mardi 30 juin 2015

Mass. AG Shifts Health Care Costs Conversation To Behavioral Health

Mass. AG Shifts Health Care Costs Conversation To Behavioral Health

If you or someone you are close to has ever tried to get more than a doctor’s appointment for deep depression, alcoholism or a drug addiction, you already know that figuring out where to get care and who will help cover the cost is messy.

Now that struggle is spelled out in the first health care costs trends report from Attorney General Maura Healey. It takes stock of behavioral health benefits and the low health insurance pay rate for these services in Massachusetts. Healey is shifting the focus of her office’s health care cost report after several, under former Attorney General Martha Coakley, that highlighted the wide gaps between payments made to high and low cost hospitals.

Attorney General Maura Healey speaks during a press conference at the State House in June. (Jesse Costa/WBUR)

Attorney General Maura Healey speaks during a press conference at the State House in June. (Jesse Costa/WBUR)

Healey says she’s changing gears because “it’s really important to look at the whole health of the patient.”

“We need to get to a place where we treat people who’ve got mental health, substance abuse issues in the same way we treat patients with diabetes or with cancer or with broken bones,” Healey says.

Seventy-nine percent of Massachusetts residents enrolled in MassHealth or ConnectorCare have coverage that separates general medical care from mental health and substance abuse. For members of commercial health plans that number is much lower but still significant: 31 percent.  Healey’s report does not say that the separation is necessarily bad, but that the state needs a better system of sharing patient information between medical and behavioral health providers, and more coordination of care.

That call, for better coordination of care, is not new. The problem is supposed to be getting better with the shift to global payments. If you have diabetes and you aren’t taking care of yourself because you are depressed, under global payments both your counselor and your primary care doctor will lose money if they don’t help relieve your depression.

But some global payments separate physical and behavioral health, eliminating the incentive for doctors from those separate worlds to work together. The AG’s report says the state needs “meaningful financial incentives” that will encourage insurers, hospitals, physicians and nurses to “integrate the delivery of medical and behavioral services.”

But Health and Human Services Secretary Marylou Sudders says the state needs to prioritize fixing the payment gaps between high and low cost hospitals.

“We have to continue to ensure that we have equity of behavioral health with physical health care before we get to global payments,” Sudders says.

But thousands of doctors and nurses have already moved into this payment system. Can the state make adjustments now?

“We have pockets of global payments,” Sudders says, “but we’re still very much paying behavioral health on fee-for-service structures, so we still have a ways to go.”

The AG’s report reinforces the need to address another long-standing problem: many doctors and hospitals lose money on behavioral health care. The report says hospitals that admit patients for mental health or substance abuse treatment lost 28 cents for every dollar spent on those services between 2010 and 2013. The loss for outpatient care was 45 cents on the dollar.

Staff in the AG’s office said they tried to get more information about who is paid what for behavioral health care in the state, but that it was difficult because providers have different names for the same services and payers don’t use a standards methods.

In the meantime, the report says patients are suffering. Healey highlights the opioid epidemic and points out that “behavioral health is the top primary diagnostic category for most age groups 44 and under” at Massachusetts acute care hospitals. Not treating addiction or depression is expensive. The report finds patients who have asthma and anxiety, or some other combination of a medical and behavioral health problem, spend between two and two-and-a-half times more on health care than do patients with just a medical condition.

The Massachusetts Association of Health Plans says it shares the AG’s concerns about making sure patients can get mental health services. MAHP points out that its plans receive good ratings and follow national guidelines for care.

“We look forward to working with the Attorney General on measures to improve care coordination of behavioral health services, while also being mindful of our collective goal of containing costs as established under the state’s 2012 Payment Reform Law,” Lora Pellegrini, MAHP president and CEO, said in a statement.

Study: Jolt Of Java Before Exercise Makes Legs Stronger But Not Arms

Study: Jolt Of Java Before Exercise Makes Legs Stronger But Not Arms

(Wikimedia Commons)

(Wikimedia Commons)

By Marina Renton
CommonHealth intern

Wondering whether you should forgo your Starbucks run in favor of a cross-country run before work? According to a study just out in the June issue of the journal Medicine & Science in Sports & Exercise, no need to skip your morning cup (or two) of coffee in favor of a trip to the gym. In fact, the caffeine could enhance your performance — particularly your legwork.

The study is titled “Caffeine’s Ergogenic Effects on Cycling: Neuromuscular and Perceptual Factors.” (Vocabulary note: “Ergogenic” means “enhancing physical performance.”) It consisted of two experiments in which young adults consumed caffeine — equivalent to between two and three cups of coffee — and then cycled using their legs and arms.

The researchers found that caffeine improved leg muscle performance but not arm muscle performance, and it decreased sensations of pain and perceived effort in both legs and arms when the exercise was at a moderate intensity level.

The takeaway? Barring any special circumstances — like being adversely affected by caffeine or having heart trouble — you needn’t hesitate to caffeinate before you exercise.

I spoke with Christopher Black, assistant professor of Health and Exercise Science at the University of Oklahoma and lead author of the study. Our conversation, lightly edited:

Could you summarize the study’s results?

There are multiple parts to the study but, in general, here’s what we found: Consumption of a 5-milligram-per-kilogram body weight dose of caffeine — which is the equivalent of maybe two to three cups of coffee depending upon how much you weigh and what kind of coffee it is — improves cycling performance if you ride the bike with your legs. But, that same dose does not improve cycling performance if you ride the bike with your arms. And that’s the big, real-world performance measure of things.

We ascribe that difference of effect to the fact that caffeine improved people’s strength in their legs but not in their arms. And it improved that strength by allowing them to turn on more of their muscle.

In what form were people given the caffeine?

It’s powdered caffeine; we mixed it up into little tablets, and they swallowed it with some water.

Is it possible to suggest that people drink caffeine before exercising?

Absolutely, they should drink caffeine. They should take caffeine in any possible form before exercising. There are 20 or 30 or 40 studies that have demonstrated a very similar thing to what we found in the legs. For endurance-type performance, caffeine is absolutely going to improve your performance.

Are there any caveats? For example, an excess of caffeine makes some people jittery, so could that wind up inhibiting muscle performance?

I don’t know that we have a lot of scientific data supporting the fact that it can in some people actually decrease performance. But, there is scientific data that in certain people, let’s say you’re a high-anxiety person, consuming large amounts of caffeine may exacerbate your anxiety. And it may make you more jittery.

There does seem to be — and this is, again, somewhat anecdotally — kind of a tipping point where, if the dose gets to be too high, you can’t concentrate and you’re fidgety. So it’s plausible to me that, at some high levels, caffeine could actually make performance worse. But, in these typically-tested doses, as long as you don’t have some sort of adverse reaction to the caffeine — which could be jittery, potentially in some people it might upset their stomach, although there’s really very limited data that suggests that’s going to be the case.

Then there are potentially some people that caffeine just does not affect. There are some people that we would term to be non-responders. It doesn’t really matter how much they have, they just do not exhibit the typical response.

And if people are not responsive to caffeine, would they not experience the improved exercise performance?

That’s a tricky needle to thread as a scientist. I’m unaware that there are data that support that conclusion, but that again seems very plausible to me.

Is there a risk for people with certain heart conditions because of the combined increased heart rate from exertion and caffeine consumption?

The general response is: not necessarily. I don’t know that caffeine plus exercise is necessarily riskier than exercise all by itself from that standpoint. Now that would be with the great caveat of: If you’re an at-risk population, then you should get physician’s clearance. I am unaware of any studies that have been done to say that caffeine makes exercising more dangerous, although exercise is inherently dangerous, especially if you’re a cardiac person.

We do tend to see a bit of an exaggerated heart rate response during exercise for the people that consumed caffeine. Heart rate is up a little bit, so there is theoretically greater stress being placed on the heart. So that could potentially be somewhat more dangerous.

It seems kind of counterintuitive, but there is some data suggesting that, if you have a cup of coffee and you sit and you rest, caffeine actually lowers heart rate. You would think, caffeine is a stimulant, so it should make my heart rate go up. And there are several studies that find that is actually not true.

What made you interested in embarking on this study?

It was well-known in our field that caffeine improves exercise performance. One of the questions that was out there, though, was: Why? How does it work? By doing arm and leg exercise, we thought that this would be a unique way to try and manipulate the effects of caffeine on muscular strength and the activation of those muscles.

Study participants also experienced less pain and less perceived effort, right?

If the exercise is done in a certain way, then they did actually experience less perceived exertion and less muscle pain. And again, that’s also a finding that is similar to several previous studies. But it only works that way in very controlled circumstances.

We prescribed an intensity of exercise to our folks; they rode either with their arms or their legs for 30 minutes. When we asked them to do that at about 60% of their maximal ability — that’s fairly similar to what a lot of people would train at, that’s kind of a jog to a somewhat brisk jog to a lot of people — it did reduce pain, and it did reduce perception of effort. When we increased that to a heavier exercise intensity, then it didn’t lower perception of effort, and it did not lower pain levels.

Is there anything else about the study you would like to share?

Caffeine does seem to improve muscle performance, and the reduced sensations of pain and effort are also potentially very useful for a general population.

