Stanford law professor and bioethicist Hank Greely predicts that in the future most people in developed countries won’t have sex to make babies. Instead they’ll choose to control their child’s genetics by making embryos in a lab.

On KQED’s Forum program, Michael Krasny spoke with Greely about his new book, The End of Sex and the Future of Human Reproduction. Greely highlights the ethical and legal questions that might arise in the future’s reproductive paradigm.

This conversation has been edited for length and clarity.

Krasny: There are a lot of new advances, technology and so forth. We reached the point where you get some sperm donor and a little piece of skin and you’re in business because of stem cells.

Greely: My book argues that two different biomedical innovations coming from different directions and not really propelled by reproduction are going to combine here. One is whole-genome sequencing, and the other is what I call easy PGD, preimplantation genetic diagnosis, [that] is, getting rid of egg harvest … which is unpleasant, dangerous and really expensive.

This ties in with in vitro fertilization also being not as onerous as it has been in the past.

What I think is going to happen, we’ll be able to take some skin cells from anyone and turn them into any cell type. Make these into eggs or sperm and that is going to make IVF much easier, cheaper and less dangerous.

You [can] decide, “Well, I want these traits,” and it becomes a selective process.

Yes, I think we will see an increased and broad use of embryo selection. I would be careful to set the time frame at 20-40 years. I think we’ll actually see a world where most babies born to people with good health coverage will be conceived in the lab. People will make about a hundred embryos, each will have its whole genome tested, and the parents will be [asked … “Tell] us what you want to know and then tell us what embryo you want.”

This could bring down health care costs, and it is also good for same-sex couples, isn’t it?

Well, yes and maybe. I think it should bring down health care costs, and, in fact, one of the advantages to it is that it would be so beneficial for public health care costs that I think it would be provided for free. If it costs say, $10,000 to start a baby this way, 100 babies is a million dollars. If you avoid the birth of one baby with a serious genetic disease, you’ve saved $3 [million to] $5 million. The same-sex issue, I think that’s going to work, but that’s another jump. That would be taking a skin cell … from a woman and turning it into a sperm. I think [it’s] probable, but that hasn’t been done yet.

This is not the end of sex — because recreational sex will always be with us — it’s the end of sex as a way of procreating.

I think it will not be the complete end. I think people will still get pregnant the old-fashioned way, right, sometimes for religious reasons, sometimes for philosophical reasons, sometimes for romantic reasons, sometimes because they are teenagers and the back seat of the car is there.

A lot of people talk about playing God, but before we get into that, there’s the rubric of consumer eugenics. And there is a eugenics fear when we start talking about selection.

There certainly is. Eugenics is a slippery word; it means many things to different people. To some, it’s state-enforced reproductive control. To some … what we had was state-enforced sterilization. To some, it’s any kind of reproductive choices, but those are different things. For me, I think the coercion is much more important than the issues of selection. The concern about the state or the insurance company or someone else, forcing you to pick particular babies, worries me a lot more than having parents make choices, though that raises its own set of questions.

What do you see as the biggest question here?

I worry about the dilemma of Republican legislators in very conservative states. They want to spend as little money as possible on Medicaid. I could imagine a state saying, “We’re not going to pay for this via Medicaid,” which would mean that the roughly 40-50 percent of babies born in that state who are paid for by Medicaid wouldn’t get to go through this, and although they are not “superbabies,” adding another 10-20 percent health advantage to the babies of the rich over the babies of the poor is a bad thing.

Listen to the full interview here. Greely shares his thoughts on cost, socioeconomics, gene editing and the ethics of designer babies.

This story was produced by KQED’s daily health and technology blog, Future of You. The blog’s host and editor is Jon Brooks.

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People who die in the hospital undergo more intense tests and procedures than those who die anywhere else.

An analysis by Arcadia Healthcare Solutions also shows that spending on people who die in a hospital is about seven times that on people who die at home.

The work confirms with hard data what most doctors and policymakers already know: Hospital deaths are more expensive and intrusive than deaths at home, in hospice care, or even in nursing homes.

“This intensity of services in the hospital shows a lot of suffering that is not probably in the end going to offer people more quality of life and may not offer them more quantity of life either,” says Dr. Richard Parker, chief medical officer at Arcadia.

Arcadia analyzed all the Medicaid claims data for a private Medicaid insurance company in one Western state and detailed how many billable medical procedures each patient received and where. Patients in hospitals were billed for far more medical interventions in the last days of their lives than people who died in other settings. The company declined to name the state or company.

The study showed that 42 percent of patients died at home at a cost of about $4,760 for their last month of life, while 40 percent died in a hospital at a cost of $32,379. Dying in a nursing home was the second most expensive locale, inpatient hospice was third and an emergency room was fourth.

“In the end, everyone died. They all died,” Parker tells Shots. “If we look at this retroactively, retrospectively — and we could go back and ask people — I bet most of them would say I’d rather be home with my family.”

Parker says the cost of hospital deaths paid for by Medicare or private insurance are likely even higher because they pay doctors and hospitals more for their services.

Many studies have shown that people, when asked, say they’d prefer to die at home rather than in a hospital. However, those wishes aren’t always realized if a person hasn’t given clear instructions to a doctor or family member.

Parker says hospitals are designed to cure people who are ill rather than to allow people to die peacefully.

“The culture of American medicine today and for the last several decades is to keep treating patients regardless of the quality of life,” he says. “A lot of physicians have been reluctant to admit that the patient’s life is coming to an end.”

