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Medicare: 50 Years and Counting

Medicare was created 50 years ago as a health insurance program for seniors and people with disabilities. Today it has over 5.6 million enrollees in California alone. We'll discuss how the entitlement program has changed the face of health care in America. And we'll examine its accomplishments and ongoing challenges, including how to pay for the extra 10,000 baby boomers who become eligible for the program each day.

Study Questions Aggressive Cancer Treatments for Terminal Patients

A new study suggests that chemotherapy given to terminal cancer patients who aren't expected to live beyond six months may do more harm than good. We'll discuss the pros and cons of chemotherapy for terminal patients, especially when weighed against the effects on quality of life. We'll also look at the high rate of intensive treatments used in the final months for teens dying of cancer.

PBS NewsHour

Why the anti-HIV pill is a hard sell to the Latino community

Louis Arevalo holds his Truvada pills. The drug Truvada, used to halt HIV infection, has been shown to be over 90 percent
         effective when used correctly. Photo by Heidi de Marco/KHN

Louis Arevalo holds his Truvada pills. The drug Truvada, used to halt HIV infection, has been shown to be over 90 percent effective when used correctly. Photo by Heidi de Marco/KHN

LOS ANGELES – Late on a Friday night at The New Jalisco Bar downtown, a drag show featuring dancers dressed in sequined leotards and feathered headdresses had drawn a crowd — most of them gay Latino men.

Inside the bar and out, three health workers chatted with customers, casually asking questions: Do you know about the HIV prevention pill? Would you consider taking it? A few men said they had never heard of it. Others simply said it wasn’t for them.

“It hasn’t really hit the Latino community yet,” Jesse Hinostroza, an HIV prevention specialist with AltaMed health clinics, said while sitting at a table with a bowl of condoms and a stack of bilingual pamphlets about the pill. “They aren’t educated about it.”

In California, New York, Texas and elsewhere, health workers are trying to get more high-risk Latino men to use the drug, Truvada. The medication, which is used for “Pre-Exposure Prophylaxis” or PrEP, was approved by the FDA in 2012 for HIV prevention and has been shown to be more than 90 percent effective when used correctly. But health workers are encountering barriers among many Latinos.

Among them are a lack of knowledge about the drug and the stigma attached to sleeping with men or perceived promiscuity. Many Latinos also have concerns about costs and side effects.

AltaMed is conducting HIV prevention outreach at several Latino gay bars in Los Angeles area. Photo by Heidi de Marco/KHN

AltaMed is conducting HIV prevention outreach at several Latino gay bars in Los Angeles area. Photo by Heidi de Marco/KHN


“Even for people who have heard about it, that makes them reluctant to use or hesitant to even inquire about it,” said Phillip Schnarrs, assistant professor of health promotion at the University of Texas at San Antonio and research director for the Austin PrEP Access Project.

Schnarrs, who is conducting a study with gay and bisexual Latino men in Texas, said 58 percent of those surveyed see themselves as good candidates for PrEP, compared to 82 percent of non-Hispanic whites, according to preliminary data.

In an ongoing study of 20 Latino gay couples in New York City, 37 of the 40 people had never heard about PrEP when interviewed last year, said Omar Martinez, assistant professor of social work at the Temple University College of Public Health.

Martinez said doctors and health workers need to focus on reaching young minority men at highest risk of getting HIV and transmitting it to others, including those who don’t regularly use condoms. “We need to do something,” he said. “And PrEP may be the solution.”

Latinos are disproportionately affected by HIV. They make up about 21 percent of new infections nationally, though they represented about 17 percent of the population, according to the U.S. Centers for Disease Control and Prevention. Latinos are also more likely than non-Hispanic whites and blacks to get diagnosed later in the course of their illness, raising the risks to their health and the likelihood of transmission to others.

At the same time, Latinos are less likely than non-Hispanic whites to be insured or have a regular doctor, although the Affordable Care Act has helped reduce that gap.

In California, health workers are trying to get more high-risk Latino men to use the drug, Truvada. AltaMed Health Services
         offered free HIV tests at The New Jalisco Bar in downtown Los Angeles on July 10, 2015. Photos by Heidi de Marco/KHN

In California, health workers are trying to get more high-risk Latino men to use the drug, Truvada. AltaMed Health Services offered free HIV tests at The New Jalisco Bar in downtown Los Angeles on July 10, 2015. Photos by Heidi de Marco/KHN


Truvada can cost up to $1,300 a month. Most insurance companies and Medicaid programs are covering at least part of that, and many local governments are also covering the pill for uninsured residents. But the high sticker price can dampen interest among patients.

