For years, Mrs. Sutton came to see me in the office every three months. Visiting the doctor quarterly was “the right thing to do,” she told me, given the fact that she had both diabetes and high blood pressure.

She always set the agenda at our visits. She brought lists of questions and requests that followed the recommendations of her fellow churchgoers and the health materials she had read.

It came as no surprise to me when she asked to undergo a colonoscopy at age 68, in order to be screened for colon cancer. She had read that colon cancer was treatable if caught early, and several friends had told her that undergoing “the scope” was the most comprehensive means of screening.

I agreed that it was a good idea and dutifully made the referral to the gastroenterologist. When the report came back a few weeks later, I was pleased to learn there were no polyps found.

When I mentioned the test to Mrs. Sutton at our next visit, I assumed she’d be as happy with the results as I had been. Instead, her reaction shocked me.

“How on earth could this cost so much?” she demanded of me. “This is an outrageous bill!” she said, referring to both the colonoscopy charges and the facility fee, which totaled more than $5,000.

“Yes, the prices of medical tests can be hard to believe, but you have Medicare” I told her. Because Mrs. Sutton had ‘Medigap coverage,’ she owed nothing.

The fact that her out-of-pocket costs were zero failed to sway her. It was the principle of the thing. She felt gouged by the price of a procedure which she valued at a few hundred dollars at most.

Unfortunately, there was no turning back. The damage had been done. Mrs. Sutton made very clear to me that she’d never undergo a test that pricey again, even if insurance paid for it.

Furthermore, she told me that she expected me to provide better information about what something might cost beforehand.

Without realizing it, I had fallen into the abyss of medical prices— a topic that still puzzles and enrages millions of Americans.

Like many doctors, what little I know about medical pricing comes from a combination of what my patients tell me and what my family and I experience personally. There was no formal training in medical school about health care spending or the cost-effectiveness of various tests and treatments.

Instead, we were taught to ignore costs and focus on the best care and treatment we could provide. This was health care, American-style. No stone should go unturned in the pursuit of a diagnosis. Any and all resources should be brought to bear in treatment. Payment was almost never discussed in polite company.

Fortunately, I think, doctors are warming to the idea that we must be better stewards of the resources we command.

Pharmaceuticals were long an exception to the cost-is-no-concern rule. Orthodox medical teaching has always emphasized the principle that a well-established, low-priced generic drug is as good as a more expensive name-brand alternative. Yet evidence shows that in spite of mutual doctor-patient desire to discuss drug costs, we docs usually shirk the duty.

Diagnostic tests are an entirely different kettle of fish. Despite patient demand to know the cost of a test or procedure, it’s been very hard to get reliable price quotes. New entities have formed to try to solve this perennial puzzle: One company provides an app that links with insurers’ databases to accurately list contracted prices. Another provides incentives to patients to get tests in-network by offering discounts and sending patients a check for a small portion of the accrued savings.

Which brings me back to Mrs. Sutton, who died before smartphones changed the way we live. Back when she confronted me about the cost of her colonoscopy, there was no app to help her shop around. Nor was there any resource for me to guide her to the most cost-effective alternative.

All of my experience to that point had taught me that patients with insurance simply didn’t care about prices. Mrs. Sutton begged to differ. Her reaction taught me never to make that assumption again.

John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa’s Medical Matters. He’s on Twitter: @GlassHospital

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Childbirth historically involved a support system of women who assisted a woman from her pregnancy through the birth and in the immediate postpartum period afterward.

Today, obstetricians and midwives provide prenatal care and help a woman deliver her baby. Doulas continue to fulfill the historical role of emotionally supporting a pregnant woman through labor and childbirth, helping her advocate for herself and communicate with her caregivers.

A study published online Thursday by the journal Birth suggests that offering women the support of a certified doula could save Medicaid and perhaps private insurers real money — nearly $1,000 a birth — by reducing cesarean and preterm births.

Previous research has shown lower rates of cesarean births, more satisfaction from mothers and better newborn Apgar scores — a measure of a baby’s condition at birth — among mothers who use doula care. In fact, the American Congress of Obstetricians and Gynecologists says in guidelines for safe prevention of cesarean births that doula care is “probably underutilized.”

This is the first study, however, to show a reduction in preterm births and a net savings for public insurance. Cesarean births — about a third of all U.S. births — cost about twice as much as vaginal births, and the 1 in 10 U.S. infants born preterm (before 37 weeks) incur medical costs 10 times greater than those of full-term infants.

“What is coming together now is a research consensus and a professional consensus of the benefits of doula care,” said lead author Katy Kozhimannil, an associate professor in the University of Minnesota School of Public Health. “The barriers to access are financial, cultural and geographic. The financial barrier ought to be the first to fall.”