If you have a cup of coffee or something before you go to your exercise bout, then you are likely to feel a little bit better during that particular exercise bout. A lot of people have probably anecdotally experienced that, especially if you tend to be a coffee drinker or someone who consumes a lot of caffeine.

Readers, thoughts? Experiences?

lundi 29 juin 2015

More Health Coverage, And Perhaps More Health, For Same-Sex Couples

More Health Coverage, And Perhaps More Health, For Same-Sex Couples

A crowd waves rainbow flags during the Heritage Pride March in New York on Sunday, June 28. (AP)

A crowd waves rainbow flags during the Heritage Pride March in New York on Sunday, June 28. (AP)

You know how it goes: You have the great joy of the wedding — or of the gay pride celebrations that followed the Supreme Court’s marriage decision — and then the honeymoon’s over and it’s time to talk about the mundanities of stuff like (sigh) health insurance.

But still, it can be at least quietly pleasing to contemplate the many a newlywed who’ll now qualify for insurance offered by their new spouse’s employer. (And that on top of the several million people whose health insurance subsidies were just saved by the previous Supreme Court decision, on Obamacare.)

Not to rain on the weddings, but it’s also likely that many employers’ “domestic partner” benefits will go away. The picture is complex, but a study just out in JAMA finds that legalizing gay marriage does indeed increase employer-based health insurance coverage for same-sex partners. It looked at New York after gay marriage was legalized there in 2011, and more than 12,000 same-sex couples wed. From the press release:

Compared with men in opposite-sex relationships, same-sex marriage was associated with a 6.3 percentage point increase in ESI [employer-sponsored health insurance] and a 2.2 percentage point reduction in Medicaid coverage for men in same-sex relationships. Same-sex marriage was also associated with an 8.9 percentage point increase in ESI and a 3.9 percentage point reduction in Medicaid coverage for women in same-sex relationships vs women in opposite-sex relationships.

I asked the study’s author, Gilbert Gonzales of the University of Minnesota, whether anyone had done a similar study in Massachusetts after our own pioneering legalization of gay marriage more than a decade ago. He replied by email:

The only Massachusetts study I’m familiar with is an American Journal of Public Health study that found potential improvements in gay and bisexual men’s health after MA enacted same-sex marriage in 2003. There were significant reductions in mental health care visits and expenditures in the year after MA enacted same-sex marriage, which suggests broad public health benefits for LGBT people when states recognize same-sex marriage.

Another related study on health insurance coverage looked at the 2005 domestic partnership law in California, and found the law increased health insurance coverage among lesbian women relative to heterosexual women. There was no similar finding for gay men. The JAMA study suggests that legal same-sex marriage–rather than domestic partnerships–may improve coverage options for both men and women in same-sex relationships.

How many people in all may gain employer health insurance thanks to the Supreme Court ruling? It’s not totally clear, Gonzales says, “partly because the health insurance landscape has changed very quickly under the Affordable Care Act. The ACA now allows married same-sex couples to seek private health insurance together in the federal and state marketplaces.”

He adds: “Meanwhile, after last week’s same-sex marriage ruling, married LGBT workers will have more options to enroll a same-sex partner in employer health plans. This may help low-income same-sex couples in states not expanding Medicaid or where coverage options are more limited.”

I also checked in with M.V. Lee Badgett, author of “When Gay People Get Married: What Happens When Societies Legalize Same-Sex Marriage.” Her take: “The gap in health insurance coverage has been closing with the ACA, but marriage equality will help.”

She, too, cites the Massachusetts study that linked legalizing same-sex marriage with health improvements. And on the new JAMA study she says it is “a simple one but well-done and has sensible results.”

Further Reading:

vendredi 26 juin 2015

Why Your Doctor Might Want To Track Your Tweets

Why Your Doctor Might Want To Track Your Tweets

The little digital breadcrumbs you blithely leave in your wake — the tweets, the online searches, and communities you join, the wearables that account for every step and bite — are beginning to coalesce into what could ultimately become a critically important portrait of your true physical and mental state.

At least that’s what John Brownstein of Children’s Hospital Boston and his colleagues argue as they analyze and collect these “breadcrumbs” amassing a wide spectrum of data to support a broad new concept of personal and public health that they call the “digital phenotype.” It’s like a contemporary extension of the more traditional phenotype — one’s observable characteristics based on a mix of genetics and the environment.

(Medisoft via Compfight/Flickr)

(Medisoft via Compfight/Flickr)

In a sort of digital phenotype manifesto published earlier this year in the journal Nature Biotechnology, Brownstein, an epidemiologist and associate professor at Harvard Medical School and chief innovation officer of Children’s Informatics program, and others, explain the idea like this:

…there is a growing body of health-related data that can shape our assessment of human illness. Such data have substantial value above and beyond the physical exam, laboratory values and clinical imaging data — our traditional approaches to characterizing a disease phenotype. When gathered and analyzed appropriately, these data have the potential to fundamentally alter our notion of the manifestations of disease by providing a more comprehensive and nuanced view of the experience of illness. Through the lens of the digital phenotype, an individual’s interaction with digital technologies affects the full spectrum of human disease from diagnosis, to treatment, to chronic disease management.

Or, put another way: the digital phenotype adds a unique, more fine-grained look at the way people actually live each day.

Here’s one real-world example: Michael Docktor, a gastroenterologist and director of clinical innovation at Children’s Hospital Boston, treats many patients with Irritable Bowel Syndrome and one thing he usually requests is a detailed food diary. “Sometimes teenagers dump a 50-page food diary on me, and it’s hard for me as a human being to comb through that and, perhaps, find that milk, for instance, is a problem.” But, he says, “if we had that information digitally, tracked by software that used algorithms and machine learning to figure out the meaningful correlations and serve it up in an easily digestible format — that could be transformative.”

Brownstein, also founder of the healthmap, a digital tool that tracks infectious diseases around the world through disparate data collection, from eye-witness accounts to government reports. adds: “The digital phenotype gives some insight into health behavior that would otherwise be difficult to obtain during a clinical interaction …The idea that you may see a doctor once, twice a year, and to capture important information on fitness, exercise, sleep, even general happiness, can be challenging. But in fact, a lot of the information we’re streaming can provide useful clinical information.”

The latest crumb of information is this growing field is a study characterizing sleep disorders and related issues through Twitter use. Other digital tracking efforts looked at “the use of cell phone activity to measure one’s activity levels and the association with depression,” researchers note. A study in 2013 looked at links between obesity and Facebook use.

In the Twitter study on sleep issues, published in the Journal of Medical Internet Research, researchers reviewed the contents of tweets to try to discern potential sleep issues.

In an interview, Brownstein says the study began with researchers suspecting that people are constantly complaining about sleep online. So, they wondered, was it possible to investigate overall, social interaction and characterize that core of people with real issus.

“Long term,” he said, “that could fuel researcth into sleep and sleep behavior and then also the idea it could improve clinical decision making.” He adds: “With this kind of work we’re trying to validate against what we already know…in this case [people with sleep issues had] more negative sentiment, and…are more isolated interms of social interactivity…with some of that validation and real world data, we can think about other ways to investigate sleep and other health outcomes; it could fuel a conversation between a patient and a clinician.”

Here’s more on the study from the Children’s news release:

Researchers from Boston Children’s Hospital and Merck have built the beginnings of “digital phenotype” of insomnia and other sleep disorders based on data from Twitter. This study is one of the first to look at relationships between social media use and sleep issues, and—based on assessments the sentiments expressed in users’ tweets — gives preliminary hints that patients with sleep disorders may be a greater risk of psychosocial issues…

Insomnia and other sleep issues affect between 50 and 70 million Americans. Apart from their impact on productivity, accidents and risky behaviors, chronic sleep disorders also contribute to diabetes, cardiovascular disease and depression.

Historically, population-level research on sleep disorders has relied on survey methods such as the Behavior Risk Factor Surveillance System. However, such methods are time- and resource intensive, expensive, suffer from long lag times before reporting and are not generalizable to the larger U.S. population.

Research based on social media data may help overcome these limitations. To support such research, Hawkins, McIver, Brownstein and their colleagues sought to develop a “digital phenotype,” or baseline profile of what a person suffering insomnia or other sleep disorders “looks” like on social media.

“Sleep deprivation and chronic sleep disorders are not well understood,” said Brownstein. “We wanted to see if we could use new forms of online data, such as Twitter, to characterize the sleep disordered individual and possibly uncover new, previously-undescribed populations of patients suffering sleep problems.”

The research team used publically available anonymized data from Twitter to create a virtual cohort of 896 active Twitter users whose tweets contained sleep-related words (e.g., “can’t sleep,” “insomnia”), or hashtags (e.g., #cantsleep, #teamnosleep), or the names of common sleep aids or medications. They then compared data from that cohort to those of a second group of 934 users who did not tweet using sleep-related terms. The team examined each user’s age, total number of tweets, total numbers of followers or people followed, number of favorite tweets (that is, the number of tweets by others that the user had favorite), length of time on Twitter (that is, how long the user had had an active Twitter account), average number of tweets per day, location and time zone.

The researchers also assessed the time of day and average sentiment—positive, neutral, negative—of each user’s tweets.

