The first thing out of John Iovine’s mouth is an apology.

“You got to forgive me if I don’t remember too much,” he says. “I had a stroke.”

Signs of that stroke are everywhere — the bed in the dining room, a shower installed in the pantry. John is thin, and sits in blue pajama pants in the wheelchair he uses to get around.

He may, however, have overstated his memory problems.

“We went to Harding … that’s the school right up here,” he says. It was 1952, and that’s where he saw the woman who would become his wife — “this girl, in this long red sweater, and her red hair. And I said, ‘That’s the girl for me,’ ” he says of Carol Iovine.

“I came out on top,” he says, laughing.

Carol, who is sitting next to her husband, explains that John’s stroke came in the middle of a bad run of health. First, he developed an ulcer, she says. Then he needed a bowel resection. After that came the stroke — and more.

“He had pneumonia, jaundice, sepsis; clot in the right lung,” she adds. All of that hit between October 2013 and January 2014.

John, a former house painter, spent 79 days in the hospital — some of that unconscious, and nearly all of it stuck in a bed.

“Aw, man — it was hell,” he says.

Sink Or Swim

John Iovine finally went home in April of last year, after several months in a rehab facility.

And this point in patients’ recovery — when they’ve been discharged and have to sink or swim on their own — is the stage that everyone in the health system is paying special attention to right now. For too long, too many people like John Iovine would take a dive at this stage, and end up back in the hospital again.

The industry calls these returns to the hospital preventable readmissions, and they are a huge drain on finances, costing Medicare alone $15 billion annually. That’s why Medicare launched an initiative a few years ago that penalizes hospitals that see too many patients readmitted too soon. And in turn, that spurred many hospitals to pay more attention to the problem.

Now insurance companies are also taking a stab at a solution.

“We are trying to identify which patients are likely to be hospitalized in the next three months — so that’s our target,” says Somesh Nigam. He’s the chief informatics officer for Independence Blue Cross, a Philadelphia-based insurance firm.

Independence Blue Cross, he says, is working to identify all those among its customers who are sick or frail enough to be on the edge of hospitalization.

To do so, the company runs algorithms on the huge amounts of health data at its disposal: billing claims, lab readings, medications, height, weight and family history. It also throws in information about the client’s neighborhood, including poverty rates.

“The health care data we provided to build these algorithms is equivalent, I think, to five Wikipedias,” says Nigam.

The computer algorithm sifts through all that information and pops out a score for each individual patient, identifying those it deems at highest risk.

Independence Blue Cross then assigns each high scorer a staff member — what it calls a “health coach,” who will work at no charge to the client to see what extra services may be helpful.

“This coordinated effort then works for the patient,” Nigam says. The coach may assemble health information tailored to the patient’s needs; make medical appointments; resolve medication issues, or maybe help arrange transportation to the doctor’s office. Sometimes the coach helps arrange for a home care nurse.

“And all of that,” Nigam says, “is beginning to show a pretty significant drop in hospitalization rates in our region.”

Independence Blue Cross has identified 18,000 clients for this sort of extra attention and, as just one sign of success, has already seen a 40 to 50 percent reduction in expected hospital admission rates for people with congestive heart failure.

Early successes include the Iovines.

Carol Iovine’s life changed, too, after her husband’s stroke: She’s having to manage his new medications, and help John shower and get to the toilet. They need to hire a wheelchair-accessible van for each appointment and therapy session, of which there are many.

She says having the support of John’s health coach has made a big difference in helping her manage her husband’s needs.

“He was supposed to get blood work, and they wanted me to take him to the ER to get blood work,” Carol remembers. ” ‘Uh-uh,’ I said. ‘No way.’ “

She called their health coach, Donna Crockett, and told her the problem. “And the next thing,” Carol Iovine says, “a nurse was here taking blood.”

Big picture: The money the health insurance plan spends on having Crockett arrange a visiting nurse, or streamline appointments is nothing compared to the cost of a hospital admission.