The picture is more complicated than the data show, says Dr. Lachlan Forrow, a professor of medicine and medical ethics at Harvard University.

Many patients move from home to hospice to hospitals and back during the last 30 days of life. And some may end up in the hospital because their pain or symptoms weren’t adequately controlled at home.

Still, he says, hospitals are just not good at caring for dying people.

“We do lots of very expensive things in hospitals to people in the last part of life who would rather be home, and we do those in part because in the hospital they get paid for,” he says.

It’s the only way to justify keeping in a hospital the people who need around the clock nursing care but can’t get it at home.

“If we really tried to make sure people at home could have what they needed at home, we could take better care of them, with less medical system-caused suffering, at lower cost, sometimes much lower cost,” he says.

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As the summer unfolds, people are understandably interested in whether travel insurance will cover them if they cancel a trip because of concerns about the Zika virus. Other readers asked whether student health plans are a better option than the coverage from a health law marketplace and how an employer can’t offer mental health coverage. Here are the answers.

My wife and I have a trip planned to South America, but we’re increasingly worried about the Zika virus. We bought travel insurance when we booked the trip. If we cancel, will we be able to get our money back?

A typical travel insurance policy won’t reimburse you for trip expenses if you cancel because you’re afraid of traveling to a country where there have been reports of an outbreak of a disease such as the Zika virus.

But if you purchased a “cancel-for-any-reason” policy, your claim is more likely to be approved, said Megan Freedman, executive director of the U.S. Travel Insurance Association, a trade group. Like standard trip cancellation policies, these policies provide financial protection for unreimbursed expenses if you have to cancel your trip before it starts or interrupt it once you’re there. These policies also allow you to cancel for any reason, including pregnancy, a particular concern with the Zika virus. They typically cost a bit more than a standard policy. If you cancel, you’ll generally be reimbursed for about 75 percent of your prepaid expenses.

The Zika virus causes only mild flu-like symptoms in most people, but if women contract it during pregnancy, it can cause a devastating birth defect called microcephaly in their baby. Researchers estimate that babies born to between 1 and 13 percent of pregnant women who are infected during their first trimester will have that problem.

The virus is generally passed along through the bite of an infected mosquito.

Even if your travel insurance policy won’t approve your claim, it’s worth contacting your airline or hotel to ask about refunds, Freedman said.

“Ask what if any concessions your hotel or airline is extending,” she said.

I’m leaving my job to go to graduate school this summer. The college offers a student health plan, but would I be better off buying an individual plan on the marketplace? Since I worked half of the year, I suspect I won’t get much in subsidies.

The best choice for you will depend on a couple of factors, including how good the student plan is at your school and your coverage priorities: Do you want a plan with generous coverage or would you prefer something that may have a higher deductible, for example, but probably has a lower price tag?

Student health plans vary widely from school to school, said Stephen Beckley, a higher education health care consultant in Fort Collins, Colo. At many schools, coverage is equivalent to a platinum level plan on the state marketplace, meaning it pays 90 percent of the cost of medical services. A survey of student health plans at 38 public and private schools conducted by Hodgkins Beckley Consulting found average premiums were $184 at public universities and $217 at private colleges.

A platinum-level plan on the health law marketplaces would likely run more than that, especially if you don’t qualify for a federal tax credit to help pay the premium. On the state marketplaces, more than three-quarters of people who buy plans get premium tax credits, which are available to people with annual incomes up to 400 percent of the federal poverty level (about $47,000 for an individual). This year, after factoring in an average premium tax credit of $290, consumers paid on average $106 per month for coverage in the 38 states where the federal government operates the marketplace. Most people buy silver plans on the state exchanges, which pay for 70 percent of medical services, leaving them to pick up more of the cost of care than a platinum plan does.

My employer does not offer mental health benefits. What can I do?

You’re in a tough spot. The federal mental health parity law doesn’t require companies to offer mental health benefits. Rather, it says that if they do, the benefits have to be at least as generous as their medical/surgical benefits.

You have several options, but none of them is a slam dunk. Some therapists charge on a sliding scale for a small proportion of their caseload, said Lynn Bufka, a psychologist who is the associate executive director for practice research and policy at the American Psychological Association.

Depending on where you live, you may be able to find a local mental health clinic or federally qualified health center that offers mental health services for less than you’d pay a private therapist, Bufka said. You could also check out universities near you that have training programs for mental health professionals. You might be able to work with a student who’s under close supervision by a trained professional.

Once you find someone, ask if there are things you can do to help accelerate the work using self-help books or guided exercises between sessions.

“It’s important for people to understand that psychotherapy does not need to be a forever thing,” Bufka said. “It could be a 10 to 12 week intervention.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Email questions for future columns: KHNHelp@KFF.org. Michelle Andrews is on Twitter: @mandrews110.

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A few months ago, the Centers for Disease Control and Prevention published a startling map that showed the parts of the U.S. that could harbor mosquitoes capable of carrying Zika.

Many readers, including myself, thought, “Zika could come to my town! It could come to Connecticut! To Ohio and Indiana! Or to northern California! Oh goodness!”

The map made it look like a vast swath of the country was at risk for Zika, including New England and the Upper Midwest.

Well, not quite.

On Thursday, CDC scientists published another mosquito map for the U.S. And it paints a very different picture.