The resulting profile of a Twitter user with sleep issues — compared to a Twitter user without — looked like this:

  • have been active on Twitter for a relatively long time
  • has fewer followers and follows fewer people
  • posts few tweets per day on average
  • more active on Twitter between 6:00 pm and 5:59 am
  • more active on Twitter on weekends and early weekdays
  • more likely to post tweets with negative sentiment

Taken together, the data suggest that Twitter users suffering from a sleep disorder are less active on Twitter on average but tweet more during traditional sleeping hours. The increase in negative sentiment in their tweets suggests that sleep-disordered users could be at an increased risk for psychosocial issues.

“These findings are preliminary and observational only, and need to be studied further,” Brownstein cautioned. “But they suggest that social media can be a useful addition to our toolkit for studying the patient experience and behavioral epidemiology of sleep disorders.”

Docktor, the gastroenterologist, agrees that all of this digital tracking is still in its infancy in terms of actually helping doctors practice medicine. And of course, he says, privacy issues are always a concern.

But, he says, the prospects are tantalizing.

“The patients were now seeing are digital natives, he said in an interview. “They don’t have email, they have Twitter and Snapchat. There’s an incredible amount we might learn — especially in patients with chronic illness. I see a patient once every six months or a year, and they remember the last couple of weeks. They don’t remember they were really sick months before — there is so much recall bias. But with these technologies…there’s an incredible amount of data being collected by patients in the 99.9 percent of time they are out of hospital, and the real question is how do we passively collect that data to make it meaningful and how do we use that data in a way that’s not totally overwhelming to the medical system and providers.” Of course, he adds, privacy issues are always a concern.

Note From A Civilized City: Boston Parks To Offer Dispensers Of Free Sunscreen

Note From A Civilized City: Boston Parks To Offer Dispensers Of Free Sunscreen

Got sunscreen? A sunbather on the Boston Common, one of the city parks that will offer free dispensers of free sunscreen. (Alonso Javier Torres/ Flickr Creative Commons)

Got sunscreen? A sunbather on the Boston Common, one of the city parks that will offer dispensers of free sunscreen. (Alonso Javier Torres/ Flickr Creative Commons)

In winter, season of germs, we can turn for a squirt of protection to the multitudes of handy sanitizer dispensers that have cropped up everywhere over the last few years, from gyms to workplaces to public buildings.

And now, in summer, when the blue skies raise the risk of skin cancer, we here in the civilized city of Boston will now be able to turn to 30 dispensers of free sunscreen that are being installed in the central Boston Common and four other popular parks. They’re expected to be up by July 1.

“Skin cancer and melanoma are among the most prevalent cancers and they’re also among the most preventable,” says Matt O’Malley, the Boston City Councilor who proposed the sunscreen initiative in April.

“So what we are doing in Boston is, we’re offering a service, we’re promoting public health and we’re reminding folks of the importance of sunscreen — at no cost to the taxpayer. It’s an incredibly wonderful initiative and I look forward to seeing it spreading across the country much like the way my freckles spread every summer.”

The dispensers being installed in Boston parks (courtesy Melanoma Foundation of New England.)

The dispensers being installed in Boston parks (courtesy Melanoma Foundation of New England.)

The idea for dispensers sprang, he says, from a medical student who argued that installing them was a growing practice, including at Hershey Park in Pennsylvania. But no major city has adopted it as a city-wide initiative, O’Malley says — until now.

If the pilot project with 30 initial sunscreen dispensers works out well, he says, the plan is to extend the dispensers to all the city’s playgrounds and parks — more than 200 of them.

The dispensers cost between $100 and $200, O’Malley says, so the ultimate price tag could be close to $50,000 — but not to the taxpayers. The dispensers are a public-private partnership including the Melanoma Foundation of New England and Make Big Change, both organizations that fight skin cancer. The Foundation is covering the cost of the dispensers, according to a press release, and Making Big Change provides the dispenser units; it has also been placing them in New Hampshire beaches and parks.

So how might Bostonians respond to the new dispensers? Well, if a recent Miami Beach program is any indication — and it may well not be, of course — the online response to a Miami Herald account — Miami Beach unveils free sunscreen dispensers on sand —  was largely positive.  “Very cool!” one commenter wrote. “Great to see sun protection efforts taken so seriously.” Though there was also, inevitably, this:

This is a great idea. Kudos to all involved for embracing such forward thinking ideas, something that is rarely seen in this crazy burg. Unfortunately, since we live in “The Litigious Age” where lawsuits spring up faster than dandelions on a new mowed lawn for just about anything, I suspect someone will blame the city and MB Brands for their future skin cancer because the product just didn’t do the job it was supposed to do. And then you got those idiots who don’t use any kind of sunburn protection who could drop a lawsuit against the city for not ENFORCING them to use it while on its beaches (unless the city erects signs warning beach-goers to lather up and that the city and MB Brands can’t be held responsible for any future skin cancer).* Ai-yi-yi.

For me, the most pressing question that arises from the sunscreen program is: If Boston is now civilized enough to supply sun protection, does this mean that we might even acknowledge human bodily needs to the point that our parks could possibly supply bathrooms to the 100 percent of the public who periodically require them?

I put that query to Matt O’Malley, and he replied that as chair of the City Council’s Committee on Environment and Parks, as a lifelong Bostonian and user of the city’s great park system, he makes it his mission “to make our parks as robust and family-friendly and offer as many amenities as we can.”

So…I think that means maybe someday? For now, Bostonians can watch out for the sunscreen dispensers here:

The Boston Common
Christopher Columbus Park (North End)
East Boston Memorial Park (East Boston)
Jamaica Pond (Jamaica Plain)
Millennium Park (West Roxbury)

And if you live elsewhere but like the idea, you might note that more than 10,000 Americans die each year from melanoma, and last year the Surgeon General put out a “Call to Action” to prevent skin cancer.

Readers, thoughts? Further reading:

Ten Latest Health Reasons To Swear Off Tanning Salons

What The Supreme Court Ruling On Obamacare Means: A Student’s Perspective

What The Supreme Court Ruling On Obamacare Means: A Student’s Perspective

By Marina Renton

CommonHealth Intern

As a public health major at Brown University, I’ll admit I’m biased: When the King v. Burwell decision was handed down this week, I was absolutely elated. The decision felt exactly right to me; people were not going to lose their health care coverage, and some might even have the chance to gain subsidized insurance.

But the case is complicated, so to really understand the take-home messages, I consulted a couple of health care policy.

One is Ira Wilson, professor of Health Services, Policy and Practice at Brown University, who taught my “Health Care in the United States” class last semester.

The other is Michael Doonan, assistant professor at Brandeis’ Heller School for Social Policy and Management and executive director of the Massachusetts Health Policy Forum

Their responses are lightly edited:

MR: What background do we need to understand the Supreme Court decision?

IW: One of the core tenets of health care reform is that people who can’t afford insurance get subsidies so that they can buy it.

The ACA:

•reforms insurance by doing things like preventing denials due to pre-existing conditions. So it requires that insurance do certain things that it hasn’t always done in the past.

•requires that everybody get insurance. That’s the individual mandate, and that was covered in the 2012 challenge and then upheld in the 2012 case.

•requires that affordable insurance be available to everyone. And this King case threw into question that third leg of the stool as it were. Or at least it brought it into question for the states that, rather than deciding to develop their own exchange, used a federal one. So without this, the entire framework for health care reform in those states that have a federal exchange begins to fall apart. And as we know because we’ve seen lots of articles about estimating how many people would lose insurance if those subsidies were taken away (estimates were in the six million range), it would have a devastating impact on people who are now insured who would lose it.

What does the ruling say about Obamacare?

MD: If the Supreme Court had ruled against the government and said that the subsidies could not be available in the 34 states that have federally-run exchanges, it might not have been the death of Obamacare, but it certainly would have put it on life support. So this decision is really critical in helping root and solidify the Affordable Care Act. And the more it gets rooted in each of the states, the harder it’s going to be to repeal.

IW: So this actually was a 6-3 decision, not a 5-4 decision. And it does seem to me the fact that both Justice Roberts and Justice Kennedy — who were the two that one might have imagined might have been on the other side of this issue — came down on the side of upholding these subsidies is a bit of a statement.

What if the ruling had gone the other way?

MD:Think about Texas. Now, in Texas, there are about 1.1 million people who are enrolled in that exchange, that marketplace. Well, 90% of them — over 900,000 people — are receiving those subsidies, and they could have lost their insurance.

And it’s not only important that people lose their insurance, which is the most critical thing, but hospitals would see many, many more uninsured patients. So even people adamantly opposed — I think that even Republican governors who are opposed to this are secretly saying, “Oh my gosh; thank goodness.” This would have caused them a tremendous, tremendous burden, because they would have seen more uninsured.

IW: Had it gone the other way, there would not only have been a whole set of immediate short-term problems that relate to the states that have federal exchanges, but you begin to develop momentum to repeal the whole thing, or you start to develop momentum for opponents of health care reform to be emboldened and to challenge more things. And so there’s this whole sense of momentum behind health care reform, which I think would be seriously impaired.

What does this mean for the future?