Truvada, which blocks the virus from spreading in the body, is helping to significantly reduce new infections, said Robert Grant, a professor at UC San Francisco School of Medicine who leads research on PrEP’s effectiveness.

But the pill does not protect against other sexually transmitted diseases, requires daily use and can cause side effects in some patients, including kidney problems.

“It is a very valuable option, but it is only one option,” Grant said. “Condoms are still very important part of a sexual health strategy.”

As customers at the New Jalisco Bar danced to traditional Mexican music beneath a disco ball and rainbow lights, Jaime Cardenas conducted HIV tests in a mobile unit parked in front. Anyone who tested on the spot received a free drink coupon, courtesy of AltaMed and the bar.

One of the first to agree was Erik Quezada, a counselor at a Los Angeles high school.

Cardenas drew a few drops of blood from Erik Quezada’s finger for the rapid test. Within minutes, Cardenas gave him the good news: He didn’t have HIV. Cardenas quickly followed up with information about the HIV prevention pill.

“One way you can prevent yourself from acquiring HIV is by taking PrEP,” Cardenas said, offering to take down Quezada’s number so the clinic could call him later.

Quezada, 35, responded that he had heard it was like the birth control pill for gay people. He agreed to be contacted but quickly added, “I don’t know I would ever sign up for it.”

Erik Quezada, 35, says he has heard Truvada is like the birth-control pill for gay people. Quezada, a counselor at a
         Los Angeles high school, says he’s not sure he would sign up for it. Photo by Heidi de Marco/KHN

Erik Quezada, 35, says he has heard Truvada is like the birth-control pill for gay people. Quezada, a counselor at a Los Angeles high school, says he’s not sure he would sign up for it. Photo by Heidi de Marco/KHN


Others were even less interested. Jose Arriola, 25, a self-described “diva,” said he didn’t want to take any medication. “It’s better to use condoms,” he said, sitting by his boyfriend at the bar.

A short video produced by AltaMed played between acts. The video featured different Latino men getting dressed: a cowboy for a night out, a day laborer for work, a buff young man for the gym. Each took the HIV-prevention pill as part of their routine. At the end of each segment, one word popped up on the screen: listo, or ready.

“We are really trying to project the message that taking PrEP can be a normal part of your everyday life,” said Dr. Scott Kim, medical director of HIV Services for AltaMed, which runs more than 40 health clinics in Southern California.

That, he hopes, will reduce stigma. Kim said health workers need to be more creative in places like East Los Angeles, where many gay and bisexual Latinos are still in the closet and aren’t getting information through traditional health-care sources. Talking about PrEP at a doctor’s office may not be as effective as doing so on social media, by text message or in a bar, he said. “There are a lot of social obstacles and challenges we have to negotiate here because it’s harder to be out,” Kim said.

AltaMed’s efforts are being paid for by Gilead, the pharmaceutical company that makes Truvada. The goal of its $80,000 grant is to help 100 high-risk gay Latino men throughout Los Angeles County get prescriptions for PrEP. The grant pays for the outreach but does not cover the cost of the medication.

Since the project began late last month, about half a dozen patients have received prescriptions. Hinostroza of AltaMed said there is more interest and more knowledge in gay-friendly Hollywood and West Hollywood. “But for East Los Angeles, where we are, it’s a struggle,” she said.

Louis Arevalo, 27, is a college student and AltaMed patient who lives in Los Angeles. He said he decided to go on the medication last month after getting scared when a condom broke. He said he uses condoms regularly and gets HIV-tested every three months, but the medication is “an extra layer of protection.”

“I’m not as anxious anymore,” he said.

But Arevalo said he understands the stigma that might prevent others from taking the drug. For years, he said, he has hidden his boyfriends from his mother, an immigrant from El Salvador. Arevalo said her church pastor repeatedly has said that homosexuality is a sin. “It’s just part of the culture, and it’s the religion,” he said.