The new map shows counties in which scientists, over the past two decades, have collected Aedes aegypti mosquitoes — the type of insect thought to be spreading Zika in Latin American and the Caribbean.

“The new map is more accurate than the initial one,” says Thomas Scott, an entomologist at the University of California, Davis. “The distribution of the A. aegypti mosquito is much more restricted than the initial map showed.”

In the map, counties colored yellow reported A. aegypti mosquitoes during one year between 1995 to 2016. Orange counties had the mosquitoes in two years. And red counties are the hotspots: Scientists there found A. aegypti mosquitoes during three or more years in the past two decades.

This map represents “the best knowledge of the current distribution of this mosquito based on collection records,” entomologist John-Paul Mutebi and his colleagues at the CDC wrote in the Journal of Medical Entomology.

Many of the hot spots for this mosquito aren’t surprising. They’re places that we already knew are vulnerable to Zika, including counties in southern Florida, along the Gulf Coast and southern Texas. These places have had problems with a virus closely related to Zika, called dengue. They’re already on high alert for Zika.

But several hot spots are bit more unexpected — and concerning. “Perhaps the most concerning development for A. aegypti is its establishment in the Southwest, most recently in California in 2013,” Mutebi and his co-authors write.

Other surprises include parts of the Bay Area, greater Washington, D.C., and the Dallas-Fort Worth region, which all have established populations of A. aegypti, the map shows.

“The country is really a patchwork,” Scott says. “When you drill down into one particular state, you find that the mosquito isn’t found across the whole state. And when you drill down into a county, you find the same thing. The mosquito is found in just a small part.”

So why did the first map from the CDC make it look like such an extensive part of the country was at risk for Zika?

“The two maps show different things,” Mutebi tells Shots. “The first map showed where the climate is able to sustain populations of A. aegypti. This new map shows reports from counties where these mosquitoes were found in the last 20 years.”

And the new map, Mutebi says, is not complete. “Not all counties have mosquito surveillance programs looking for mosquitoes,” he says. In places that do, they are often targeting the mosquito that causes West Nile virus, not A. aegypti.

“So just because a county hasn’t reported having any A. aegypti mosquitoes, doesn’t mean they’re not there,” Mutebi says.

A. aegypti mosquitoes are nasty critters. They chase down people so they can feed on their blood, says virologist Scott Weaver at the University of Texas Medical Branch in Galveston.

“A. aegypti lives in close association with people, feeds almost exclusively on people — not animals — and even comes into people’s home,” he says. “Its behavior and its ecology are almost ideal for a mosquito to transmit a human virus.”

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Few people have the unusual set of professional experiences that Lonny Shavelson does. He worked as an emergency room physician in Berkeley, Calif., for years, while also working as a journalist. He has written several books and takes hauntingly beautiful photographs.

Now he’ll add another specialty.

California’s End of Life Option Act, a law legalizing physician aid-in-dying for people who are terminally ill, took effect this week. Shavelson has become a consultant aimed at answering questions from physicians and patients about the practice — and plans to become a physician to terminally ill patients seeking to end their lives.

I first met Shavelson in 1996 as I was covering the reaction to Oregon voters’ approval of Measure 16, the state’s Death with Dignity Act.

Oregon was the first state to approve the practice, and in 1996 the law was held up in court. I turned to Shavelson as he had published A Chosen Death, a moving book that followed five terminally ill people over two years as they determined whether to amass drugs on their own and end their lives at a time of their choosing. He was present at the death of all of them.

He followed the issue of assisted suicide closely for several years more, but ultimately moved on to other projects, among them a book about addiction and a documentary about people who identify as neither male nor female.

Then last fall came the surprising passage of California’s End of Life Option Act, giving terminally ill adults with six months to live the right to request lethal medication to end their lives. The law took effect Thursday.

Shavelson decided he has to act, although he feels “quite guilty” about having been away from the issue while others pushed it forward.

“Can I just sit back and watch?” Shavelson told me from his cottage office in his backyard in Berkeley. “This is really an amazing opportunity to be part of establishing policy and initiating something in medicine. This is a major change … [that] very, very few people know anything about and how to do it.”

His website, Bay Area End of Life Options, went up in April, and he outlined the law at grand rounds at several Bay Area hospitals this spring. His practice will be focused on consulting not only with physicians whose patients request aid-in-dying, but also with patients themselves, including offering care to patients who choose him as their “attending End-of-Life physician,” as he indicates on his site.

Shavelson is adamant that this is “something that has to be done right.” To him, that means starting every patient encounter with a one-word question: “Why?”

“In fact, it’s the only initial approach that I think is acceptable. If somebody calls me and says, ‘I want to take the medication,’ my first question is, ‘Why? Let me talk to you about all the various alternatives and all the ways that we can think about this,’ ” he predicts he will say.

Shavelson worries that patients may seek aid-in-dying because they are in pain. So first, he would like all his patients to be enrolled in hospice care.

“This can only work when you’re sure that the patients have been given the best end-of-life care, which to me is most guaranteed by being a part of hospice or at least having a good palliative care physician. Then this is a rational decision. If you’re doing it otherwise, it’s because of lack of good care.”

California is the fifth state to legalize aid-in-dying, joining Oregon, Washington, Vermont and Montana. The option is very rarely used. For example, in 2014 in Oregon, 155 lethal prescriptions were written under the state’s law, and 105 people ultimately took the medicine and died, a death rate under this method of less than 0.5 percent.