MD: Repeal of Obamacare is almost off the table. This is the number one domestic policy legacy issue for the President, and it just got saved. Millions more people are going to have health insurance, and the ACA is going to be something that gets even stronger because of this. I bet we see some of the states who are not participating participate by expanding their Medicaid, by looking to the federal government to see if they can cover more people in creative ways.

IW: Repeal still could happen. But the point is it becomes much, much harder. You have two major Supreme Court decisions in support of the constitutionality of proceeding in this direction.

I think the big picture is that there’s a lot to do to continue to implement, and implement effectively, the ACA. This is a marathon, not a sprint. It’s a long process. And what the ruling means is that people can keep focused on doing that implementation work rather than rethinking it altogether.

Read more about the Supreme Court’s ruling, here, here and here.

jeudi 25 juin 2015

Those Who Worked On Mass. Law Cheer As Supreme Court Upholds Obamacare Subsidies

Those Who Worked On Mass. Law Cheer As Supreme Court Upholds Obamacare Subsidies

Jessica Ellis, right, with "yay 4 ACA" sign, and other supporters of the Affordable Care Act, react with cheers as the opinion for health care is reported outside of the Supreme Court Thursday. The court upheld the nationwide tax subsidies under President Obama's health care overhaul. (Jacquelyn Martin/AP)

Jessica Ellis, right, with “yay 4 ACA” sign, and other supporters of the Affordable Care Act, react with cheers as the opinion for health care is reported outside of the Supreme Court Thursday. The court upheld the nationwide tax subsidies under President Obama’s health care overhaul. (Jacquelyn Martin/AP)

Obamacare supporters everywhere are celebrating a win from the U.S. Supreme Court. With a 6-3 vote, the court decided Thursday that Americans who buy coverage through health care exchanges run by the federal government can continue to receive subsidies.

“It’s just a happy, happy day,” said Rosemarie Day, who was the first chief operating officer of the Massachusetts Health Connector, the state exchange that’s seen as a precursor to Obamacare.

The Supreme Court’s decision has no direct impact for Massachusetts.

“Because Massachusetts operates its own health benefits marketplace, in contrast to those states relying on the federally facilitated marketplace, to our understanding there is no direct impact expected to Massachusetts as a result of [the] decision in King versus Burwell,” Massachusetts Health Connector Director Louis Gutierrez said in an interview before Thursday’s ruling.

The case before the Supreme Court, King v. Burwell, claimed that offering tax credits through health insurance websites run by the federal government was not legal.

But many in Massachusetts who worked on the state law that became a blueprint for Obamacare say Thursday’s decision is a victory for Massachusetts.

“Massachusetts led the way when we piloted health reform back in 2006,” said Day, who now runs the consulting firm Day Health Strategies. Now people across the country “are starting to get used to the idea that health care coverage should be something everyone has, regardless of whether they have a job with health insurance.”

A ruling against Obamacare would have meant that exchanges in at least 34 states (and as many as 37 states) and subsidies for almost 6.5 million people were no longer legal.


Are Skinny Jeans Bad For Your Health?

Are Skinny Jeans Bad For Your Health?

This is the kind of headline that can trigger a snarky response even in the most compassionate person:  “Squatting in ‘skinny jeans’ can damage nerve and muscle fibres in legs and feet.”



Yes, it’s true: a case report published this week in the British Journal of Neurology, Neurosurgery and Psychiatry, describes a 35-year-old woman who suffered serious muscle damage and nerve blockage after squatting in her super tight skinny jeans. (The jeans were so tight, in fact, that doctors had to cut them off to treat her.)

Here’s the top of the report:

A 35-year-old woman presented with severe weakness of both ankles.

On the day prior to presentation, she had been helping a family member move house. This involved many hours of squatting while emptying cupboards. She had been wearing ‘skinny jeans’, and recalled that her jeans had felt increasingly tight and uncomfortable during the day. Later that evening, while walking home, she noticed bilateral foot drop and foot numbness, which caused her to trip and fall. She spent several hours lying on the ground before she was found.

On examination, her lower legs were markedly oedematous bilaterally, worse on the right side, and her jeans could only be removed by cutting them off. There was bilateral, severe global weakness of ankle and toe movements, somewhat more marked on the right… Sensation was impaired over the lateral aspects of both lower legs, and the dorsum and sole of both feet…Nerve conduction studies showed conduction block in both common peroneal nerves between the popliteal fossa and fibular head…

[My bold]

The story of the skinny jean medical emergency went viral, with fashionishtas and feminists weighing on whether the era of super-tight jeans is over. The New York Times did a piece headlined “Why You Shouldn’t Throw Out Your Skinny Jeans,” and interviewed the paper’s fashion director, who declared:

Not all skinny jeans are created equal, and it would be alarmism to jump to the conclusion that one pair of skinny jeans created health issues, ergo all skinny jeans are bad. I think the takeaway is skinny jeans are one thing, jeans that actually inhibit movement something else. Maybe we should call them straitjacket jeans. Those should be avoided.

Still, after reading the study, it’s hard not to feel a little empathy. Who among us hasn’t worn a heel just a bit too uncomfortably high, or a pair of movement-limiting pants (and don’t even get me started about thong underwear) in an attempt to feel better/younger/sexier?

I asked Emily Sandoz, a clinical psychologist in Louisiana and author of the book “Living with Your Body and Other Things You Hate” for her thoughts on the study. Here’s what she wrote back:

It’s terribly unfortunate the ways we are willing to treat our bodies in order  to look a certain way. This woman is really not alone.

There are truly daily reports of people injuring themselves with efforts to reign their bodies in this way or that – working out past the point where proper form is possible, putting food or medications in our bodies that make us ill, wearing  clothing that causes pain, or at times, permanent damage.

My hope is that we can come to a place where caring for our bodies is more important than making them look a certain way.

mercredi 24 juin 2015

Medical Marijuana Is Now For Sale In Mass.

Medical Marijuana Is Now For Sale In Mass.

Marijuana plants at In Good Health Inc., in Brockton (Jesse Costa/WBUR)

Marijuana plants at In Good Health Inc., in Brockton (Jesse Costa/WBUR)

There’s another milestone in the storied history of Salem. On Wednesday, the state’s first dispensary for medical marijuana opened on the ground floor of a former factory here, a few blocks off a busy thoroughfare.

Salem resident Wendy Atwood had a 10:30 a.m. appointment at Alternative Therapies Group. 

Atwood uses marijuana to relieve physical pain. “I’m 53,” Atwood said with a shrug. “You have knee pain, back pain, I have arthritis. You know, you just kind of get older and it hits you.”

Truth be told, Atwood has been smoking pot since she was a teenager — long before she needed pain relief. But the option of walking into a store where she can buy marijuana legally is a change that she says is long overdue.

“I’m a law-abiding citizen, two kids, daycare provider, no criminal record,” Atwood told me, “so I feel like I’m a good example of someone who can use [marijuana] responsibly.”

But Salem police are wary. Chief Mary Butler likes the fact that during an initial period, Alternative Therapies Group is selling marijuana by appointment only. “I’m going to reserve judgment as to when it’s actually open — what effects or impact that has,” Butler said.

Butler says no one will be allowed to use marijuana in the store or just outside. No prospective buyers will be able to enter the dispensary without a marijuana patient registration card issued by the state.

Bulter says it may be easier to police the drug, so to speak, now that the dispensary is open and fewer patients will be growing marijuana at home. The chief toured the facility before it opened.

“There is no, like, glass display that has all kinds of marijuana out that people are looking at,” Butler recounted. “So when they go into the site, they’re typically just looking at a computer screen to identify what it is that they are going to purchase.”

After making their selections, patients pay and wait for a salesperson to go in the back and retrieve their marijuana, which is “totally removed from the client until such time as they’ve made the purchase,” Butler added.

Police will be keeping an eye on how the marijuana is transported from the growing facility in Amesbury and then delivered.

Salem Chamber of Commerce Director Rinus Oosthoek has his eye on the dispensary too. He wants them to join his organization.

“They’re a hot prospect,” Oosthoek said. “We would enjoy seeing them come in as a member. We’ve talked to them already, of course.”

Oosthoek — who is from the Netherlands, where marijuana has been widely available for some time — says he’s impressed with the state regulations and the dispensary setup. He expects the chamber’s 570 members to welcome the dispensary, as they would any new employer in town.

“We’ve had no negative comments whatsoever,” Oosthoek said. “People were just wondering mostly where the dispensary would go, and I think the location that they found is just off the beaten path but close enough to the other facilities so that it’s going to work.”

But one of the largest health care facilities in Salem is trying hard to keep some distance from the dispensary.

“We don’t want to, in any way, imperil our federal funds,” Margaret Brennan, the CEO at North Shore Community Health, said in an interview. “So we are really watching from the sidelines.”

For patients who want to use marijuana for medical purposes, “that means that our providers, both physicians and nurse practitioners, won’t be prescribing at all,” she said.

It’s not clear how many physicians across the state are willing to sign a marijuana certificate for patients. In Salem, Mayor Kim Driscoll says most residents supported the ballot question that passed in November 2012, making the use of marijuana for medical purposes legal.