Her analysis compared 1,935 women in Minnesota who accepted state doula services covered by Medicaid with 67,147 Medicaid-covered women throughout the northern and midwestern U.S. who didn’t get help from doulas.The doulas visited with the mothers four times leading up to the birth, provided support during labor and delivery and made two postpartum visits to the women.

In comparing the groups, 4.7 percent of the women using doulas had preterm births compared with 6.3 percent of the women who didn’t get doula help. Similarly, 20.4 percent of doula-supported women had cesarean deliveries compared with 34.2 percent of the women without doulas All told, an estimated $986 per birth would be saved if all the women received doula services, the analysis found.

How doulas decrease the odds of a cesarean birth isn’t entirely clear. One way might be by reducing cesareans recommended out of convenience, such as during a more slowly progressing labor.

“One of the questions doulas are trained to help women remember to ask is, ‘Is this an emergency or do I have time to think about it?’ ” Kozhimannil said. “If it’s an emergency, it’s outside the doula’s scope of work. If it’s not, that’s an opportunity for the doula to help the woman come to a decision with her clinician.”

However, there is a potential risk if inadequately trained doulas practice outside their scope of care, says Aaron Caughey, chair of the Department of Obstetrics & Gynecology at Oregon Health & Science University in Portland.

“I can’t think of a lot of negatives fundamentally in the routine use of doulas,” he said. “But in my clinical experience, the one possible negative is that a lot of the time the individuals who use doulas have a certain mindset about birth, and the doula can sometimes serve to block the clinician from practicing in the way the clinician might wish.”

For example, a doula might discourage a woman from agreeing to a rupture of membranes recommended by a clinician even if breaking her waters is medically indicated, he said. If physicians, midwives and doulas work together from the start, disputes over care are less likely.

Why doula care might affect preterm birth is also uncertain but might partly result from a reduction in stress because of the support of a doula during prenatal care, Caughey said.

Kozhimannil’s team analyzed preterm births and cesarean births separately, but another analysis that combined them revealed no reduction in cesareans among preterm births. She said that’s a good thing because it means the reduction occurs among healthy deliveries and not the complicated ones more likely to need a C-section.

Although the researchers adjusted the analysis for mothers’ age and race/ethnicity and having high blood pressure or diabetes during pregnancy, the groups may still have been too different for adequate comparison, wrote Adam Powell, a health economist and president of Payer+Provider Syndicate, in an email.

He pointed out that the larger control group may have included some doula-assisted births, albeit a small number, but that the better health of the women in the doula group may not have been fully accounted for in the statistical adjustments.

“It is not surprising that the intervention group was in better health than the control group as the intervention group had to be proactive about their health in order to be included in the group,” he wrote since only 15 to 20 percent of the mothers eligible for Medicaid-covered doula services used them.

The study’s findings would be stronger if the women had been randomized through a lottery to receive doula support or not, Powell said.

Even so, insurers can look through their own claims for answers. “Medicaid programs and health care companies generally have the data to conduct these analyses with their own data,” Kozhimannil said. “There is no reason they shouldn’t consider adding doula care or at least exploring that option.”

She pointed out the importance of this study’s findings in terms of the racial disparities in poor birth outcomes in the U.S.

“It’s important in an equity context because preterm birth is so much more frequent among black women compared with white women and preterm birth is the largest contributor to infant death,” Kozhimannil said. “The infant mortality rates and the disparities in infant mortality are something we’ve been reckoning with as a country for 100 years without good progress. Any identification of interventions that can help address issues related to preterm birth and especially disparities in preterm birth is urgently needed.”

Tara Haelle is a freelance health and science writer based in Peoria, Ill. She’s on Twitter: @tarahaelle

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The mammography debate heated up once again in April 2015, when the U.S. Preventive Services Task Force issued a draft of its latest breast cancer screening recommendations.

Now, after the public had a chance to comment, the influential task force has finalized the advice, reiterating that women ages 50-74 ought to receive a screening mammogram every two years. The USPSTF says that women between 40 and 49 don’t get as much benefit from screening as do older women, so they should make an individual decision on when to start based on how they view the benefits and harms. (Women with a family history of breast cancer may benefit more from starting screening before age 50.)

“Our recommendations support the entire range of decisions available to women in their forties,” Kirsten Bibbins-Domingo, a physician and vice chair of the USPSTF, told Shots. Some women may choose to begin at 40 or soon after, deciding they want to lower their cancer risk as much as possible and can handle the chance of false positive results or possible overdiagnosis, when cancer is discovered that never would have been harmful to health.

