.net for more information.

More Americans Are Checking Prices Before Getting Health Care

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How much will that cost, doc?

Do you shop around for the best price on a visit to the doctor, a CT scan or surgery at a hospital? If so, it looks like you've got a little more company.

In the latest NPR-Thomson Reuters Health Poll we asked people across the country whether they size up the prices for care before making decisions. And, if so, how they do it. We put the same questions to more than 3,000 people back in September 2010, and we were curious to see how much had changed.

Right off the bat, we wanted to find out the proportion of households that included someone who had received health care services in the past year. About 81 percent of the households we asked in April had, virtually the same as the 80 percent we found in 2010.

Among the recent health care consumers, 16 percent said they'd looked for prices beforehand, compared with 11 percent who'd answered that way in the previous poll.

 

OK, so where do they turn for price info? The most common source is a doctor's office, cited by 50 percent of those households that had checked recently on prices. But, that was down 10 percentage points from 2010.

The second-most-popular source was insurance companies at about 49 percent. And insurers were big gainers since 2010, when only about 26 percent of the price checkers consulted them.

Most commonly, people got the information in person � at about 53 percent. That's up a bit from 2010, when it ran 47 percent. As a shopping tool, the telephone dropped in popularity to 48 percent from 61 percent in 2010. Email and the Internet zoomed to 45 percent from 22 percent.

A solid majority of people who sought information found what they were looking for. Most said it was accurate, though the overall proportion on that score dropped to 86 percent from 98 percent in 2010.

A little less than two-thirds said the information influenced their health care decision this time around. "In every age group, regardless of income, more than half of the respondents said that it influenced their choice of provider," says Dr. Ray Fabius, chief medical officer for Thomson Reuters' health unit. "To me, that's the biggest revelation."

Changes in insurance may be spurring interest in the prices charged for health services. There's been a big increase in high-deductible insurance plans paired with health savings accounts. That kind of coverage gives people a strong incentive to shop around, Fabius notes.

Still, how much pricing information will alter consumers choices more broadly is far from clear. "Even if we assume for argument's sake perfect price transparency, we still have the problem that most health care demand is price inelastic," Richard Evans, a health care analyst at Sector & Sovereign Research, said in an email after reviewing the results of the poll.

"I think much of the reason is that the majority of health care spending comes from a minority of persons, and because each of these persons has very large spending amounts in excess of their deductibles," he wrote. "By extension, a great majority of total spending is by or on behalf of persons who are in effect spending someone else's money � and this remains true even if we move to quite large deductibles."

The nationwide telephone poll of 3,008 adults was conducted during the first half of April. The margin for error is plus or minus 1.8 percentage points. Click here to read the questions and complete results. You can find the previous polls here, or by clicking on the NPR-Thomson Reuters Health Poll tag below.

Hearing loss technology wins global mHealth competition

CAPE TOWN, South Africa – Massachusetts Institute of Technology (MIT), in partnership with Brazil’s Federal University of Rio Grande Do Norte, won the Mobile Health University Challenge with software that screens for hearing impairment.

With an estimated 588 million people worldwide and 5.7 million Brazilians afflicted by some level of hearing loss, the technology – dubbed the Sana AudioPulse – aims to make testing easier for hearing-impaired populations in rural and poverty-stricken areas that may not have access to medical care. Laws in Brazil mandate that newborns be screened for hearing loss; however, the implementation process has been stymied by funding limitations and shortages of staff and proper equipment. This AudioPulse technology could help overcome these obstacles. 

As the winning team, MIT and the Federal University of Rio Grande Do Norte will be offered mentoring towards the future development of their innovation and the opportunity to exhibit at key industry events such as the GSMA's Connected Living Latin America Summit, which is being held in Brazil in June 2012.

The competition, held at the GSMA-mHealth Alliance Mobile Health Summit in Cape Town, asked university students worldwide to develop a mobile health concept that would address a specific healthcare need. From the initial group of entrants, the top 13 teams were invited to attend this week's finals at the GSMA-mHealth Alliance Mobile Health Summit to present their ideas to a judging panel comprised of venture capitalists and major players in the mobile and health industries. From these 13 teams, four were chosen to present to the judging panel in a final round, and from the final four, one overall winner was selected.