“There were a fair amount of people who expressed concern for things that are in our local drugstores like CVS or Walgreens, being more worried about those sorts of things, the opiate addiction and pills, than they are about this product in this location,” Driscoll said.

Driscoll has a team of health, public safety and other city officials who will continue to monitor this moment in Salem’s history, when, for the first time, Massachusetts patients can walk into this licensed store, point to marijuana they want, pay and leave — with no fear of breaking state law.


mardi 23 juin 2015

An Uptick In Non-Jews Choosing Jewish Circumcision? Maybe.

An Uptick In Non-Jews Choosing Jewish Circumcision? Maybe.

Reporter Jessica Alpert may have stumbled on a trend: non-Jews choosing to have their infant sons circumcised by traditional mohels, Jews trained to perform the ritual procedure, rather than doctors.

Alpert, a frequent CommonHealth contributor, writes in the current Atlantic:

Finch isn’t the only non-Jew who has felt a connection to the religious elements of the procedure. Nationwide, circumcisions have decreased over the last few decades—from 64.5 percent of newborn boys in 1979 to 58.3 percent in 2010, according to Centers for Disease Control data—but among those opting to circumcise their sons, some non-Jews are forgoing the hospital or doctor’s office and requesting Jewish mohels for reasons both practical and religious. (Reliable statistics on religious circumcisions are hard to come by, but several mohels I talked to said they’ve noticed an uptick in their popularity in recent years.)

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

Whether or not the practice is taking off, Alpert suggests that this co-mingling of religious and non-religious realms may have “tricky implications for mohels performing non-Jewish circumcisions,” and raise thorny legal questions:

The right to perform brit milah is protected under the First Amendment, but when it’s no longer a religious ritual, mohels may run up against laws that forbid the practice of medicine without a license, explains Marci Hamilton, a church-state scholar and professor at the Cardozo School of Law at Yeshiva University. There is no legal gray area for mohels who are also health professionals—these mohels can perform the procedure on non-Jews as part of their medical practice, even if the primary purpose is religious rather than medical. But others, Hamilton says, may be subject to prosecution when they perform the procedure outside of its religious context.

When it’s a non-Jewish family using a mohel, “The mohel is not acting as a religious participant, and therefore his acts are not protected as free exercise,” she explains.

“This is really a medical business transaction, not a religious transaction.”

Last year, a study published in the Mayo Clinic Proceedings concluded that the health benefits of newborn male circumcision outweighed the risks. However, that data did little to sway critics of the practice who have called it “a disservice to American parents and children” (and worse) in remarks posted on the American Academy of Pediatrics web site after the group published a policy statement supporting insurance coverage for the procedure and also underscoring the health benefits.

Dietland: A Fat Heroine, And The Politics Of Weight

Dietland: A Fat Heroine, And The Politics Of Weight

By Jean Fain

The heroine is the news in Dietland, the new novel by Sarai Walker. That’s because she’s got the rarest of qualities in a female protagonist: she’s fat.

Also, she has next to no sense of self, and expects to remain selfless until she can afford weight-loss surgery and find her true self as a thin person. In the meantime, Plum Kettle, our heroine, works as a ghostwriter for the slender, glamourous and self-absorbed editor of a teen magazine called Daisy Chain. In short, Plum’s got no life of her own.

Plum’s transformation from fat girl to full-bodied rebel with a cause is the narrative arc of Walker’s provocative and insightful book. Like Alice in Wonderland, Plum’s sense of self gets turned on its head by a cast of oddball characters, from the daughter of a famous diet guru and her feminist cohort to a murderous terrorist cell of women avenging crimes against women. When the daughter of the diet guru offers Plum $20,000 to postpone her surgery and confront the real costs of beauty, the plot and subplot blend and thicken.

dietlandDespite the rave reviews from my inner circle and the world at large, I didn’t expect to be drawn in by the writing. But, truth be told, it’s fresh, playful and sometimes hilarious: the parody of the diet industry is spot on. I also didn’t expect to be touched by the rejection and humiliation the 300+ pound Plum encounters along the way to finding herself.

Most unexpected of all: I kind of looked forward to spending my evenings with a fictional someone desperately seeking weight loss. Generally, if I’m desperate for anything at the end of the day with clients (I’m a therapist specializing in eating disorders and food issues), it’s non-diet-related downtime.

I can’t say I always loved reading Dietland. Violence, even when served as Walker serves it — with sarcasm and panache, isn’t my cup of tea. I also had trouble swallowing the meanness of the male characters, and the complete self-acceptance of the female ones. And yet, my curiosity kept me turning all 307 pages. I wanted to know if Plum would live more happily ever after. Plus, I wanted to discuss the book with members of my mindful eating support group. (Dietland is the group’s first unofficial book club selection.)

At the same time, I kept reading between the lines to learn the author’s story. From the book-jacket flap, I knew Walker writes from professional experience. Before she did her doctoral research on the feminist issue that is fat, she wrote about body image for Our Bodies, Ourselves, the feminist classic by the Boston Women’s Health Collective.

From the author photo, I also knew Walker is a fat woman. And yet, combing through the reviews and interviews, I could find very little about Walker’s personal experience with food and body image issues.

The therapist in me really wanted to know if Walker, like Plum, had tried and failed to lose weight over and again? If she’d been a victim of fat shaming and stigma? If she’d been discriminated against because of her appearance? What was Walker’s story?

My curiosity moved me to set up a Skype interview with the NYC-based author. What follows are questions and answers from that recent interview with Sarai (pronounced SUH-ray) Walker.

JF: You seem to know a lot about food and body image issues even though you’re not a medical person or scientist. What can you tell me about your personal experience in this arena?

SW: Well, I’m a fat woman, and so I think one of the reasons I wanted to write Dietland is I wanted to explore what it’s like to be a fat woman in our contemporary society because I think, while there are some novels with fat heroines, I feel like there aren’t any novels that explore the issue in a serious way.

Author Sarai Walker (Photo: Marion-Ettlinger)

Author Sarai Walker (Photo: Marion-Ettlinger)

Which is interesting because our society is so obsessed with “obesity.” There was actually an article in the Wall Street Journal a couple of years ago where they wrote about the fact that people are so obsessed with the fat body, but there really aren’t a lot of novels that deal with that subject. So that was kind of my motivation for writing the book, and I felt like I had the kind of personal experience to make it very authentic.

JF: So does that mean you were a dieter and had your own body image issues?

SW: Yeah, I would say that I started dieting as a teenager, so I kind of did all sorts of commercial diet programs, and then diet books, things in magazines, just sort of everything. And so I’m kind of well familiar with the dieting industry and, I think, how diets really don’t work for most people. I’m sure they do work for some people, but I think they’re largely ineffective as calorie-restrictive dieting.

So you’ve been through the diet mill. How about body image issues? What can you say about that?

So I was doing my Ph.D., and then I started to attend Fat Studies conferences, and that sort of introduced me to fat acceptance, health at every size, these different movements. And it was really just a radical transformation in my way of thinking. And as soon as I was exposed to these ideas, it just sort of clicked, that’s what I had been looking for but hadn’t been able to find. So it definitely changed the way I viewed my own body and made me realize that I don’t want to take what people project onto me and internalize it. I can’t help what people say about me or think about me, but I can help how I think about my own body, and that was really a radical shift for me.

That’s fantastic, because this is a really tough culture. It’s toxic. So how would you describe your body image at this point, because it sounds like it’s been kind of a long journey?

I would say that part of it is getting older; I’m not sure if that factors into it as well. Even though I know some great fat activists who are in their twenties or even teens, so who knows. I think for me getting older perhaps helps a bit. I feel more confident, I think. I hate to use the cliché, but knowledge is power. Really understanding the power dynamics of how all of these things work in terms of why fat women are marginalized, treated the way that we are. I think understanding the dynamics at play, at least for me, helps me deal with it. But it very much places the responsibility on the shoulders of individual person. Maybe everybody can’t deal with that; some people may be more susceptible to societal pressure. I don’t want to make it seem like it’s easy, because it’s not. Some people are perhaps more capable of it than others.

You’re not a therapist, and yet one of your characters prescribes a really unconventional therapy to help Plum face her worst fears. I’m curious how you came up with the therapeutic strategies, some of which are a little bit aversive, like getting a full body wax and dating jerky men.

So in the novel, there’s this diet plan called Baptist Weight Loss that Plum’s on when she’s a teenager. And then as an adult, she meets the daughter of the founder who is this activist who’s trying to undo the damage that her mother did with this weight-loss mega empire that she had. So basically Plum kind of goes through the reverse of a weight-loss program. So the woman in the novel calls it the New Baptist Plan, so it’s a new kind of diet plan. And instead of focusing on the body, making your body smaller, it’s focusing on the more underlying issues of our obsession with thinness. So part of it was trying to open Plum’s eyes and trying to make her angry about the treatment that fat women receive. So basically helping her turn her anger outward rather than at herself. But I’m not a therapist; I just kind of used my knowledge of dieting culture and my creativity to craft this plan.

It’s hard because when you’re a fiction writer you have to be concerned with the story as well. An interesting story, having the readers turn the page. So it’s a lot different than nonfiction, even though it might deal with some of the same issues, where there are a lot of different factors at play. I just made it up myself based on what I thought would be useful.

