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UCSF Launches Decades-Long LGBT Health Study With New App

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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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How coordinated care gives patients the freedom to stay at home

Editor’s note: As America’s population ages, more families will be faced with rising health care needs. As we reported in November, nearly 79 percent of adults who need long-term care live at home or in community settings, not in an institution. And in January, Medicare started paying primary care doctors a monthly fee to better coordinate care for the most vulnerable seniors — those with multiple chronic illnesses — even if they don’t have a face-to-face exam. The goal is to help patients stay healthier between doctor visits, and avoid pricey hospitals and nursing homes.

So how does coordinated caregiving work? Meet three older Americans with chronic illnesses who are benefitting from coordinated caregivers in their homes.

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Betty Valdez has chronic lung disease, known as COPD, high blood pressure, kidney disease, arthritis and diabetes. Remembering when to take her 20-plus medications is difficult. Getting up from a chair is a significant obstacle, making any regular exercise unlikely. With a primary care provider and help at home, maintaining her current health would be a challenge. Without them, the 65-year-old Valdez spent a lot of time in the emergency room.

At least she did until about a year ago. After complaining of problems breathing, Valdez visited the ER at a Denver hospital. While there she agreed to enter a new program called Bridges to Care, run by Metro Community Provider Network, a community health center outside Denver. “We usually come into contact with patients who are dealing with one or more acute issues. That’s why they end up on our radar,” said Linda Skelley, a clinical care coordinator in the program. “Typically, there are also multiple underlying issues or preventative services they might not have been receiving.” The main goal of the program is to reduce ER visits for patients like Valdez, so-called high utilizers, by conducting an initial assessment and organizing resources to fill the major gaps.

In the ten months Valdez has been in the program, she has seen a primary care provider who performs regular preventative screenings and maintenance tests for existing conditions. She also sees a nurse several times a week at home for help with taking medications and to check vital signs. Skelley works with the rest of Valdez’ healthcare team to identify areas of need. When Valdez’ pulmonologist recommended a lift chair to ease problems standing up, Skelley got the chair approved and paid for through Medicaid. When Valdez’ primary care provider suggested an automatic pill dispenser to simplify her daily medication routine, Skelley again made sure it was approved and paid for.

The Bridges to Care approach has been effective. When she began the program, Valdez was not only visiting the ER, she was often admitted to the hospital. After 3 admissions in the first 3 months of the program, Valdez has been once in the last 3 months. She has seen the difference. “Since all the medical care that I got here, my mobility is stronger, I got so much better. It gives you more of a reason to want to keep going and live longer.”

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Eighty-seven-year-old Eileen Daniels lives by herself in New York City. She prepares her own meals and pays strict attention to even the smallest aches and pains, scheduling doctor visits when necessary. Daniels is remarkably healthy and motivated to stay that way.

“She’s in great shape. She takes responsibility for her medication, for her care,” says Michele Walcott, who has coordinated Daniels’ care for four years, helping her manage her hypertension and sporadic mobility issues. People with more serious chronic conditions have significantly more complex daily routines and a much greater need for outside help. For a comparatively healthy patient like Daniels, that means helping to organize (and reminding her to take) prescriptions, setting up a regular home health care aid and referring specialists according to need.

As she ages and the severity and number of health issues increases, Daniels will likely depend more on Walcott to keep her healthy at home.

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If Burt Kramer wants to keep living at home, he knows he needs help. “When you’re elderly, you have to have people to help you.” Even a relatively healthy 75 year old may have problems with grocery shopping or household tasks. Kramer has to manage two serious chronic conditions: congenital heart disease and diabetes. He takes 15 different medications a day — some more than once.

Christine Spates, a care coordinator at Visiting Nurse Service of New York (VNSNY), checks in with Mr. Kramer regularly to make sure he remembers to take his medications, eats right and reports any indications of heart problems. Kramer also has a home health aide who helps with personal care (bathing and fixing meals). “He needs another set of eyes, another set of ears to make sure he is adhering to all the instructions as related to his illnesses, so that he can remain healthy at home,” Spates says.