Writing The Rules

That promise of savings has a lot of health care specialists taking a harder look at the useful potential — and possible drawbacks — of these predictive computer formulas.

“There is a lot of interest in the area right now,” says Glenn Cohen, a professor at Harvard’s law school, who has written about the legal and ethical concerns raised by the collision of health care and big data. “It is a great coming together of the health care world and the computer science world, as well as the patient experience world.”

Still, he has some qualms.

“There are questions of whether people whose data is going to be used to build the engine have the right to opt out,” Cohen says. “Do they have to affirmatively opt in? Do they have to even be notified it’s being used?” These are still grey areas, he says.

The field is so new it doesn’t yet have established standards for how this information should be handled, Cohen says.

Independence Blue Cross says it follows federal health privacy guidelines regarding anonymity, and is only using the information to better serve its members. But it doesn’t ask the clients who subscribe to its health plans if they want to opt in.

“The data is only used to improve or coordinate care,” Nigam says. “And that is something that you would agree is our role.”

Health-wise, coordinated care seems to have made all the difference for John Iovine. He hasn’t been hospitalized in the year since Independence Blue Cross assigned him a health coach.

The insurer says the early results are so promising that the company is expanding its efforts. The firm is partnering with New York University’s Langone Medical Center on a next target — Type 2 diabetes. The goal is to spot people who are most at risk of getting diabetes before they start showing symptoms — and then intervene, in hopes of preventing the illness.

This story is part of NPR’s reporting partnership with WHYY and Kaiser Health News.

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By the end of June, the Supreme Court is expected to rule on King v. Burwell, a case challenging the validity of federal tax subsidies helping millions of Americans buy health insurance if they don’t get coverage through an employer. If the court rules against the Obama administration, those subsidies could be cut off for people in about three dozen states using HealthCare.gov, the federal exchange website.

Here are answers to some frequently asked questions about the case.

1) What is this case about?

The case challenges the federal government’s ability to provide subsidies to individuals who buy health insurance on the federal marketplace, sometimes called an exchange. Those subsidies are provided to lower- and middle-income customers since the health law mandates that most people have insurance. At issue is a line in the law stipulating that subsidies are available to those who sign up for coverage “through an exchange established by the state.” In the heated politics following the health law’s passage, a majority of states opted not to set up their own exchanges and instead rely on the federal government.

In regulations issued in 2012, the Internal Revenue Service said the subsidies would be available to those enrolling through both the state and the federal health insurance exchanges. Those challenging the law insist that Congress intended to limit the subsidies to state exchanges, but the Obama administration says the legislative history and other references in the law show that all exchanges are covered. Many lawmakers and staff members involved in the debate agree.

2) What happens if the court rules against the Obama administration?

According to the Department of Health and Human Services, more than 6 million people would lose their subsidies in the states where the federal government operates the health insurance exchanges.

An analysis from the Kaiser Family Foundation found that subsidized enrollees would face an average effective premium increase of 287 percent if the court rules against the administration. (Kaiser Health News is an editorially independent program of the foundation).

Florida would have the most people lose subsidies (1.3 million), worth nearly $400 million, with Texas ranked second in both categories (832,000 residents losing $206 million per month), according to the state-by-state analysis.

Even people who weren’t getting subsidies could be indirectly affected by a Supreme Court ruling against the administration. That’s because the elimination of subsidies would likely roil the insurance risk pool. Without the subsidies, many healthy people are likely to give up their coverage and that would drive up costs for those continuing to buy insurance.

Individuals in state-run exchanges and the District of Columbia would keep their federal subsidies.

3) If the Supreme Court rules against the Obama administration, when would subsidies disappear? Would those who lose subsidies still be required to buy health insurance under the law’s “individual mandate?”

Supreme Court decisions generally take effect 25 days after they are issued. That could mean subsidies would stop flowing as soon as August, assuming the decision is issued later this month, as expected.