Over the course of the novel, Plum learns to accept her body without losing weight, which as we’re saying is no small task, especially in this fat-phobic society. How about you? What can you tell me about accepting your body just as it is right now?

I think it’s not like where you get to a place where you say, “Ok, as of today I just accept my body and that’s it.” It’s something that I wouldn’t say is a constant struggle, but it’s a constant issue, something you have to work on a lot. It’s never just one moment where you’re perfect and everything’s fine. Again, having access to fat acceptance, body positivity, health at every size, these different movements I think just are very empowering. And I think it helps a lot to have a community of other people as well, which is essential to Plum in the novel, finding other like-minded women. So if you can find a group of women, or people online, that’s been very helpful to ne, to know that I’m not alone and other people are going through the same thing.

My favorite quote is when one character tells Plum: “There comes a moment when you realize you’ve changed in some irrevocable way, and you’ll never go back to the way you were. Think of it as crossing over to a new place.” Do you have such a moment in your own life?

When I started attending these fat study conferences, it just kind of clicked for me; all of a sudden it made sense. And I knew that while it’s always a process – as I said before, it’s never just one moment where everything’s perfect, it’s a continuing process – there was a point where something inside me, a kind of consciousness raising, and once that happened, something shifted in me, and I knew that I would never go back to the way I was before. So not that everything was going to be perfect, but it was a before and after kind of moment. I wouldn’t say that it was one instant, but it was a period of time when I became exposed to these ideas and it shifted my way of thinking.

Tell me how working on Our Bodies, Ourselves influenced the writing of Dietland, because I could swear I could see little instructional moments that might have ben straight out of that book.

That’s funny because that was about 10 years ago I worked there. For one thing, I wrote the chapter on body image, so that was my first experience writing about the body from a feminist perspective, because before that I had worked at women’s magazines, so that was a big shift for me. But I also think working on Our Bodies, Ourselves made me very comfortable talking about the body in more explicit ways. All day we would deal with all sorts of issues, childbirth, everything, whatever it was, we would have graphic photos and illustrations surrounding us all day long. It made me lose some of the shame I had perhaps when thinking about the body, because I think that’s quite common in our culture, to be raised with this kind of embarrassment or shame about the body.

And after I worked there I lost that, just thinking about the body, talking about those sorts of issues in general. So that’s one of the things I think really helped me with the novel, kind of liberated me in that sense. But I also think Dietland kind of has that spirit of the 70s feminism in it. So of course, Our Bodies, Ourselves was such an integral part of 70s feminism, so I really value that experience. Getting to experience a kind of feminist collective – it’s not really a collective I guess in the traditional sense anymore – definitely influenced me in all sorts of ways I would think.

Anything else you want to tell me about?

The thing about the difference between a novel and nonfiction, for example, because I think most books on this topic are nonfiction, and a novel just functions differently on a more emotional level, a gut level. So I think it’s interesting for me to see how people respond to – particularly people who’ve never been exposed to these ideas before. It’s been fun to see some people are sort of like “Oh, I never thought of that before; you changed my way of thinking.” That kind of shift we were talking about; I love when people experience that after reading the book. So that’s been one of my favorite things so far.


Jean Fain, LICSW, MSW, is a Harvard Medical School-affiliated psychotherapist and the author of “The Self-Compassion Diet.”

lundi 22 juin 2015

Baker Announces Plan To Combat Opioid Addiction Epidemic

Baker Announces Plan To Combat Opioid Addiction Epidemic

One person living in Plymouth County will die today from an overdose of heroin or another opiate. Gov. Charlie Baker says that sobering average, from just one county, offers a glimpse into the opioid epidemic that rages through every community in Massachusetts.

To combat this epidemic, Baker released a plan of attack. It includes 65 recommendations, drawn from a task force of experts who heard from 1,100 people this winter and spring, many of whom crowded into public hearings to tell their stories.

Massachusetts Gov. Charlie Baker announces his recommendations of his Opioid Working Group along with Attorney General Maura Healey and Health and Human Services Secretary Marylou Sudders at the State House. (Jesse Costa/WBUR)

Massachusetts Gov. Charlie Baker announces his recommendations of his Opioid Working Group along with Attorney General Maura Healey and Health and Human Services Secretary Marylou Sudders at the State House. (Jesse Costa/WBUR)

“Opioid addiction is a health care issue that knows no boundaries across age, race, class or demographics,” Baker said during a press conference Monday. “From the Berkshires, to Boston, to Cape Cod, too many people have heart-wrenching stories of loved ones or friends who have battled with addiction and in some cases lost their lives. Opioid abuse is stealing the livelihood of our children, our siblings, relatives and friends, one person at a time.”

The recommendations include more education for doctors, young people, those at risk for addiction and their family members about the dangers of pain killers. The state will look to add 100 treatment and recovery beds by this time next year. Pharmacists will be required to add pain prescriptions to a statewide database within 24 hours, much more quickly than the current seven days, which Massachusetts is working to connect to databases in other states.

“This is a complicated issue so there’s not going to be a simple fix,” said Health and Human Services Secretary Marylou Sudders.

The Baker administration will rely on partnerships at the federal, state and local level to make many needed changes. One recommendation is to let medical residents prescribe a federally controlled treatment drug; another would increase or eliminate a cap on the number of patients to whom a doctor can prescribe the same drug, buprenorphine.

HHS secretary Marylou Sudders speaks to the press during a press conference at the State House to announce recommendations from the Governor’s Opioid Working Group. (Jesse Costa/WBUR)

HHS secretary Marylou Sudders speaks to the press during a press conference at the State House to announce recommendations from the Governor’s Opioid Working Group. (Jesse Costa/WBUR)

The state does not have, but will try to establish timely statewide reports on overdoses and deaths. Right now, Sudders says, the state has a general sense of so-called hot spots, areas with the highest number of deaths.

“Hot spots are in Fall River, New Bedford, Middlesex County has a very high rate of opioid deaths, Plymouth, Brockton,” Sudders said. “The difference here is instead of using anecdotes, really use data to [identify] where we need to intervene.”

Close to real-time data will help the state determine which towns need more Naloxone, the drug that temporarily reverses an overdose, or, which cities and towns need more treatment programs, beds and coaches to help substance abuse patients with recovery.

An underlying theme in the report is that substance abuse is a health care, not criminal, issue.

“We are not going to arrest or incarcerate our way out of this,” said Attorney General Maura Healey. “This is a disease, a public health crisis and we must treat it as such.”

Healey says she’ll focus on making sure doctors are prescribing pain killers responsibly and that insurers are covering addiction as they would diabetes or asthma or any other chronic illness.

The Baker administration plans to spend $34.5 million to implement these recommendations, $27.8 million of which is new spending. The sum includes:

  • $5.8 million to move substance abuse disorder out of prison and into Taunton State Hospital
  • $14 million for recovery beds
  • $5 million for school-based education
  • $3 million for case managers and coordinators at MassHealth

The spending started last week with an $800,000 public service campaign.

[Watch on YouTube]

In this video, Janis McGrory and her daughter Amy LeFort from Harwich tell the story of Liz, the daughter and sister who died from an accidental heroin overdose four years ago. McGory says Liz switched to heroin after taking a pain medication.

“Prescription drugs are dangerous. Parents be vigilant. Addiction is a disease and don’t be fooled, it can happen to anyone,” McGrory said.

Baker’s report is, in part, a commitment to Liz and 6,600 Massachusetts residents killed by opioids in the last decade — a commitment to slow or stop the epidemic.

“All of those with this disease matter. My daughter Liz still matters. And all who have died still matter,” McGrory said.

Baker says he’ll issue updates on the results of his plan on a regular basis. Four of his proposals cannot take effect without approval from the state legislature. Baker and his aides say they are hopeful that working with partners, opioids will stop stealing so many lives.


New Normal In Age Of Hookup Apps? Rhode Island Rises In Syphilis, Gonorrhea, HIV

New Normal In Age Of Hookup Apps? Rhode Island Rises In Syphilis, Gonorrhea, HIV

(Rhode Island Department of Health)

(Rhode Island Department of Health)

By Marina Renton
CommonHealth intern

The numbers are striking: Recent double-digit rises around the country in long-familiar sexually transmitted diseases — gonorrhea, HIV, even the old scourge of syphilis.

Perhaps even more striking is what Thomas Bertrand of the Rhode Island Department of Health said recently about the rising numbers on Here&Now: “I would not call it a crisis, I’d call it a new normal right now, and we need to push against it.”

Last month, the Rhode Island Department of Health put out a press release with its data from 2013 to 2014: Reported cases of infectious syphilis increased 79 percent, gonorrhea cases increased 30 percent, and newly-diagnosed HIV cases increased 33 percent.

While these figures are dramatic, particularly the increase in syphilis, it’s important to remember that year-to-year changes aren’t always the best data to look at, said Bertrand, who is chief of the office of HIV, STDs, Viral Hepatitis, and Tuberculosis for the state Department of Health. It’s better to examine a period of five to 10 years, he says.