Louis Arevalo, 27, says he decided to go on the medication last month after getting scared when a condom broke. The college
         student from Los Angeles says he uses the pill as an extra layer of protection. Photo by Heidi de Marco/KHN

Louis Arevalo, 27, says he decided to go on the medication last month after getting scared when a condom broke. The college student from Los Angeles says he uses the pill as an extra layer of protection. Photo by Heidi de Marco/KHN


AltaMed’s efforts are just one part of a larger effort to get the word out about Truvada. The nonprofit Latino Commission on AIDS, based in New York, also recently started a campaign in five cities — Long Beach, Calif.; New York City; Chicago; Miami; and San Juan, Puerto Rico.

Gustavo Morales, the commission’s director of access to care services, said now is the time to educate people about PrEP — lest too many people form negative opinions about it and health workers become “like salmon swimming against the current.”

Morales said patients aren’t the only ones who need more information. When he decided to go on PrEP late last year, he went to two different doctors who didn’t know about Truvada. A third asked him why he wanted to poison himself. Finally, he got a prescription from an HIV specialist.

“I was definitely disappointed,” said Morales. “There is a lot of work that still has to be done.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. Jay Hancock contributed to this report. Blue Shield of California Foundation helps fund KHN coverage in California.

The post Why the anti-HIV pill is a hard sell to the Latino community appeared first on PBS NewsHour.

After 50 years, how do we ensure Medicare and Medicaid longevity?

medicaid

Watch Video | Listen to the Audio

JUDY WOODRUFF: Health spending in the U.S. grew by 5.5 percent last year to more than $3 trillion. And new projections show spending will keep rising by nearly 6 percent a year over the next decade.

This comes after several years of a slowdown in spending growth. And it potentially has major implications for Medicare and Medicaid, which together cover about one of every three Americans. By 2024, nearly four out of every 10 health care dollars will be spent on enrollees in the two programs. The latest warnings comes as both programs are celebrating their 50th anniversary.

Before President Lyndon Johnson signed Medicare and Medicaid into law in 1965, with President Harry Truman by his side, the country’s social safety net left many seniors living in poverty in their retirement years.

FORMER PRESIDENT LYNDON JOHNSON:
There are those alone in suffering who will now hear the sounds of some approaching footsteps coming to help.

JUDY WOODRUFF: Fifty years later, the programs cover tens of millions more people and are deeply woven into the fabric of the American health care system. Nearly one in six Americans, or about 53 million people, receive coverage through Medicare.

Medicaid, which provides care for low-income and disabled people, has grown even larger. It covers nearly one in four Americans, 71 million in all.

The success of both programs was hailed by President Obama at a recent White House event.

PRESIDENT BARACK OBAMA:
When Medicare was created, only a little more than half of all seniors had some form of insurance. Before Medicaid came along, families often had no help paying for nursing home costs. Today, the number of seniors in poverty has fallen dramatically.

JUDY WOODRUFF: But new projections underscore worries over long-range solvency. Among them, 10,000 people become eligible for Medicare each day. Medicare’s growth rate is below that of the private sector, but the Hospital Insurance Trust Fund will run out of money by 2030, and only be able to cover 86 percent of costs, unless there are more changes, such as higher costs for beneficiaries, raising taxes or cutting benefits.

Choice of doctors and providers has shrunk in recent years, as payment rates decline. Beneficiaries’ out-of-pocket costs are rising. People enrolled in Medicaid have a harder time finding specialists and dentists willing to treat them. Nearly a third of beneficiaries reduced their use of dental, vision and hearing care.

Medicaid, which has expanded through the federal health care law, remains the focus of major political battles around the country.

I sat down recently with two former secretaries of health and human services, who oversaw the programs, Kathleen Sebelius, who served under President Obama until last year, and Dr. Louis Sullivan, who served under President George H.W. Bush.

Welcome, Secretary Sullivan, Secretary Sebelius.

And, Secretary Sebelius, let me start with you.

What difference have Medicare and Medicaid made in this country?

KATHLEEN SEBELIUS, Former Health and Human Services Secretary: Well, I think they have made an incredible difference in the lives of about 120 million Americans and counting.

So, seniors were the poorest group of Americans when Medicare was passed 50 years ago. They were going bankrupt because of medical bills. They couldn’t afford the care they needed. And to have that guarantee once you turn 65 or are so disabled that you qualify early, that you have a set of benefits, and you don’t have to be qualified by health, you qualify by age, has made a huge difference in this country.