Under the California law, two doctors must agree that a mentally competent patient has six months or less to live. One of the patient-doctor meetings must be private, between only the patient and the physician, to ensure the patient is acting independently. Patients must be able to swallow the medication themselves and must state in writing, in the 48 hours before taking the medication, that they will do so.

Shavelson says he has been surprised by the lack of understanding he hears from some health care providers about the law. One person insisted the law was not taking effect this year; another asked how the law would benefit his patients with Alzheimer’s disease. To be clear, the law took effect June 9, and patients with dementia cannot access the law because they are not mentally competent.

The law does not mandate participation by any health care providers. Many physicians are “queasy” with the new law, Shavelson says he’s hearing, and are unwilling to prescribe to patients who request the lethal medication — even though they tell him they think the law is the right thing to do.

“My response to that is as health care providers, you might have been uncomfortable the first time you drew blood. You might have been uncomfortable the first time you took out somebody’s gall bladder,” he says. “If it’s a medical procedure you believe in and you believe it’s the patient’s right, then it’s your obligation to learn how to do it — and do it correctly.”

Shavelson said he predicts that many physicians who are initially reluctant to provide this option to their patients may become more comfortable after the law goes into effect and they see how it works.

Burt Presberg, an East Bay psychiatrist who works with cancer patients and their families, saysa talk he attended by Shavelson sparked a conversation at his practice. In my own talk with him, he peppered his statements with “on the other hand,” as he clearly wrestled with his own comfort level of handling potential patient requests.

Presberg spoke of his concern that patients can suffer from clinical depression at the end of life, sometimes feeling they are a burden to family members who could “really push for the end of life to happen a little sooner than the patient themselves.” He spoke from his experience of successfully treating terminally ill patients with clinical depression.

“Depression is something that’s really undertreated,” Presberg said. “I often talk to people about the difference between [that and] normal sadness and normal grieving at the end of life.”

He said he believes Shavelson will be aware of treating depression, “but I do have concerns about other physicians,” he said. “On the other hand, I think it’s really good that this is an option.”

Shavelson says he’s already received a handful of calls from patients, but he mostly spent the time before the law took effect talking to other physicians. He needs a consulting physician and a pharmacist who will accept prescriptions for the lethal dose of medicine.

Then he returns to the patient. “It’s important … that we’re moving forward,” he says. “It’s crucial that we do that because this is part of the rights of patient care to have a certain level of autonomy in how they die.”

To many of the doctors who feel “queasy” about moving to end a patient’s life, this type of care “isn’t so tangibly different to me,” Shavelson says, than other kinds of questions doctors address.

“I’m just one of those docs who sees dying as a process, and method of death is less important than making sure it’s a good death.”

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During the wars in Iraq and Afghanistan, the U.S. military did an about-face on detecting and treating brain injuries caused by explosions. After years of routinely sending blast-exposed troops back into combat, the military implemented a system that requires screening and treatment for traumatic brain injury.

The change came about in large part because of a remarkable campaign by an elite team of military officers who were also doctors and scientists. They worked for the highest-ranking officer in the armed forces. And they were known simply as the Gray Team.

The Gray Team began with a contentious job interview between the doctor who would lead the team and the man who would be his boss.

It was 2008 and Army surgeon Christian Macedonia had been told there was a high-level opening for a doctor who wanted to change the military’s approach to battlefield brain injuries. When Macedonia arrived for the interview, he found himself face to face with Adm. Michael Mullen, chairman of the Joint Chiefs of Staff.

“And he looks at me and he goes, ‘Who are you and what are you doing in my office?’ ” Macedonia says.

Macedonia explained he was there about the job. Mullen replied that he had decided he didn’t need a doctor on his staff. “And I said, ‘Sir, I’m going to disagree with you,’ ” Macedonia recalls.

Macedonia, a lieutenant colonel, told the admiral that if he really wanted to do something about brain injuries, he did need a doctor. What’s more, he needed one with combat experience, strong scientific credentials and a high-level security clearance. “I said, ‘Sir, you really only have one person and that’s me.’ “

Mullen smiled. He had been looking for someone he might have to rein in, but would never have to push. “And Macedonia fit that model for me perfectly,” he says. “He’s very outspoken, very straightforward. We talk about out-of-the-box thinkers; he just lives outside the box.”

Assembling The Gray Team

Macedonia’s first assignment was to put together a team. He recruited four other military doctors with combat experience and impressive resumes.

They were called the Gray Team, after the brain’s gray matter, the gray issues surrounding traumatic brain injuries and the graying team members themselves.

Their mission was to challenge something military doctors had been taught about blast exposure since World War I:

“If you don’t have blood coming out of your head, if you don’t have a penetrating injury, you have not been injured,” Macedonia says. “Your job as a doctor at that point is to say, ‘You’re gonna be fine’ and basically minimize any of the symptoms.”

Macedonia himself believed that when he was deployed to Iraq in 2004, to serve as chief of a combat support hospital near Fallujah. He was seeing horrendous injures, so he didn’t have much time for people who looked OK, even if they’d been dangerously close to a blast.

Macedonia and other military doctors actually became suspicious of service members who suggested blast exposure was the cause of their headaches, fatigue or sleep problems. “The attitude was that these people were trying to get a Purple Heart or something like that,” he says. “In retrospect, it was just awful. It was really a bad thing to do to people.”