But those numbers don’t look good either: Since 2009, Rhode Island, along with the rest of the country, has seen increases in chlamydia, gonorrhea, and syphilis, Bertrand said in a phone interview. “We mirror the national trends in general.”

“The acceleration or the increase may be a little bit steeper in Rhode Island than the rest of the country, but just a little bit,” he added.

Can swiping right lead to STDs?

The Rhode Island Department of Health’s statement mentions the use of hook-up apps as a “high-risk behavior” that could be associated with the increase in STDs. However: “We don’t have data to say that the use of social media or the people who use it are more infectious or transmitting disease more than people who don’t,” Bertrand said.

But the apps do add to tracking problems: When people use social media such as Tinder and Grindr to arrange hookups, the encounter can be casual and brief, so people don’t share much information, Bertrand said. So, when someone is diagnosed with an STD, he or she might not be able to provide contact information for his or her sexual partners, making it harder to curb the spread of the disease.

Given the use of social media to arrange sexual encounters, there is opportunity for the health department to move online, Bertrand said.

“Most of the work we’ve been doing [recently] has been Internet-based,” he says, “getting information out there that is easy to understand and very practical.”

What else might be at work?

The CDC reported a 10 percent increase in syphilis from 2012 to 2013, but between 2009 and 2013 there was a 24 percent increase in cases of syphilis nationally, Bertrand says. Gay and bisexual men are at particular risk for the infection, the CDC wrote in a fact sheet on the 2012 to 2013 changes.

Rhode Island health officials have also observed that gay and bisexual men seem to be at higher risk for syphilis and, at the end of 2014, the health department implemented a social marketing initiative to encourage gay and bisexual men to get screened, Bertrand says.

More screening?

The RI Department of Health suggests an additional reason for the increase in reported cases of STDs: better testing.

When syphilis is in its early stages, it’s possible to miss the symptoms, Bertrand says. The primary stage manifests as a sore, or chancre, that might be hidden and painless enough that someone doesn’t know it’s there. With more regular screenings, a doctor is able to catch the disease before it progresses enough to have serious complications, he says.

Syphilis is commonly transmitted through oral sex, as well as anal and vaginal, Bertrand said, so “we need to…educate people that some STDs, like syphilis, can be transmitted through oral sex.”

Societal shifts might also play a role in the recent rise in STDs.

“I’m finding anecdotally that younger people are choosing to self-identify in many different ways sexually,” Bertrand says. “High school students who self-identify as part of the LGBTQ population…have higher risk factors. So that’s a group that we want to make sure that we’re working with.”

STDs seem not to scare young people as much as they used to, Bertrand added. While many of them are treatable, they can still have long-term consequences, such as reproductive health problems, he added.

“Society is evolving in so many ways, whether it be the Internet or contraception or advances in society’s acceptance of people who don’t identify as straight or heterosexual,” Bertrand says. “I don’t think there’s one single magic bullet [to halt the increase in STDs]…we have to be very sensitive to people’s needs and behavior and…see if we can work with them.”

Numbers in perspective

Bertrand also notes that because Rhode Island is such a small state, a large percent increase in the number of cases might not point to an immediate crisis. For example, a change from two to three is a 50 percent increase, but the numbers are still objectively small.

“We have small numbers sometimes, and so we’ll see an increase and the percentage increase looks really large, but if there were larger numbers there wouldn’t be as much of an increase,” Bertrand says.

Again, the longer-term trends are key. But a short-term spike can serve as a red flag: The 2013 to 2014 jump was “bigger than something we would have predicted,” he says.

So are these recent rises just blips or possibly trends of concern?

One thing seems certain: The world is changing quickly, from technology to sexual identities, Bertrand tells Here&Now. “Our traditional tools for trying to keep STD rates down are not as useful as they once were, and I just think we need to be more progressive.”

vendredi 19 juin 2015

For Salem Dispensary, Mass. Issues One-Time Waiver From Marijuana Safety Tests

For Salem Dispensary, Mass. Issues One-Time Waiver From Marijuana Safety Tests

Massachusetts’ first medical marijuana dispensary will be allowed to open, but for limited sales, while the state reviews safety standards.

Marijuana grown so far tests for lead higher than allowed in Massachusetts, and the state says labs are not equipped to test for seven of 18 restricted pesticides. But the Baker administration will let Alternative Therapy Group, a proposed dispensary in Salem, open as long as it limits each patient to 4.23 ounces and instructs patients to consume no more than two grams a day.

Marijuana plants at In Good Health Inc., in Brockton (Jesse Costa/WBUR)

Marijuana plants at In Good Health Inc., in Brockton (Jesse Costa/WBUR)

“Patients have waited to access marijuana for medical purposes for far too long,” Gov. Charlie Baker said in a statement. “This waiver will allow industry laboratories a little more time to reach full operation while providing safe amounts of medical marijuana for qualifying patients who need it.”

Baker approved a one-time, three month waiver from the safety requirements.

“We carefully considered the initial testing results and we will review the standards going forward,” Dr. Monica Bharel, the Department of Public Health (DPH) commissioner, said in the statement.

Now that marijuana has been cleared for sale through a dispensary for the first time in Massachusetts, DPH will conduct a final inspection of the store in Salem. If the dispensary passes inspection, it could open next week.


When My Mother Died: A Story Of ‘Incomplete Mourning’

When My Mother Died: A Story Of ‘Incomplete Mourning’

By Sarah Baker

I was 8 years old, and the sky was black, the day my mother died.

That morning, after a five-year struggle with a brain tumor, she’d passed away at Bethesda Naval Hospital, where she had been admitted a couple of days earlier. I hadn’t seen her since.

Grieving wasn’t an option in our house. We were a “chin up, shoulders back” group led by Dad, a rising star in the Navy. At my mother’s graveside in Arlington National Cemetery, my 10-year-old brother and I stood like little replicas of John F. Kennedy Jr. 12 years earlier when he saluted his father’s coffin. There were no tears, no signs of weakness. Long periods of mourning or sadness were not in our family culture — our grief was put on hold. There were bags to pack, and new ports of call. I was Soldiering On.

The Hardest Thing

According to the advocacy group SLAP’D (Surviving Life After a Parent Dies), 1 in 9 Americans loses a parent before age 20. Of those, nearly half said it was difficult to talk about their grief and only 7 percent said a guidance counselor helped. Six out of 10 adults interviewed, who lost a parent when they were children, said it’s the hardest thing they’ve had to deal with.

Sarah Baker at age 6, two years before her mother died (Courtesy)

Sarah Baker at age 6, two years before her mother died (Courtesy)

For us, the coping mechanism of Soldiering On worked splendidly for years, even decades. I survived all of the moves due to Dad’s deployments, even thrived, people might say. I went to college, graduate school, found great jobs, married a wonderful man, and had two beautiful children. All seemed well, at least on the surface.

But years of anxiety and disassociation gripped me. Recently, though, I felt all that emotional baggage was not sustainable. My external world appeared blissful (and it was!) but my internal world reeled. I had periods of blankness, inability to focus, sleeplessness, feelings of isolation when I was surrounded by loving people; despair, longing for something else, numbness, repeating negative loops in my mind, and sensations of being half dead. These feelings came in waves — days of it followed by lightness and connection. The longest darkness lasted three months — the world drained of its colors and none of my usual “reset,” or coping, tools seemed to work.

Necessary Grief

Importantly, coping is not grieving. “There is a kind of sanity to grief,” says Kay Jamison, a professor of psychiatry at the Johns Hopkins School of Medicine and author of “An Unquiet Mind.” “It provides a path — albeit a broken one — by which those who grieve can find their way. Grief is not a disease; it is a necessity.”

Funerals and other rituals bring people together and defend against loneliness. But if the grief lingers too long, is too severe, or unprocessed, it might begin to resemble depression. It’s a fine line indeed.

I now know I had never fully experienced the pain and sorrow of my grief.

Thirty-eight years after my mother’s death, I was standing at the kitchen sink in my house in Cambridge, Massachusetts, looking out the window at our young tulip poplar tree, cleaning my 10-year-old’s lunchbox for his day at moviemaking camp. My husband and son were cheering over the headlines they’d just read about the Red Sox’s winning record. Our 13-year-old daughter, Anna, was eating her favorite breakfast, Greek yogurt with honey and toast with peanut butter. Washing the dishes, without any warning, I had a terrifying vision. The room emptied of its color and sound and I became overwhelmed with feelings of gloom.

A Scary Vision

I could not see the deep blue and yellow of the painting of coffee cups that hangs over our espresso machine. I could not make out my toaster and the windowsill above it lined with the colorful bowls my daughter made in pottery class. I saw everything in a gray hue, as if I was looking out through a gauzy shroud.

Suddenly, into this vision a crowd appeared — ghost-like and massed together, as if formed from one piece of clay. They were lined up behind one woman and screaming at me.

I couldn’t hear my family’s chatter, the humming of the dishwasher, the gurgling our freezer makes when it releases new ice. All I could hear were these strangers’ taunts.

That moment in the kitchen felt eternal but might have lasted only a minute or two. I must have dropped the Tupperware but nobody noticed. In the midst of it, after I found my way to the sofa and tried to calm my racing heart, an image of my favorite candle found its way into my terror. A friend had once suggested that the best way to ground yourself when disassociating is to focus one of your senses. For me, this candle with its strong scent of mint, ginger, tea and tobacco seemed like my best chance. Somehow I found my way up my stairs and into my bedroom where the candle was. The next thing I remember is my nose deep in it and my sense of self back to normal.