JUDY WOODRUFF:
And, Secretary Sullivan, what about Medicaid?

DR. LOUIS SULLIVAN,
Former Health and Human Services Secretary: Medicaid has also contributed greatly to improving the health and access to health care for our citizens.

For example, 50 percent of the births in the country are paid for by Medicaid, most of the care for HIV/AIDS patients, poor patients and families. So this is really the safety net for the health system. So I think Medicaid, along with Medicare, are two successes that we can all congratulate.

JUDY WOODRUFF:
At the same time, we know that so many more people in this country depend on these programs than was ever envisioned. The costs have skyrocketed to the government at the federal level, and, in the case of Medicaid, also at the state level.

Secretary Sebelius, how sustainable are these two programs?

KATHLEEN SEBELIUS: Well, I think that the cost issue is something that this administration particularly has taken head on.

And part of the framework around the Affordable Care Act was really to look at government spending on health and whether we’re getting the best bang for the buck. The good news, Judy, is in the five year since the president signed the ACA into law, health costs have risen at the lowest level in 50 years. And, in fact, Medicare was supposed to be insolvent by 2017. When I came in with the president, that was what the trustee report said. It’s now 2030.

And each year, years are added onto that solvency, because costs are going down, in spite of the fact that we have 11,000 people a day turning 65 in this country. We have a baby boom increase in Medicare, but the costs are lower than they have ever been.

JUDY WOODRUFF: At the same time, Secretary Sullivan, there is still concern about the long-term financial viability of these programs, isn’t there?

DR. LOUIS SULLIVAN: Oh, yes. And that’s a fair question.

I think all of us want to be sure that we do a better job in holding back the increases in health care costs. But one of the features in the Affordable Care Act that I’m very pleased with is a greater emphasis on prevention. I believe that the 21st century really will be the century in which we improve health literacy of our citizens and have them play a more active part in remaining healthy, staying out of the hospital, coordinating care better than we have been able to do it in the past.

So there a number of things that can be done to help ameliorate the increase in costs, while seeing that our patients and our citizens get access to care.

JUDY WOODRUFF: How does that happen, Secretary Sebelius, in the long run?

And we already — we know many doctors are saying they won’t accept patients who come to them saying they depend on Medicaid. And, in some cases, Medicare physicians are saying they won’t see them.

KATHLEEN SEBELIUS: Well, it is still about 70 percent of the doctors, less than 100, but 70 percent take Medicaid patients. And almost 95 percent of doctors accept Medicare patients.

So we still have the vast majority of providers. But I think, again, it’s reasonable to look at what their payment is. Are they being compensated enough? And, as Dr. Sullivan said, what we don’t do very well is pay doctors for keeping their patients healthy in the first place. That payment system is changing rapidly within the government.

Paying for outcomes, paying for health, paying for people to actually have less contact with the hospital system is a new way of actually using the trillion dollars that the government spends every year to try and drive health and wellness, and not wait until somebody comes into the acute care system, goes into the hospital, does more tests, does more prescriptions. It’s really about health and wellness at the outset.

JUDY WOODRUFF: Secretary Sullivan, what else needs to be done?

We know there are proposals out there to cut benefits, to raise premiums, to make it harder for people at various income levels to access Medicare. What do you think needs to be done to make these programs sustainable?

DR. LOUIS SULLIVAN: Well, I believe there are a number of things that we can do.

For example, the 20th century was a tremendous growth in the scientific community, with many advances that really were miracles. We have developed vaccines of all kinds. When I was a medical student, I took care of patients with paralytic polio. In the mid-50s, when the polio vaccine was introduced, overnight, polio almost disappeared from our country.

But we have a misunderstanding with some of our citizens about the value of vaccines, where people have misunderstandings, so they’re not using these advances that have been made properly. So, that’s why I say we need to improve the health literacy of our citizens, have them understand the value of these scientific advances.

And they have to be partners with the health professionals to see that they get the care that they need. The 21st century is going to be a century in which our citizens play a more active role in maintaining their health, working with their health professionals. But we also need to have new kinds of health professionals.