Macedonia’s conversion occurred one day in Iraq, when he got caught in a mortar attack.

“I was out with a young Marine. We were in the middle of the attack. And the mortar was probably about 50 meters away,” he says.

The blast wave shook them violently. But they were alive. And they weren’t bleeding. So Macedonia went back to the hospital. He did surgery until midnight. Then, he headed for bed.

“I had a shaving mirror hung up by my cot and I looked in that mirror and I didn’t recognize the person looking back at me,” he says. Macedonia realized that he couldn’t remember anything from the operating room that night.

And he recognized the vacant expression he saw in the mirror: “The same sort of strange look in the eye that I had seen in people who had been in IED blasts up and down the route near our base.”

Macedonia was pretty sure he wasn’t having a purely psychological reaction to combat. The blast had injured his brain.

The Brain Battle Begins

In early 2009, Mullen’s Gray Team headed for Iraq and Afghanistan. By this time, IEDs had become the weapon of choice for insurgents attacking coalition forces. Tens of thousands of soldiers were being exposed to bomb blasts. And many were experiencing memory loss, confusion and sleep problems.

But the military still wasn’t taking the problem seriously. “We would tolerate multiple blasts [in] deployment after deployment,” Mullen says. “And I was determined to see if I could do something about this.”

So he sent the Gray Team to the battlefield to have a close-up look at what was happening to troops exposed to bomb blasts. “Quite simply, the Gray Team was there to establish ground truth with respect to traumatic brain injury,” Macedonia says.

And the truth was pretty grim. Often, troops weren’t even being checked for TBIs.

The military relies on something called the MACE exam — Military Acute Concussion Evaluation — to assess service members who have sustained a TBI or concussion. And Macedonia had been told the MACE exam was being administered to pretty much every service member near an explosion.

“But then you would go out and you would talk to these young medics and corpsmen — who are great patriots and doing wonderful things — and you would say, ‘Hey, son, how often do you administer the MACE exam?’ And they would look at you and say, ‘Sir, I’m sorry, what’s a MACE exam?’ “

Because the military wasn’t doing much to look for TBIs, it was usually up to individual service members to report their own brain injuries.

“If you were in a blast, you basically had one of two choices,” Mullen says. “You either didn’t admit you had a problem, or if you admitted a problem we put you on a plane, sent you home.”

And Mullen knew from visiting hundreds of wounded troops that they didn’t want to get sent home. “The first thing they tell you is they want to get back in the fight,” he says. “So nobody would admit they had a problem.”

When the Gray Team got back to the U.S., they began suggesting reforms. Their ideas got a hostile reception in the Pentagon.

“I would literally have people behind closed doors say, ‘Who gave those people medical degrees?’ ” Macedonia says. It was a surprising allegation, considering the team members included people like Geoffrey Ling, an M.D.-Ph.D. considered the military’s leading expert on traumatic brain injury.

But many senior medical officers just couldn’t accept that there were real brain injuries you couldn’t see on MRI or CT scans, Macedonia says. “The organized military medical system was still trying to hold back the ocean and say: No big deal, most of these injuries are psychiatric and our job is basically to provide counseling centers and get these people over the shock of being at war.”

In the Pentagon, some medical officers feared that TBIs could become the next Gulf War syndrome — a poorly defined problem with no obvious cause and no good treatment.

Others had visions of the military medical system stateside being overwhelmed by newly diagnosed TBI patients. And more than a few just didn’t like having someone outside their chain of command telling them what do.

Macedonia says bureaucratic concerns often seemed to trump the growing scientific evidence that blast-induced TBIs were real. “I can’t tell you the number of times I walked out of rooms just being sorely disappointed at people who knew what the right thing to do was but chose to look the other way,” he says.

But Macedonia was equal parts tenacious and ferocious. “He was a dog on a bone,” Mullen says.

“Christian Macedonia doesn’t give a f*** what anybody thinks if he believes he’s on the right course,” says Kit Parker, a Harvard professor and Army lieutenant colonel who served on the Gray Team in 2011.

MRIs On The Battlefield

The conflict between the Gray Team and the military medical establishment reached a peak over the issue of MRI scanners.

Conventional scanners usually couldn’t detect the damage from a blast. But the Gray Team now included David Brody, a civilian scientist from Washington University in St. Louis, who was using a new MRI technique to study troops at the U.S. military hospital in Landstuhl, Germany.

“We went out there to Landstuhl, started enrolling patients, and started discovering immediately all sorts of injuries that were completely invisible to the conventional scans,” Brody says.

Even though the Department of Defense was paying for Brody’s research, the military medical establishment wasn’t embracing the results. “There was a strong current in the military at that time that this was a problem that was going to go away if we ignored it,” he says.

Macedonia wanted to deploy the new technology to hospitals near the battlefield. So during a Gray Team trip to Iraq, he made a pitch to a group of senior medical staff.

“I said, ‘We’re very seriously considering putting MRI machines in theater, what say you?’ ” he recalls. The reaction was as if he had proposed “bringing in a pile of radioactive waste to drop in your hospital.”

Macedonia eventually got his MRIs, largely because his boss, Mullen, had clout. As chairman of the Joint Chiefs, Mullen was the highest-ranking officer in the armed forces. “But even the chairman can be ignored,” Mullen says.

To make sure that didn’t happen, Mullen, Macedonia and the Gray Team had been building a coalition that included Gen. Peter Chiarelli, the Army’s vice chief of staff, and Gen. James Amos, assistant commandant of the Marine Corps. The Gray Team’s allies simply outranked its opponents.