This tale sounds crazy. I don’t do drugs. Never have. But, it felt as if someone had slipped some LSD into my latte. For the rest of the day, I felt tender and pulled apart.

An Intimate Sorrow

After a couple of weeks of piecing myself back together — talking to therapists, doctors and friends — and researching what might have happened, I began to think of the episode, strangely, as a gift. Ever since my mother’s death and without proper grieving, I’d been carrying her loss inside me. That morning in the kitchen, two summers ago, for the first time, I became conscious of the unresolved grief I’d been lugging around for decades.

The feelings of grief are completely individual — no two griefs are the same. That is why counselors recommend against saying to someone bereaving, “I know how you feel,” because most likely, you don’t. And as C.S. Lewis wrote in, “A Grief Observed,” “Sorrow…turns out to be not a state but a process. It needs not a map but a history.”

That being said, it is possible to make generalizations about grief, according to Holly Prigerson, professor of sociology of medicine at Weill Cornell Medical College and clinical researcher on grief.

The physical responses to grief vary but may include digestive problems, insomnia or other sleep troubles, sore or tight muscles, fatigue, headaches, chest pain or pressure, dryness of mouth, numbness, inability to concentrate and then, of course, the rollercoaster of emotions. Generally, these feelings are most intense in the first six months after the death. Then typically, they taper and begin to habituate.

Much has been written about Elizabeth Kubler Ross’s now-debunked five stages of grief — denial, anger, bargaining, depression and acceptance. Prigerson believes that grief should be considered in states, not stages. People might experience some of these reactions; but not all, in differing order and in differing degrees and not necessarily through a sequence of distinct stages. And, what’s missing, most crucially, from Kubler-Ross’ list is yearning — perhaps the most intensely felt state.

Incomplete Mourning

But what happens when you don’t go through this process? I didn’t have an answer, so I started researching.

What I learned was that the stories of childhood loss differed from adult loss. And in cases where the person didn’t mourn, I saw similarities to my own story — years of disassociation, hyper-vigilance, churning thoughts and depression.

In the midst of these grief conversations, my brother Sam — the only person who could possibly understand my history and feelings — sent me William Styron’s, “Darkness Visible,” an honest and engrossing account of the author’s depression. I was moved by the writing but mostly intrigued to keep reading because Sam said the book had been very meaningful to him. Then on page 80 in this 84-page book, I read, “The death or disappearance of a parent, especially a mother, before or during puberty — appears repeatedly in the literature on depression as a trauma sometimes likely to create nearly irreparable emotional havoc. The danger is especially apparent if the young person is affected by what has been termed ‘incomplete mourning’ — has, in effect, been unable to achieve the catharsis of grief, and so carries within himself through later years an insufferable burden of which rage and guilt, and not only damned up sorts, are a part, and become the potential seeds of self-destruction.”

“Incomplete mourning — according to Dr. Peter Shabad, associate professor of clinical psychology at Northwestern University Medical School and author of the book “Despair and the Return of Hope” — “is when people present a picture that something was left behind that they keep returning to.” In other words, it’s when people, for whatever reason, can’t let go of a trauma, loss or unacknowledged suffering. It’s a variation of what Sigmund Freud called “repetition compulsion” — a psychological phenomenon where a person repeats, or “relives,” a traumatic event over and over again.

In my case, because I didn’t process my grief, and as an 8-year old didn’t even have the language for the intense feelings, it was as if I put them in a metal box, welded it shut, and buried it inside of me. Those feelings were too terrifying to let out. But over the years as I learned new coping mechanisms, for instance, the ability to be present and also to rely on others, that box’s seal weakened, maybe it even rusted a bit. That morning in my kitchen, it finally burst open. No wonder the people in my vision were so angry. You would be too if you’d been locked up for 38 years.

Sarah Baker is a freelance writer and independent radio producer.

Calling All Gene Detectives: Solve Diagnosis Mysteries To Win Contest, Play Role In Film

Calling All Gene Detectives: Solve Diagnosis Mysteries To Win Contest, Play Role In Film
[Watch on YouTube]


What in the world is wrong with Dr. Katia Moritz?

When she was 43, Moritz felt like she had life all figured out. Always a high-energy extrovert, she would begin her workdays as a clinical psychologist treating severely ill patients at 7:15 a.m., and get home in time to be with her three young children after school.

There was no time for slacking in a life so full, so when she was scheduled for a minor diagnostic procedure that involved inserting a tube down her throat to look into her stomach, she figured she’d recover from the sedation and come right back to work that afternoon.

But afterward, she felt so sick she went to bed and slept for three days. “I felt like I was poisoned,” she recalls. “It felt like the worst flu ever. I had a low grade fever, my body hurt, everything hurt. After a few days, I improved, but I never felt well. And then it became an episodic illness — a few days later I’d get it again, and a few weeks later I’d get it again.”

Moritz, now 48, has never been the same. For the last five years, she has seen dozens of doctors, trekked to leading medical centers around the country in search of a diagnosis and cure, to no avail. Her fevers come and go, and other symptoms; sometimes it’s hard to swallow, even walk.

Dr. Katia Moritz shares a happy post-interview moment with 5-year-old Jeremy, who is also undiagnosed. (Courtesy "Undiagnosed")

Dr. Katia Moritz shares a happy post-interview moment with 5-year-old Jeremy, who is also undiagnosed. (Courtesy “Undiagnosed”)

If this were the television show “House,” or the popular New York Times column “Think Like A Doctor,” her story would have a neat ending, a solution to her mystery. But as Moritz has learned in her exhaustive travels, in real life, a great many people — millions of them, she estimates — are clearly very sick but never get the answer that could help them get well. Call them “the undiagnosed.”

Now, she’s working on a documentary on their plight (see the trailer above) and — in a lucky convergence — she’s combining forces with the bright minds at the cutting edge of genomic research to seek answers.

Five undiagnosed patients from the documentary are the focus of a new contest run by Boston Children’s Hospital, titled “CLARITY Undiagnosed.” Aiming to advance the field of genomic medicine — using a patient’s gene information in the clinic — it offers a $25,000 prize to the research team that best solves the patients’ diagnostic mysteries.

In an unusual twist for such an exercise in competitive crowd-sourcing, the teams may also appear in the documentary that Moritz is creating. Titled simply “Undiagnosed,” It is still filming and thus far chronicles the patients’ struggles but has no happy endings. (The medical detectives can also opt out if they’re camera-shy.)

Up to 30 competing teams in the CLARITY contest will be given each patient’s full medical record — no small file, given the medical odysseys they have endured. The contestants will also be given extensive data on the patients’ genes.

Teams have until June 25 to apply, says Dr. Isaac Kohane, chair of Harvard Medical School’s Department of Biomedical Informatics, and they will then have two months to work. Results will be announced in November.

“I would say that, based on the performance from the Undiagnosed Disease Program at the National Institutes of Health, the probability that we’re going to find something in any of these individuals is about 50 percent,” Kohane says.

The contest aims to advance “the diagnostic art,” he says, in the big-data era of the human genome.

“We bandy about numbers these days — gigabytes come so easily to our lips,” he says. “But evolutionarily speaking, the old brain in our cranium really has no idea what 3 billion looks like. So when we start having literally hundreds of mutations — each genome is larded with thousands of mutations that are personal to only you — you have to appeal to a lot of ancillary data and knowledge to come to a conclusion. Because otherwise, an overly trigger-happy interpretation of our genomes is going to bring us back to incidental findings — and we’ll start removing body parts incautiously.”

The contest is also looking for strong performance in communicating potentially tricky results to non-expert doctors and patients.

This is the second such contest that the Boston Children’s Hospital team has run. The first, back in 2012, solicited diagnoses for three families with children who had serious illnesses, and yielded diagnoses for two out of the three. (See the Children’s video below.)

[Watch on YouTube]


One noteworthy element of that contest, Kohane says: Some of the winning teams came from hospitals where the children had previously been seen but not diagnosed.

“That tells me that the usual clinical visit is just not the same thing as a team of people looking at this family as a competitive puzzle,” he says.

Dr. Isaac Kohane (courtesy)

Dr. Isaac Kohane (courtesy)

Kohane and Moritz had been traveling along two very different paths. She had been criss-crossing the country seeking a diagnosis and interviews with experts on the problems of undiagnosed patients and how the current medical system fails them. He represented what that system is doing to try to improve: He is the coordinator of a $9 million NIH project called the Undiagnosed Diseases Network, which aims to use genomics to diagnose rare and new diseases.

When Moritz contacted Kohane last year, he offered to try to help the patients in the film, but he tried to manage her expectations, he says, warning her that the contest may not bring the results she wants.

Moritz said she understood, he recalls — but that it was tremendously meaningful that he was even willing to try. Even for patients convinced they would surely die before medical science would ever find the answers they needed.

Readers, please stay tuned. There will be no media access to the families involved during the contest, but we will cover the results in November. The contest website is here