We don’t need doctors or dentists in every town or hamlet. We have developed physician’s assistants and nurse practitioners. They are valuable members. In dentistry, we are developing dental therapists, mid-level dental providers. We can get care to citizens at less costs.

So there are a number of things we can do to change the way we provide care and keep our costs under control.

JUDY WOODRUFF: Just quickly, what would you add?

KATHLEEN SEBELIUS: Well, I think he’s right.

And I think the notion that people need more information, they want to stay healthy, they don’t know exactly what to do, but that, in the long run, focus on prevention and away from acute care, having a real health care system, not a sick care system, is really what I think the goal is in the long run.

JUDY WOODRUFF: Secretary Kathleen Sebelius, Secretary Louis Sullivan, we appreciate your being with us on this 50th anniversary of Medicare and Medicaid. Thank you.

KATHLEEN SEBELIUS:
Nice to be here


DR. LOUIS SULLIVAN:
Thank you. And happy anniversary, Medicare.

The post After 50 years, how do we ensure Medicare and Medicaid longevity? appeared first on PBS NewsHour.

Hospitals look to laborists to fill gaps left by on-call obstetricians

Newborn baby creative image. Photo by Getty Images

Hospitals are employing laborists, doctors who handle births and obstetrical and gynecological emergencies, as they seek to improve patient safety and as physicians increasingly recognize they need help responding to emergencies. Photo by Getty Images

MILFORD, Del. — When the only hospital in this southern Delaware town saw two of its four obstetricians move away, it knew it had to do something to ensure women in labor could always get immediate medical help. But recruiting doctors to the land of chicken farms and corn fields proved difficult.

So in late 2013, Bayhealth Milford Memorial Hospital shifted from using on-call doctors who came in as needed to a new model of maternity care that’s catching on nationally: It hired OB hospitalists, also called laborists, who are always at the hospital to handle births and obstetrical and gynecological emergencies.

As a result, the two remaining obstetricians here no longer have to worry about being on call every other day because an obstetrician is always at the hospital. “This gives my patients a safe passage for delivery,” said Dr. Albert French, 64, who has been delivering babies in Milford for 16 years.

But the change has also meant his patients sometimes may be delivered by a doctor they’ve never met before. “It’s a trade-off of familiarity for availability,” he said.

Milford is one of about 250 hospitals nationally that use OB hospitalists, up from 10 a decade ago, and several are adding the service each month, according to the Society of OB/GYN Hospitalists, a trade group. With the new model of care, private practice obstetricians typically still see their patients in the hospital, but they can also defer to, or work alongside, the laborist.

Despite concerns about turning the obstetrical specialty into “shift” work similar to emergency physicians, the laborist trend is growing as hospitals seek to improve patient safety and physicians increasingly recognize they need help responding to emergencies.

Some hospitals use laborists 24 hours a day, while others use them just nights and weekends. Some use community doctors to take 12- or 24-hour shifts as laborists. Other hospitals hire doctors as laborists who only work in the hospital and don’t have an office practice. Some, like Milford, use a hybrid approach.

Regardless of the laborist model, pregnant women like knowing a doctor — even one they don’t know — is there when they show up at the hospital rather than waiting 30 minutes or more for an on-call physician.

“I was very glad a doctor was here and I could just come right up to the labor and delivery floor,” Kelsey Katro, 27, said in early July while at Bon Secours St. Francis Hospital in Charleston, S.C., which adopted the model two years ago.

Katro had come to the hospital when she thought her water had broken, signaling the start of labor. Tests, though, showed it had not, which relieved Katro since she had been scheduled for a cesarean section the following week in anticipation of a breech birth.

Improving Safety, Satisfaction

Doctors say problems in childbirth can occur so fast that having patients wait 20 minutes or more for a doctor can make the difference between a healthy baby and a mom or baby facing severe complications.

Dr. Caroline Keller, a laborist at St. Francis, gave Katro the news that she was fine to go home. “Patients like knowing I’m just outside their door … it gives them comfort,” Keller said. Nurses also like knowing a doctor is there so they can have help if mother or baby is in trouble, and doctors don’t have to leave a busy office at a moment’s notice. “It’s hard to walk out of the office with 10 pairs of eyes staring at you,” she said.