The team’s decisive victory came in 2010, when the Department of Defense issued a memo that transformed the system for managing battlefield brain injury. “I can still remember Macedonia coming into my office saying, ‘Chairman, we got it,’ ” Mullen says.

The memo requires evaluation and a 24-hour rest period for troops within 50 meters of a blast, and several other measures to ensure that TBIs are detected and treated. It also includes special provisions for service members who sustain multiple TBIs.

And the 2010 mandate was just the beginning. Today, combat troops often wear sensors that indicate when a bomb blast is strong enough to cause a brain injury. Military doctors are taught that blast waves really can cause physical brain injuries. And service members can get treatment for a TBI without being put on a plane and sent home.

The sweeping changes have brought solace to Macedonia, who still regrets that he once doubted blast waves could physically injure the brain.

“Doing the Gray Team’s missions was probably the most awesome healing process that could have ever happened for me,” says Macedonia, who has retired from the military. “It really was a way for me to make up for the lapses, the lack of understanding about TBI.”

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Doctors-in-training learn a lot about the workings of the human body during medical school and residency. But many are taught next to nothing about the workings of the health care system. One university in Washington, D.C., is trying to change that.

A three-week fellowship in health policy for medical residents is run jointly by the George Washington University schools of medicine and public health. In addition to hearing lectures from policy experts in and around the nation’s capital, the residents take field trips to Capitol Hill, the Supreme Court, other federal and local health-related agencies, as well as local health care facilities.

Dr. Fitzhugh Mullan, a pediatrician and GW professor, has led the program since it began more than a decade ago. When he went to medical school in the 1960s, he says learning how the health system worked was barely an afterthought.

“Things such as public health were recognized with a one credit course in the curriculum that everybody thought was terrible, partly because it was and partly because they discounted it as being important,” he says. “The notion of engaging with public policy or being concerned with the state of the future of [health care] service delivery in the U.S. was not remotely a part of our training.”

That’s changing, though. On this Tuesday afternoon in early spring, the 20 or so medical residents in the current class are getting a tour of a community health center in Washington run by Unity Health.

They stop at the dental clinic, which can accommodate six dentists and a dental hygienist. “If you think that the crisis of medically uninsured is high, the crisis of dental uninsured is even higher,” says Andrea Anderson, Unity’s medical director. “So many of our patients suffer for not having proper dental insurance.”

It’s not just dental services that gives the health center added value. For example, instead of just telling patients to eat more vegetables, the staff gives out farmers market vouchers and then demonstrates how to cook the veggies patients buy in an on-site kitchen.

“So we use the test kitchen to say ‘here’s how we chop it up, here’s how we cook it,” she says. “Look, here’s your kid chopping it up, having fun.”

Mullan says medical residency is a particularly good time to teach policy because the newly minted doctors have seen enough of the health system up close to get an idea of where its flaws are.

“They’re in the game, and the opportunity to stop and talk about the game and how the game could be played better is very appealing to them,” he says.

That’s certainly true for fellow Chris Cahill. He’s a third-year pediatric resident at Children’s National Health System in Washington. He says he got interested in policy as a medical student at the University of Vermont a few years ago. At the time, the state was debating whether or not to create a new single-payer health care system. That didn’t happen. But Cahill says now that he’s later in his training, the policy aspects are even more relevant.

“It’s a great time to do it now because we still have those idealistic ideas, but we also have a lot of practical experience,” Cahill says. “We know what the face of these problems looks like much better than we did in medical school or college even.”

There’s a growing awareness that doctors need more training in the nonclinical parts of health care.

“You know as a profession we provide the most expensive services that any American will spend money on in their whole lifetime,” says Neel Shah, an OB-GYN in Boston and a health policy researcher at Harvard. “And yet at the point of service we can’t tell anybody what anything costs. That’s crazy.”

Even worse, says Shah, most doctors are trained explicitly not to take cost into consideration.

“Clinical training teaches you to be a terrible steward of health care resources in every way,” he says. “When you’re being chastised as a trainee, it’s always for the things that you didn’t do but could have. It’s never for the things you did do but didn’t have to do. When, of course, patients can be harmed both ways.”

For now, the program is mostly limited to residents from GW and other Washington-area facilities. But Mullan is in the process of creating a new version for Kaiser-Permanente at three sites in California.

Those residents won’t have the advantage of being right down the street from the White House and the U.S. Capitol. “But we reasoned that in California there would be state-level issues or city-level issues that had an equal relevance,” Mullan says.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. (Kaiser Permanente has no relationship with Kaiser Health News.)

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When clinical psychiatrist Cher Morrow-Bradley and other health care providers call the Veterans Choice program, they are greeted with a recorded, 90-second “thank you” from Veterans Affairs Secretary Bob McDonald.

It’s not having the intended effect.

“Why don’t you make this easier? The process is so cumbersome, and I have to listen to you thanking me for spending all this time and then I get put on hold,” says Morrow-Bradley, adding that she hasn’t figured out how to skip the message.

She and many others say this is emblematic of the Veterans Choice program that was intended to quickly work through the backlog of vets waiting for medical care. Anyone more than 40 miles from a Veterans Affairs facility or waiting more than 30 days for an appointment could go get private care outside the VA system.