So far it’s worked. Kramer hasn’t been hospitalized in more than a year while under VNSNY’s care.

The post How coordinated care gives patients the freedom to stay at home appeared first on PBS NewsHour.

State health insurance markets grapple with high costs

A woman calls for the next person in line at a health insurance enrollment event in Cudahy, California, March 27, 2014.
         State insurance markets are struggling with high costs and low enrollment, including in California, which fell short of its
         sign-up projections this year by nearly 20 percent. Photo by Lucy Nicholson/Reuters

A woman calls for the next person in line at a health insurance enrollment event in Cudahy, California, March 27, 2014. State insurance markets are struggling with high costs and low enrollment, including in California, which fell short of its sign-up projections this year by nearly 20 percent. Photo by Lucy Nicholson/Reuters

WASHINGTON — State-run health insurance markets that offer coverage under President Barack Obama’s health law are struggling with high costs and disappointing enrollment. These challenges could lead more of them to turn over operations to the federal government or join forces with other states.

Hawaii’s marketplace, the latest cautionary tale, was awarded $205 million in federal startup grants. It has spent about $139 million and enrolled 8,200 customers for individual coverage in 2015. Unable to sustain itself, the state marketplace is turning over sign-ups to the federal for 2016.

Twelve states and the District of Columbia fully control their markets. Experts estimate about half face financial difficulties. Federal taxpayers invested nearly $5 billion in startup grants to the states, expecting that state markets would become self-sustaining. Most of the federal money has been spent, and states have to face the consequences.

“The viability of state health insurance exchanges has been a challenge across the country, particularly in small states, due to insufficient numbers of uninsured residents,” said a statement from the office of Hawaii Democratic Gov. David Ige, announcing last month that his state’s sign-ups were being turned over to the federal government.

Now that the Supreme Court has ruled the Obama administration can keep subsidizing premiums in all 50 states through, no longer is there a downside for states turning to Washington. If the decision had gone the opposite way, state exchanges would have been a leaky lifeboat for preserving a major expansion of taxpayer-subsidized coverage under the law.

With the pressure gone, “I think you are going to see much more of a hybrid across the nation,” said Peter Lee, who heads California’s state-run marketplace. Covered California fell short of its sign-up projections this year by nearly 20 percent, but Lee says it remains “a solid business proposition.”

States are “talking a lot about shared services,” Lee said. “It’s how you get economies of scale.”

States could pool resources on functions such as labor-intensive call centers or use’s technology for online enrollment. They generally want to keep control over marketing, consumer education and oversight of insurance plans.

Sustainability is the focus of the administration’s annual meeting with state exchange directors, scheduled for the end of the month in the Washington area. The two-day meeting is closed to the media.

“Each state has a different set of circumstances that informs their approach, and we will continue to support their efforts,” said Mayra Alvarez, the federal liaison to state marketplaces.

The pendulum probably will swing toward a greater federal role in the next couple of years, said Jim Wadleigh, director of Connecticut’s Access Health. Eventually, more states will want to take the lead, he said, because it gives them greater control over health care, particularly modernizing Medicaid programs for low-income people.

In New England, there’s talk of a regional exchange.

The insurance industry would welcome consolidation.

“Our biggest concern is that you may see many states looking to enact taxes and fees, and that makes health care less affordable,” said Justine Handelman, policy chief at the Blue Cross Blue Shield Association.

Hawaii is the third state exchange going to the federal sign-up system, following Nevada and Oregon, which made the switch last year. Among the problems confronting states:

-Minnesota’s MNsure faces a murky financial future. Its budget is balanced as a result of repeated cuts when enrollment has come in below projections, a tactic that cannot work forever. Despite a slew of proposals, no concrete changes came out of the state’s most recent legislative session. Democratic Gov. Mark Dayton has signaled that MNsure’s fate is on the table, including the option of shifting operations to

-The U.S. attorney in Boston has subpoenaed records dealing with the troubled rollout of the Massachusetts Health Connector, dating to 2010.