Other women, she says, may opt to wait until later in their 40s or until they turn 50.

The task force’s supporting materials include statistical models estimating the lifetime consequences of screening women from ages 50-74 and from 40-74. For each 1,000 women screened, the model finds that starting screening at 40 means an estimated one additional breast cancer death averted (deaths drop from eight to seven), with 576 additional false positive tests (1,529 vs. 953), 58 extra benign biopsies (204 vs. 146) and two additional overdiagnosed cases of breast cancer (21 vs. 19).

The task force also says there’s not enough evidence to say whether or not women 75 and older benefit from routine screening for breast cancer. The recommendations were published Monday in the Annals of Internal Medicine.

Since the draft was made public last spring, the American Cancer Society changed its advice for breast cancer screening, saying that average-risk women don’t need to begin annual mammograms until age 45 and can start screening every other year beginning at age 55. Other medical groups still recommend annual screening starting at 40.

While mammography guidelines differ, “it’s important for women and physicians to understand how much convergence there is,” says Bibbins-Domingo. The groups agree that mammography has value as a screening tool, and that the value of screening generally rises with age.

The Affordable Care Act guarantees private insurance coverage of preventive services without out-of-pocket costs for consumers if the evidence supporting the test has an A or B grade from the task force.

But Congress requires full coverage of mammography in women in their forties, despite the C grade, which indicates there is “at least moderate certainty that the net benefit is small.” In an editorial, the task force says that “coverage decisions are the domain of payers, regulators, and legislators” and that the group “cannot exaggerate our interpretation of the science to ensure coverage for a service.”

Just to be clear, this ongoing debate is over screening mammography, which means looking for signs of breast cancer in healthy women who have no symptoms of the disease. No matter your age, or whether or not you’ve started regular screening, if you have symptoms, you need to see a doctor.

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She’s on Twitter: @katherinehobson.

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Promising workers lower health insurance premiums for losing weight did nothing to help them take off the pounds, a recent study found. At the end of a year, obese workers had lost less than 1.5 pounds on average, statistically no different than the minute average gain of a tenth of a pound for workers who weren’t offered a financial incentive to lose weight.

“Our study highlights some of the weaknesses” of workplace wellness programs, said Dr. Mitesh Patel, assistant professor at the University of Pennsylvania’s Perelman School of Medicine and the study’s lead author.

The study, published in January’s issue of the journal Health Affairs, reported the results of a yearlong randomized controlled trial to test the effectiveness of financial incentives to encourage weight loss among 197 obese employees of the University of Pennsylvania health system.

Participants were asked to lose 5 percent of their weight. Each was assigned to one of four study groups. The control group wasn’t offered any financial rewards. The three other groups were offered an incentive valued at $550.

People in one group were told they would begin receiving health insurance premium discounts biweekly immediately after reaching their weight-loss goal. In another group, the people were told they would receive biweekly premium adjustments the following year if they reached their goal. Volunteers in the final group were eligible for a daily lottery payment if they met their daily weight loss goal and weighed in the previous day.

At year’s end, no group had met the 5 percent weight-loss target. Participants’ average weight was virtually unchanged, whether or not they had a financial incentive to lose pounds. Nineteen percent of participants did meet the 5 percent target, but they weren’t concentrated in any particular group.

The study was structured to reflect typical employer workplace wellness plans. “Our study showed that the incentive is not what motivated people, at least in this design,” Patel said.

Eighty-one percent of employers with 200 or more workers that offer health insurance also offered weight loss, smoking cessation or lifestyle coaching programs, according to the 2015 employer health benefits survey by the Kaiser Family Foundation and Health Research and Educational Trust. About two-thirds of large companies offered workers cash or merchandise for participating in these programs, the survey found, with 34 percent offering lower premiums or cost sharing. (Kaiser Health News is an editorially independent program of the foundation.)

The health law encourages wellness incentives by increasing the maximum reward for outcomes-based wellness incentives from 20 to 30 percent of the cost of health coverage, and up to 50 percent if the program is aimed at reducing tobacco use.

This study shows that how incentive programs are designed can make a big difference in how effective they are at changing behavior, Patel said.

The incentives may have failed for a number of reasons, he said. The $550 premium discount may not have been large enough. Bundling the financial reward into the insurance premium on a paycheck rather than making a separate payment to the worker may have affected how it was perceived. Other details — such as the fact that participants weighed themselves at work rather than at home — may have been off-putting to some participants.

Patel also noted that many employer plans don’t pay workers anything until they reach their goal, a situation similar to this study.