But nearly two years in, there are more vets waiting than before. Health care providers are frustrated with the program, which makes it hard to keep them in the network. Without enough providers to see them, vets end up waiting anyway.

Or, in Morrow-Bradley’s case, the vets get the care and the doctors don’t get paid in a timely fashion, if at all.

She moved to North Carolina to work with veterans, first at the VA and now in a small private practice. Previously she gave VA patients care as a private doctor through a program called PC3. When Veterans Choice started in 2014, she was happy to participate, because she knows VA mental health specialists are overwhelmed.

A Satisfied Patient

One Afghanistan vet, Jacob Hansel, gives Morrow-Bradley a rave review.

“I believe therapy is stronger than medicine,” says the former Marine, who returned from deployment with serious anxiety and depression issues. When the local VA told him it would be a four-month wait for a therapist, he used the Choice program to see Morrow-Bradley.

“I have days when I almost have panic attacks. … A lot of it is just realizing when the anxiety comes; she’s helped me figure how to keep it under control,” says Hansel.

Morrow-Bradley has treated Hansel since last year, along with others in the Choice program. She has submitted her bills to a company called Health Net, which administers Veterans Choice across most of the Eastern United States.

“I just assumed I was being paid. I found out six months later I had five, six [thousand dollars] outstanding to Veterans Choice,” says Morrow-Bradley.

It took her most of a year to get paid. Health Net refused requests for an interview.

Dr. David Shulkin, the head of the Veterans Health Administration, acknowledges this problem has hindered the Choice program in getting providers big and small.

“One thing I know is that when you perform a service, when you see a patient, you want to be paid. And these hospital systems don’t have the cash flow to be waiting around for months and months to get paid,” he says.

Shulkin points to one rule that has been scrapped to speed up reimbursement — originally providers wouldn’t get paid until they had returned an updated medical record to the VA.

Challenges In Getting Certified

Other providers say they want to join the Veterans Choice program but can’t jump through the hoops to get certified.

Psychologist Diane Adams devotes a portion of her practice in Renton, Wash., to veterans, saying it’s something she considers important.

She sees patients at her home office at the midpoint of a steep winding hill. Adams has provided counseling to veterans as part of the VA’s community care programs for nearly a decade.

Last July, she got a letter inviting her to join the Choice program, from TriWest Healthcare Alliance, the company that administers Veterans Choice in most of the Western U.S.

Adams went online together to begin the credentialing process. It all seemed pretty straightforward.

“We checked that box and waited and waited,” Adams said.

In December, after hearing nothing for five months, Adams finally gave TriWest a call.

“I spoke with somebody and yes, they had received my information and they thought, well maybe it’s just taking a long time for the contractual process,” Adams said.

Adams called back again in January and March. Each time a courteous TriWest representative took a message. No one called back.

Tri West’s chief medical officer, Frank Maguire, acknowledges the Veterans Choice program isn’t exactly nimble.

“Things have gotten much better but I’ll tell you we still have persistent educational confusion issues. The program itself is not uncomplicated,” Maguire said.

As a result, small mistakes can mean big problems. Turns out, way back, when Adams filled out the first form, she checked the wrong box. And that held everything up. Finally, in March, Adams was informed that she’d been credentialed since January and should have gotten a welcome letter. It never arrived.

Maguire says the program is still new and may need more time.

“We think we’ve done consistently a much better job as time has gone on,” Maguire said. “At the same time there’s not a lot of patience. People want it perfect right away and it’s a new program. I think still needs more time to mature.”

Now that she’s in, Adams faces a new hurdle: Some of her regular veteran patients can’t get Veterans Choice to approve visits to see her.

Vets are supposed to be able to call the number on the back of their Choice card and get an appointment. But so far it’s been like climbing that steep winding hill to her office — more phone calls, more faxing, more forms.

“I guess what I’m worried about is what happens to the veterans who can’t handle it and they just don’t have the internal resources to put up with it and so they throw up their hands and they give up,” Adams said.

Interrupting Care

A possible interruption in treatment is a particular problem for mental health care, where continuity is paramount.

It’s no accident that both Adams and Morrow-Bradley are mental health care providers. That’s one of the areas in shortest supply at the VA. Unfortunately the Choice program hasn’t been well-suited to fixing that problem.

In North Carolina, Morrow-Bradley keeps seeing her Choice patients. Some come free. Others use secondary insurance that at least pays some of the bill. She says she can’t just halt treatment.

“It’s not like I’m a dentist. If I start working on your teeth then you could go [elsewhere to] be seen and the work would be completed,” she said. “Post-traumatic stress disorder work is very sensitive. You need to have a relationship with the person; it’s stressful for the therapist and the client.”

And Healthnet won’t authorize enough visits at a time, she says. For patients she needs to see twice a week it would take a new authorization almost every month.

“People have been not very interested in participating,” said Chuck Ingoglia, with the National Council on Behavioral Health, a group of 2,800 mental health organizations nationwide.

He says the Choice program doesn’t cover much beyond basic therapy. If you do anything additional you won’t get reimbursed.

“Participating in the Vets Choice program would limit the kind of robust mental health and substance use treatment they have historically been able to provide to veterans.”

For those reasons and others, at least two states, Maine and Montana, have taken the extraordinary step of excluding mental health care from their Choice program. They use other programs to pay for it and have sent harshly critical letters to the VA about the Choice program.