-Colorado officials are considering big changes to the state’s marketplace, from pooling call centers with other states to dismantling the exchange and relying on instead. Although the market is on solid financial footing, it has fallen short of best-case enrollment goals.

-A federal audit concluded that Maryland used exchange establishment grants from Washington to pay for $28.4 million in costs that should have been allocated to the state’s Medicaid program. State officials dispute that, but federal officials say Maryland should pay the money back. Separately, the original lead contractor for the state website has agreed to repay $45 million to avoid legal action over rollout problems last year.

-In Vermont, a debate has been raging about whether to abandon the state exchange. Democratic Gov. Peter Shumlin originally wanted a single state-run system for all residents, along the lines of Canada. Shumlin backed off because it would have meant prohibitively high taxes. He wants to fix the state exchange, still grappling with technology problems that plagued it from launch.

The post State health insurance markets grapple with high costs appeared first on PBS NewsHour.

Proposed label would tell you how much added sugar to eat

SAN FRANCISCO, CA - FEBRUARY 18:  Nestle Butterfinger and Baby Ruth candy bars are displayed on a shelf at a convenience
         store on February 18, 2015 in San Francisco, California.  Nestle USA announced plans to remove all artificial flavors and
         FDA-certified colors from its entire line of chocolate candy products, including the popular Butterfinger and Baby Ruth candy
         bars, by the end of 2015.  (Photo by Justin Sullivan/Getty Images)

SAN FRANCISCO, CA – FEBRUARY 18: Nestle Butterfinger and Baby Ruth candy bars are displayed on a shelf at a convenience store on February 18, 2015 in San Francisco, California. The Food and Drug Administration proposed Friday that nutrition labels include the percent daily value for added sugars. Photo by Justin Sullivan/Getty Images

WASHINGTON — Wondering if you are eating too much added sugar? The nutrition label on your food may one day help you figure it out.

The Food and Drug Administration on Friday proposed that nutrition facts labels include the percentage of your recommended daily intake of added sugars in a food item — the “percent daily value.”

Adding new line for added sugars, or those that don’t occur naturally, is part of an overhaul of the nutrition facts label proposed last year by the Obama administration.

While the labels include percent daily values for other nutrients, the proposal didn’t include one for added sugars. Since then, a government advisory committee recommended that people get no more than 10 percent of calories daily from added sugars.

The FDA proposal would be based on that number, meaning that added sugars should be no more than 200 calories, or about 50 grams, in a recommended daily diet of 2,000 calories.

So if a food label says something has 50 grams of added sugars, the percent daily value for added sugars would be listed as 100 percent.

“For the past decade, consumers have been advised to reduce their intake of added sugars, and the proposed percent daily value for added sugars on the Nutrition Facts label is intended to help consumers follow that advice,” said Susan Mayne, director of the FDA’s Center for Food Safety and Applied Nutrition.

Currently, the nutrition facts label lists percent daily values for total fat, saturated fat, cholesterol, sodium, total carbohydrates, dietary fiber, iron, calcium and vitamins A and C.

The Center for Science in the Public Interest, an advocacy group that has pushed for more information on nutrition facts panels, called the FDA’s move “a major public health victory,” pointing out that a 20 ounce sugary soda can have 130 percent of the sugar a person is supposed to consume in a day.

The sugar industry said there isn’t enough science to justify the proposal.

“The Food and Drug Administration has an important role in our nation’s food supply to ensure that consumers are not misled by positive or negative claims about the food and beverages they purchase and consume,” The Sugar Association said in a statement.

The FDA said the proposal is open for public comment for 75 days. The agency is also re-opening public comment on the larger nutrition facts panel overhaul first proposed in March 2014. A final rule determining what the new panels will look like will come after the agency reviews the comments.

In addition to a new line for added sugars, the new labels proposed by the FDA last year would make calories more prominent and serving sizes more realistic. The idea is to make the labels less cluttered and more user-friendly.

The post Proposed label would tell you how much added sugar to eat appeared first on PBS NewsHour.