“Someone should be encouraged along the way,” he said. “We’ve found from studies that if you want to motivate people, they need regular feedback.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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Van Zyl and Garcia Flores hold hands as van Zyl promises to do everything she can to ease his pain and control symptoms. Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News hide caption

toggle caption Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News

When she first heard that California’s new aid in-dying law was signed, Dr. Carin van Zyl was relieved to hear that assisted death would be an option for her if she ever needed it herself. But as a palliative care doctor at the University Of Southern California Keck School Of Medicine, she’s worried the law might lead people to consider lethal medications over other options that may better accommodate their wishes.

“Patients feel as though their choices are between untreated suffering or physician-assisted suicide,” she told NPR’s Renee Montagne. “Palliative medicine, when it’s applied skillfully and at the right time, often relieves most of the suffering that prompts people to ask for [death] in the first place,” she says.

Van Zyl is head of palliative care medicine at Los Angeles County-USC Medical Center. Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News hide caption

toggle caption Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News

But palliative care, which is focused on managing symptoms and relieving pain, isn’t available to everyone, van Zyl says. There are smaller hospitals that don’t have palliative medicine teams, and it may be hard to get treatment even in urban areas. Van Zyl thinks more work should be done to make palliative medicine more accessible. “I worry that we make [lethal medication] available before we put the necessary effort forward,” she says.

Not everyone can be helped with palliative care, van Zyl says, and some people truly would have benefited from the aid-in-dying law had it been passed earlier. “I think about those patients all the time. I do recall a patient who understood that his death would be sudden and unpredictable and likely quite painful.”

He had a cancer that had spread and become intractable. A tumor developed in his neck that was swelling into both an artery and his windpipe; eventually it would connect the two. “This gentleman with very little warning might have his airways flooded with blood, and he would drown,” van Zyl says. “He asked if it would be possible to shorten his life before that.”

The care team was able to administer pain medication that would ease his death when it happened, which worked, van Zyl says, but he wasn’t able to die in the way he wanted — at home, surrounded by his family. Aid in dying would have offered more control over his situation, van Zyl says.

Still, the reasons why people choose aid in dying can be complicated. “You’ll notice in the Oregon data, many people chose this option not because of physical suffering. It was the loss of dignity, control and independence,” she says. “I would imagine writing a prescription for somebody for whom palliative sedation is not an option or would not relieve intolerable physical distress. I struggle with emotional and existential requests.” Times like that, van Zyl says she would rather administer palliative care.

Dr. Carin van Zyl talks to patient Jose Garcia Flores about his treatment options for his advanced stage colon cancer in October. Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News hide caption

toggle caption Heidi de Marco/Kaiser Health New/Heidi de Marco/Kaiser Health News

Choosing the best course of action is a conversation that van Zyl says she’ll continue to have with her patients. “Palliative medicine discussions are about learning the story of the person, helping this patient navigate choices. If [death] is an option that gets them closest to the things they hold dearest, then we will explore those things honestly.”

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Dr. Anne Merriman is determined to give the dying relief from pain in their last days. Courtesy Hospice Africa Uganda hide caption

toggle caption Courtesy Hospice Africa Uganda

Food coloring, water, a preservative and a pound of morphine powder. These are the ingredients in Dr. Anne Merriman’s recipe for liquid morphine.

“It’s easier than making a cake,” says Merriman, a British palliative care specialist who founded Hospice Africa in Uganda in 1993 and helped design the formula that hospice workers in Uganda have used for 22 years to craft liquid morphine. The lightest dose, dyed green to indicate the strength and to make sure people don’t confuse it with water, costs about $2 per bottle to make. Stronger doses are dyed pink and blue. A 16-ounce bottle is about a week’s supply for most patients.

Those cheap bottles of green, pink and blue liquid morphine have changed the way people die in Uganda — and are a key reason why Uganda has the best quality of death among low-income countries, according to global Quality of Death Index published by the Economist Intelligence Unit.

Back in the 1990s, two of the biggest barriers to good death in Uganda were simple: not enough doctors and not enough morphine. Largely through Merriman’s drive, Hospice Africa Uganda developed professional education in palliative care that would spread the responsibility to nurses, rather than relying on doctors. They helped make it mandatory for medical students in Uganda to study pain management -– before Germany did. And Hospice Africa Uganda made liquid morphine.

“I had been one of the doctors who had said to people, ‘Sorry, there is no more we can do. You have to go home,'” says Merriman, of the time she spent working with cancer patients in Singapore starting in the 1960s. There, she says, “I found that patients with cancer were getting every treatment possible with chemotherapy, and then when it didn’t work they were sent home and they were dying in agony.”

So she sat down with a couple pharmacists from the National University Hospital and came up with a formula to make a liquid from pure morphine powder.