Although the law’s requirement that individuals have health insurance would remain in effect, individuals aren’t required to purchase coverage if the lowest-priced plan in their area costs more than 8 percent of their income. So without the subsidies, many, if not most, people who had been receiving help would become exempt.

4) Will Congress fix this?

Congress could restore the subsidies by passing a bill striking the line about subsidies being available through exchanges “established by the state.” But given how many Republicans oppose the law, that sort of bipartisan cooperation is considered unlikely.

GOP lawmakers generally want to scrap the health law, but some back legislation that would keep the subsidies flowing temporarily.They would attach strings that Democrats and President BarackObama will surely object to. For example, a proposal from Sen. Ron Johnson, R-Wis., would maintain the subsidies for current beneficiaries through August 2017 but repeal the health law’s individual and employer mandates and requirements for specific types of coverage. However, a report from the American Academy of Actuaries said some changes favored by Johnson and other Republicans, such as eliminating the individual mandate, “could threaten the viability” of the health insurance market. Republicans have not coalesced around a specific strategy.

States could consider setting up their own exchanges, but that is a lengthy and complicated process and in most cases requires the consent of state legislatures. Many of those legislatures will likelynot be in session when the court rules and would have to be called back to take action.

Sylvia Burwell, the secretary of Health and Human Services, told Congress earlier this year that the administration has no authority to undo “massive damage” that would come if the court strikes down subsidies in federal exchanges. But she also has said the administration will work with states to help mitigate the effects.

5) Is this the last legal hurdle the health law will face?

No, but it’s probably the most significant one left. In other suits,House Republicans are challenging the money used for the law’s subsidies, saying it was not properly approved by Congress and that the administration did not have the power to delay the law’srequirements that larger employers provide coverage or face a penalty. Additional legal challenges include several dozen cases still pending over birth control coverage.

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The Affordable Care Act says that preventive health tests or services recommended by the U.S. Preventive Services Task Force have to be available to most insured consumers without any out-of-pocket cost.

Since the law was enacted, the list of services that people are entitled to has grown. In 2014, the task force recommended two new services and tweaked a handful of others that had previously been recommended.

Under the health law, preventive care that receives a grade of A or B on the recommended list by the nonpartisan group of medical experts must be covered by health plans without charging consumers. Only grandfathered plans are exempt from the requirement.

The newest recommended services are hepatitis B screening for adolescents and adults at high risk for infection and low-dose aspirin for pregnant women who are at high risk for preeclampsia, a condition characterized by an abrupt increase in blood pressure that can lead to serious complications for the woman and baby.

In its hepatitis B screening recommendation, the task force said there was new evidence that antiviral treatments improved outcomes in people at high risk for the liver infection, including those from countries where the infection is common, people who are HIV-positive and injection drug users.

Although it’s not a big cost from an insurance perspective, the March of Dimes welcomes the task force recommendation regarding use of low-dose aspirin to prevent preeclampsia in high-risk women, says Dr. Siobhan Dolan, an OB-GYN at Montefiore Medical Center in the Bronx, who’s a medical adviser to the March of Dimes.

“What’s exciting about this is that now we have something to offer women that’s a low-risk strategy,” says Dolan. Preeclampsia accounts for 15 percent of all preterm births.

The task force also issued a recommendation for gestational diabetes screening after 24 weeks in asymptomatic pregnant women. That service, however, is already being offered at no cost by health plans following an Institute Of Medicine study commissioned by the Department of Health and Human Services that identified gaps in existing coverage guidelines.

In its review of screening for gestational diabetes, the task force found sufficient evidence that it reduces the risk for complications such as preeclampsia, large birth-weight babies, and shoulder dystocia, when the baby’s shoulders become stuck inside the mother’s body during delivery.

The task force recommendations take effect for the plan year that begins one year after they’re issued so for many consumers, these provisions won’t take effect until 2016.