The laborist trend is being driven by several factors, among them hospitals striving to improve patient satisfaction rates and reduce their malpractice risk, and doctors wishing to work for a salary instead of running their own practice. Obstetricians, who are increasingly women, also want more time away from their practice and relief from treating an emergency patient who may lack insurance and often prenatal care.

“There has been a generational shift that modern physicians who come out of residency programs tend to want a better work-life balance and the hospitalist program allows doctors to have that so you can go home and have dinner with your family and not have to pay constant attention to the labor deck in the hospital afraid that something bad is happening,” said Dr. Kyle Garner, chief of obstetrics and gynecology at Sarasota Memorial Hospital in Florida.

“We’ve all had the 2 a.m. calls where the hospital needs you now and you have a 5- to 15-minute drive in to the hospital that’s a terrifying time for patients and the nurse can only tell the patient so many times ‘your doctor is on the way,’” he said.

At 3 a.m. in early July, Dr. Eleanor Oakman got a call from a nurse at St. Francis that one of her patients was ready to deliver — and she got to the hospital 19 minutes later. But she was 10 minutes too late. The laborist had delivered the baby. In the past, a nurse might have had to deliver the baby, which is not as ideal as having a doctor there, she said.

Despite some initial skittishness by community doctors, hospital officials from Washington state to Florida say the new maternity model is paying benefits. A study published in the American Journal of OB/GYNs showed the presence of full-time laborists reduced C-section rates at a Las Vegas hospital from 39 percent to 33 percent, saving money and reducing hospital stays.

Officials at Milford, St. Francis and Sarasota Memorial say they’ve seen an 8 to 10 percentage point drop in their C-section rates. Hospitals attribute the drop to laborists’ willingness to spend more time with patients in labor before opting for the surgical option.

Hospital officials also say use of laborists has also led to fewer early elective deliveries done before 39 weeks, which can put babies and mother at increased risk, the hospitals say.

Shift Medicine?

But the model does have detractors, particularly from some older doctors who believe its anathema for an obstetrician to back away from delivering babies. “This is turning the OB/GYN into shift work no different from emergency medicine,” said Dr. Edward Yeomans, chairman of OB/GYN at Texas Tech University Health Sciences Center. “It goes against what I feel is the major calling of OB/GYN to be caring for their patients for months and years … I think the previous generation of OB/GYNs had more of a sense of obligation to be there for their patients no matter what.”

Yet, Yeomans said he sees little stopping the laborist movement since most doctors and women like it: “It’s like stepping out in front of a moving train.”

Indeed, hospitals are increasingly employing hospitalists to handle many other departments, from intensive care to medical-surgical floors. The laborist is part of this evolution, said Dr. Robert Pretzlaff, chief medical officer at Dignity Health, which has two hospitals in Las Vegas using laborists.

Hiring obstetricians to work full time in the hospital isn’t cheap. Sarasota Memorial says the initiative costs about $1.5 million a year to pay for doctors and their malpractice insurance. But with happier doctors and patients and a reduced chance of paying a multimillion dollar malpractice verdict, hospital officials say the cost is worth it.

“It’s a win, win, win for our patients, nurses and doctors,” said Sean Gregory, CEO of Health First’s Holmes Regional Medical Center in Melbourne, Florida. Laborists have helped reduce the wait for OB/GYN patients to be treated and released from an average of four hours to two, he said.

HCA Inc., the nation’s largest for-profit hospital chain, says about 1 in 4 of its hospitals with maternity services use laborists. But few HCA hospitals have adopted the model the past five years partly because of some resistance from doctors who prefer to maintain continuity of care for their patients, the company said in a statement.

Dr. Brian Iriye, an OB/GYN in Las Vegas who was the lead author of a study on laborists’ effect on C-sections, said the trend has also met resistance from doctors worried that laborists would steal their patients or not have the credentials to provide good care. “There always can be a lack of trust,” he said.

For French at Milford Hospital, the OB hospitalist model means he doesn’t have to be worried about having to provide emergency care while feeling sleepy or having to leave an office full of patients. “When I was young I could tolerate 80 hours a week and longer and managing the office. … One year I did 230 deliveries, but I was worried about being tired,” he said.

French, who still has a solo practice, works four, 24-hour shifts a month as an OB hospitalist to supplement the two full-time hospitalists hired by the hospital. “This model makes me want to keep practicing and makes me enjoy practicing at an older age when I would have quit sooner.”