An HIV-positive woman, living alone in a one-room house, speaks with a visiting doctor. Morgana Wingard/African Palliative Care Association hide caption

toggle caption Morgana Wingard/African Palliative Care Association

Merriman would eventually be invited to Kenya to set up a hospice care program in Nairobi before founding her own organization in 1993, based in Uganda. At that time, palliative care in Africa only existed in Zimbabwe and South Africa, and the services, she says, were “started out by whites for whites.” Medication was prohibitively expensive for most patients. “The strongest they had there was codeine — if you had money. But if you didn’t have money, you only had aspirin and sometimes nothing at all,” says Merriman.

Today, the organization’s three hospice centers serve some 2,100 outpatients. “It’s not always the pain that’s their greatest worry,” she says. “It’s often ‘What’s going to happen to my children when I die?’ It may be spiritual problems, it may be cultural — things they have to carry out before they die. We try to help with all those kinds of things.”

Relieving pain is step one — and it has many benefits. Patients eat better, sleep better and live higher quality lives, even in their last days, says Merriman.

Cost was one obstacle to pain management that Merriman had to address. Another, which persists in many countries, was a deep-rooted fear of opioid painkillers.

Though morphine is considered the gold standard in palliative care for pain management, in many parts of the world fear of opioid addiction and misuse is so rampant it has a name: opiophobia.

Merriman ran up against opiophobia in Singapore and Uganda, where she says, people thought she was providing morphine so that patients could kill themselves. “And morphine can kill,” she says. But with the right regulations in place, and the right explanation to the patient and their relatives, she says, “it’s very safe.”

For over a decade, the Ugandan government has provided morphine free to the patients of prescribers who are members of a special registry, all trained through Hospice Africa Uganda.

“You’ve got to be careful, everything has to be signed for and we have to follow the regulations,” she says. “But for the last three years, we’ve been making morphine for the whole country.”

Merriman says of the 24,000 patients in total that they have prescribed oral morphine to, “we’ve had no addiction, no diversions. And the patients keep the bottle at home.”

In Uganda, she had to work hard to surmount the fear of opioids. For example, Hospice Africa Uganda worked with narcotics police, teaching them what morphine is and that it’s a legal medication.

“They need to understand that patients can take morphine and that they are not addicted, that it is handed to patients after careful assessment, and that it is a safe medication,” says Dr. Eddie Mwebesa, clinical director at Hospice Africa Uganda. Without police cooperation, he says, “there will be a lot of trouble with patients having their morphine in the home” and in transporting the drug between hospices or patient homes.

Clinicians prescribe the morphine and instruct patients to sip a dose from a marked cup. For adults, it’s usually about a teaspoon every 4 hours. Merriman says hospice workers frequently have to warn people about morphine — not because of the risk of addiction but to explain that it will not wipe out their illness. She says they feel so good after it, they often feel normal again. “They think we’ve cured them,” she says.

Even with the innovations in Uganda, there are still challenges. The organization estimates that only 10 percent of Ugandan patients in need of palliative care can access it.

“The biggest challenge we have right now is the sheer number of patients who need palliative care,” says Mwebesa — he puts the number at 250,000 to 300,000. But there is about one doctor for every 20,000 Ugandans, he says.

Mwebesa says palliative care can cost about $25 each week for one patient. “It doesn’t sound like a lot,” he says, “But actually most people can’t afford it.” Only 2 percent of Ugandans have health insurance, so many families have to pay out-of-pocket to care for sick relatives.

A palliative care physician visits an HIV-positive patient who lost her family to the AIDS epidemic. She’s resting on a mat outside her home. Morgana Wingard/African Palliative Care Association hide caption

toggle caption Morgana Wingard/African Palliative Care Association

Even though Uganda is far from perfect, it remains in many respects a model country for its neighbors. “We had the minister of Swaziland visit Uganda to see how Uganda reconstitutes oral morphine and then when we went back, they started doing the same,” says Dr. Emmanuel Luyirika, executive director of the African Palliative Care Association. He says the same happened with Rwanda and Malawi.

Merriman is now turning her attention to French-speaking countries in Africa. She says some countries in the region remind her a lot of Uganda back in the ’90s. “They’ve got a fear of morphine. Doctors don’t want to prescribe it because they think if they prescribe it, they’ll be accused of being addicts themselves,” she says. World Bank data shows the region has the world’s highest maternal mortality and lowest national health budgets. And people there largely pay for health care out-of-pocket.

“If you haven’t got money,” says Merriman, “you can’t even get an aspirin.” At age 80, she’s still determined to see that the dying don’t have to face such dilemmas when they seek relief from pain.

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