Besides MIT and Federal University of Rio Grande Do Norte, the finalists were:

Jordan University of Science and Technology (Jordan) - Snore Detector, a smartphone application used for detecting and monitoring Obstructive Sleep Apnea Syndrome (OSAS). UC Berkeley (US) – LifeCheck, a digital checklist technology for hospitals aimed at reducing redundancy and hospital errors.  University of Oxford (UK) – BabeeMon, a baby monitoring technology, specifically for preterm infants, that detects respiration, blood oxygen saturation and heart rhythm.

"The teams were challenged and encouraged to use their originality and creativity to create a compelling and viable mHealth solution, and we commend the enthusiasm and commitment shown by all those who took part in our inaugural competition," said Jeanine Vos, Executive Director, mHealth at the GSMA. "Our congratulations to the winning team, MIT and the Federal University of Rio Grande Do Norte and our thanks to all those who participated."

In this week’s Health Wonk Review:

The June 22 edition of Health Wonk Review is posted now at Managed Care Matters, and�features columns from healthinsurance.org bloggers Maggie Mahar, Harold Pollack, and Henry J. Aaron.

They discuss the pending Supreme Court decision on the constitutionality of the Affordable Care Act and its individual mandate, the 2012 elections and what both will mean to the health reform law.

Health Wonk Review is a biweekly compendium of the best of the health policy blogs. More than two dozen health policy, infrastructure, insurance, technology, and managed care bloggers participate by contributing their best recent blog postings to a roving digest, with each issue hosted at a different participant's blog.

Catholic Groups Sue Obama Administration Over Birth Control Rule

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In a compromise, President Obama proposed to allow religious universities and charities offer birth control coverage through their own health insurers.

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In a compromise, President Obama proposed to allow religious universities and charities offer birth control coverage through their own health insurers.

So much for compromise.

A total of 43 Catholic educational, charitable and other entities filed a dozen lawsuits in federal court around the nation Monday, charging that the Obama Administration's rule requiring coverage of birth control in most health insurance plans violates their religious freedom.

Among the plaintiffs in the suits are the University of Notre Dame and the Catholic University of America, as well as the Archdioceses of New York, Washington, Dallas, St. Louis and Pittsburgh.

They join several other, mostly smaller entities that have sued over the requirements for no-cost coverage of regular birth control, sterilization and so-called morning after emergency contraceptives. Because one of the ways those drugs may work is by preventing the implantation of a fertilized egg into a woman's uterus, Catholics believe they can cause a very early abortion, even though they are classified by the Food and Drug Administration as contraceptives.

 

President Obama tried to defuse the controversy over the requirement back in February, after religious groups complained that the exemption from the requirement, which applied effectively only to actual houses of worship and groups that employ only members of a specific faith, was too narrow.

The president's proposal was not to expand the exemption, but to allow religious universities and charities to have their health insurers offer the coverage instead.

"The result will be that religious organizations won't have to pay for these services, and no religious institution will have to provide these services directly," Obama said. "But women who work at these institutions will have access to free contraceptive services, just like other women, and they'll no longer have to pay hundreds of dollars a year that could go towards paying the rent or buying groceries."

The president's Catholic allies were pleased, as were some of those who had been complaining. Even the president of Notre Dame, Father John Jenkins, called the announcement "a welcome step toward recognizing the freedom of religious institutions to abide by the principles that define their respective missions."

But over time, discussions over how to make it work appear to have broken down.

Even taking the actual benefits out of the hands of the religious organization "does not solve our moral dilemma," said Catholic University President John Garvey in a statement. Garvey noted that, "The only change the 'accommodation' offers is that the insurance company, rather than the University, would notify subscribers that the policy covers the mandated services." But the students and employees would still have to pay for "objectionable" prescriptions and services.

The Obama Administration declined comment on the suits, citing a policy of silence with regard to ongoing litigation.

But Cecile Richards, president of Planned Parenthood, which is among the groups most strongly backing the requirement for contraceptive coverage, said, "It is unbelievable that in the year 2012 we have to fight for access to birth control."