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

The post Hospitals look to laborists to fill gaps left by on-call obstetricians appeared first on PBS NewsHour.

To boost patient health, rehab sometimes starts before cancer treatment

Photo of cancer researchers by Joseph Nettis via Getty Images

Photo of cancer researchers by Joseph Nettis via Getty Images

Cancer patients who do rehabilitation before they begin treatment may recover more quickly from surgery, chemotherapy or radiation, some cancer specialists say. But insurance coverage for cancer “prehabilitation,” as it’s called, can be spotty, especially if the aim is to prevent problems rather than treat existing ones.

It seems intuitive that people’s health during and after invasive surgery or a toxic course of chemo or radiation can be improved by being as physically and psychologically fit as possible going into it. But research to examine the impact of prehab is in the beginning stages.

Prehabilitation is commonly associated with orthopedic operations such as knee and hip replacements or cardiac procedures. Now there’s growing interest in using prehab in cancer care as well to prepare for treatment and minimize some of the long-term physical impairments that often result from treatment, such as heart and balance problems.

“It’s really the philosophy of rehab, rebranded,” says Dr. Samman Shahpar, a physiatrist at the Rehabilitation Institute of Chicago.

The main component of cancer prehab is often a structured exercise program to improve patients’ endurance, strength or cardiorespiratory health. The clinician establishes baseline measurements, such as determining how far a patient can walk on a treadmill in six minutes, and may set a goal for improvement. He also evaluates and addresses existing physical impairments, such as limited shoulder mobility that could be problematic for a breast cancer patient who will need to hold her shoulder in a particular position for radiation. Depending on the program, patients may also receive psychological and nutritional counseling or other services.

Some early research suggests prehab may improve people’s ability to tolerate cancer treatment and return to normal physical functioning more quickly. In one randomized controlled trial of 77 people with colorectal cancer who were awaiting surgery, two groups of patients participated in an exercise, relaxation and nutritional counseling program. Half went through the program in the four weeks prior to surgery and half in the eight weeks after it.

Eight weeks after their surgery, 84 percent of prehab patients’ performance on a six-minute walking test had recovered to or over their baseline measurements compared with 62 percent of rehab patients, according to the study, published last year in Anesthesiology.

“Prehab could be a relatively cheap way to get people ready for cancer treatment and surgery, both of them stressors,” says Dr. Francesco Carli, a professor of anesthesiology at McGill University in Montreal who co-authored the study.

More study is needed to determine whether prehab actually improves cancer patients’ outcomes, experts say.

“There are some physiatrists who don’t believe in prehab,” says Catherine Alfano, vice president of survivorship at the American Cancer Society. “They feel like the science isn’t there yet.”

Insurance plans typically cover rehabilitation services such as physical therapy and occupational therapy. But patients can face problems with coverage such as preauthorization requirements and limits on visits. There may be even more coverage obstacles with prehab.

“What we need is a system that systemically screens people for problems with physical and mental health that is then coordinated with their oncology care,” Alfano says.

The STAR Program is one effort to accomplish that. It helps hospitals and cancer centers establish interdisciplinary teams to improve cancer rehabilitation services, including offering prehab services.

“What we know from the literature is that 65 to 90 percent of cancer patients could benefit from rehab services, but delivery of those services is often less than 5 percent,” says Dr. Julie Silver, an associate professor at Harvard Medical School who founded STAR — it stands for Survivorship Training and Rehab–in 2009.

The Peoria, Ill.-based Institute of Physical Medicine and Rehabilitation is STAR-certified. It was originally launched as a program to help breast cancer and other patients cope with problems associated with lymphedema, a swelling of the arms or legs following removal of lymph nodes. But it became clear that cancer patients could benefit from a much broader array of services, says Kate Horst, the institute’s director of research and clinical innovation. Now, in addition to occupational, physical and speech therapists, the institute also offers cancer patients acupuncture, oncology massage and nutritional counseling.

Many of their patients are referred by physicians for prehab following their cancer diagnosis, says Horst. Specialists do an evaluation to determine if patients need any prehabilition services. Some don’t, and they’re discharged.

“But most of the time, people are about to embark on the most difficult period of their lives, and they’ve already got some problems,” says Horst.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. You can view the original report on its website.

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