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Think of how often you stop by Walgreens or CVS. You run in and grab some Band-Aids or restock your ibuprofen supply. Maybe you even get a flu shot on your way to work.

Soon, it will be that easy for women in California to get birth control, too. Under a new state law, women will be able to go to a pharmacy, get a prescription for contraceptive pills, the ring, or the patch, get it filled and walk out 15 minutes later.

“For a woman who can’t get in to see their doctor, the pharmacist will be able to furnish that for them now,” says Lisa Kroon, a professor at University of California, San Francisco’s school of pharmacy who oversees students who work at the Walgreens store on campus.

That pharmacy will be one of the first to take advantage of a new law in California allowing pharmacists to prescribe hormonal contraception. The law, SB 493, was passed in 2013. State health officials are now finalizing the regulations for the law to take effect. The California pharmacy board met Thursday to review them. The law is expected to be fully implemented later this year.

But the law goes beyond birth control pills. It also authorizes pharmacists to prescribe medications for smoking cessation and travel abroad. Pharmacists can administer routine vaccinations to children ages 3 and older. They can even order lab tests and adjust drug regimens for patients with diabetes, hypertension, or other conditions. Kroon says the idea is to make it easier on patients.

“Maybe a working parent can now come after work because the pharmacy is open later,” she says.

The law was passed amid growing concern about doctor shortages. As more baby boomers hit age 65, and millions of people get health coverage under the Affordable Care Act, there aren’t enough primary care doctors to go around.

Advocates says California is the first state to recognize that pharmacists can help fill the gap.

“The pharmacist is really an untapped resource,” Kroon says. “We are graduating students that are ready for this, but the laws just haven’t kept up with what the pharmacist training already is.”

But there’s a big drawback for pharmacists. Now they can perform all these services once reserved for the doctor’s office. But, they won’t get paid for the extra time it takes to provide them.

The law does not compel insurance companies or Medi-Cal, the state’s version of Medicaid, to reimburse these services, says Jon Roth, CEO of the California Pharmacists Association.

In the long run, Roth says the law could ultimately save money, because reimbursement rates for pharmacists will inevitably be lower than what doctors charge.

“We are working to try and identify where it makes sense to pay pharmacists as opposed to other more expensive providers in the health care delivery system,” he says.

Pharmacists’ growing power has some physicians bracing for a turf war. The California Medical Association opposed an early version of the law, citing patient safety concerns. It later withdrew its opposition after lawmakers added a special licensing procedure and continuing education requirement for pharmacists.

Still, some doctors are concerned that if women don’t come to the clinic for their birth control, they won’t get screened for cervical cancer or tested for sexually transmitted diseases.

“Family planning for women is often an access point to assessing other health issues,” says Amy Moy, vice president of public affairs for the California Family Health Council, an advocacy group that supports the law. “Women accessing birth control through the pharmacist would be faster and more convenient. But they will also not have the comprehensive care available in another health care setting.”

Studies of women living on the border of Texas and Mexico found that women who get their birth control over the counter in Mexican pharmacies are less likely to go to the doctor for other preventive care, compared with women who get contraception at clinics. But women at the clinics were also more likely to stop using their birth control, in part because of having to schedule a doctor’s visit to get it.

Moy’s group and other women’s advocates say the benefits of improving access to birth control and reducing unintended pregnancies are critical to women’s health and outweigh the potential risks.

Pharmacy professor Kroon says the plan is for pharmacists to communicate regularly with patients’ doctors. “We are not a lone ranger out there doing something,” she says.

If things go well with the pharmacists law, it could bode well for efforts to expand the scope of practice for other health care practioners. Sen. Ed Hernandez, who led the effort on the pharmacist law, has also proposed bills to increase authority for nurse practitioners and optometrists. Both are working their way through the legislature.

Other states are watching California to see how the pharmacist law plays out. Lawmakers in Oregon and in Congress are considering similar laws.

“They are all watching what happens in California,” Kroon says.

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.

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