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At home, parents try to keep their children on a regular sleep schedule, with the evening bedtime transition marked by rituals like reading stories, flipping on night lights and getting tucked in with favorite stuffed animals.

But the difference between night and day blurs in hospitals, making it more difficult for young patients to rest when they need it the most.

Between the fluorescent lights, the chatter of on-duty doctors and nurses, and being roused for baths and vitals checks, getting eight hours of shut-eye is challenging. So now, with research increasingly highlighting the link between sleep and good health, children’s hospitals are rethinking just how they work at night.

“If we’re going to try to heal kids, we need to try to have them do the one thing that’s so important for their brain development. And that’s optimizing their sleep,” said Dr. Sapna Kudchadkar, an assistant professor of anesthesiology, critical care and pediatrics at Johns Hopkins Children’s Center in Baltimore. She launched an initiative to improve sleep in the hospital’s pediatric intensive care unit a year ago.

Children’s hospitals are now adopting some of the strategies used to foster better sleep at hospitals serving adults. For example, some are enforcing quiet hours after dark, clustering things like overnight blood draws and medication doses to minimize interruptions, and bringing in white noise machines to promote a soothing environment.

Activities such as bathing children are shifted to daylight hours. Also, playtime is promoted in the afternoon to help maintain a sense of normalcy and contrast nighttime rest. The hope is that children will sleep better and heal faster.

Physicians and hospital administrators are starting to recognize that “we’re doing some stuff in our hospitals that doesn’t really reflect what we’re telling people to do at home,” said Dr. Jennifer Jewell, a pediatric hospitalist at the Barbara Bush Children’s Hospital in Portland, Maine, who chairs the American Academy of Pediatrics’ Committee on Hospital Care.

Children’s hospitals aren’t yet held to the same patient satisfaction standards as other facilities. But there is growing interest in better catering to both children and their parents, doctors said. There’s the competitive element, noted Heather Walsh, a registered nurse who coordinates some of the quality improvement training for clinical staff at Children’s National Health System in Washington, D.C. If families don’t like the care they get, they can go elsewhere.

And doctors are starting to realize that poor sleep isn’t just inconvenient. It can make children sicker.

In the intensive care unit, for instance, children who aren’t disturbed at night don’t need as much sedation or anesthesia, Kudchadkar said. That matters, she noted, since some of those drugs — benzodiazepines and prescription opioids — can be more dangerous for young patients to take. Kids who rest well at night are also more likely to get up and move around in the daytime.

In addition, because many children’s hospitals encourage parents to spend the night in their child’s room, late-night interruptions — whether a temperature check or the cleaning machine in the hallway — wake them, too. As a result, parents aren’t rested when getting instructions for kids’ follow-up care. It’s easier to mishear or misremember a complicated medication instruction, said Lisa Meltzer, associate professor of pediatrics at National Jewish Health in Denver. Meltzer has also researched sleep quality in children’s hospitals.

“There’s more evidence really showing a direct link between insufficient and poor quality sleep and negative outcomes,” she said.

The changes can seem small. At Hopkins, blinds are typically lowered between 8 p.m. and 8 a.m., though nurses might adjust that based on a particular family’s needs and habits.

Parents are asked about their children’s favorite music to sleep to. The ICU’s child life staff will find those songs to play on portable radios. One teenager requested Tupac, while some patients might bring in the soundtracks from their favorite video games. In a number of rooms, many alerts no longer trigger loud beeps blasted from overhead speakers. Instead, they’re sent straight to the relevant nurse’s phone. He or she can see to the child’s need, but the noise doesn’t disturb the whole unit.

Finding a balance can be tough. With very sick children, doctors and nurses do need to wake them more often at night. Some tests and medications can’t wait, especially in the ICU, said Patricia Hickey, vice president of cardiovascular and critical care services at Boston Children’s Hospital.

Plus it’s hard to accommodate what patients need at different ages. Think of the habits of a 2-year-old versus a teenager. One goes to sleep and wakes early. The other may be unable to sleep before 11 p.m. Hospitals need to accommodate both.

The jury’s still out on how effective these strategies are. It’s difficult to prove reduced chatter leads to shorter hospital stays for kids. But there’s anecdotal support. At Boston Children’s, which launched its sleep-promotion campaign last summer, hallways are markedly quieter, and families have said they appreciate the attention, Hickey said. The hospital’s conducting a survey this fall to better assess that, she added.

But challenges remain. Foremost is teaching doctors and nurses to be quiet and considerate.

“For some people, the night is no different than the day — that’s when they work,” said Myke Federman, a critical care pediatrician who started a sleep initiative at Mattel Children’s Hospital UCLA in Los Angeles.

Curbing the nighttime ruckus requires continued attention, she said. Mattel, which launched its program in 2015, is trying to bring its noise levels down. So far, they haven’t budged significantly from 50 decibels at night. That’s north of their goal: 30 to 40 decibels, the sound of a quiet library.

Many nighttime interruptions — like bathing a child at 3 a.m. — happen because they suit the staff’s schedule, Hopkins’ Kudchadkar said. Getting away from that required a major recalibration of the ICU’s workflow and culture. At Hopkins, it took about a year, she added. The ICU used to be as loud as an emergency department. Now, the staff speaks in hushed whispers, even by day.

Changes haven’t been easy but they are taking root.

“The bottom line is, ‘How do you create a peaceful, healing environment?'” she said. “We’re getting there.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. You can follow Shefali Luthra on Twitter:@shefalil.

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