Health - Patient Money: Treating Chronic Pain and Managing the Bills

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• Patient Money: Treating Chronic Pain and Managing the Bills
• In a Graying Population, Business Opportunity
• Vital Signs: Childhood: Obesity and School Lunches
• Vital Signs: Disparities: A Growing Gender Gap in Doctors’ Pay
• $1 Million to Inventor of Tracker for A.L.S.
• Recipes for Health: Potato and Chard Stalk Gratin
• Yoga’s Stress Relief: An Aid for Infertility?
• Returning the Blessings of an Immortal Life
• World Briefing | AFRICA: Health Fund Adds Fraud Checks
• Governors Get Advice for Saving on Medicaid
• Virginia to Ask Supreme Court to Rule on Health Law
• Close Look at a Flu Outbreak Upends Some Common Wisdom
• Two Teams Show Divide in Debate on Safety
• Doctor and Patient: How Aggressive Is Your Hospital?
• Senate Rejects Repeal of Health Care Law
• Medical Detectives Find Their First New Disease
• Officials Consider Requiring Insurers to Offer Free Contraceptives
• Smoking Ban for Beaches and Parks Is Approved
• Well: Laura Hillenbrand Escapes From C.F.S.
• Well: When It's Tater Tot Day at School
• Well: Warm Up With Winter Vegetables
• Well: Treating Pain That Won't Go Away
• Well: Teenagers and Bad Decisions
• The New Old Age: The New Business of Old Age
• The New Old Age: Nurses Without Borders
• Prescriptions: Teva Warns, and Merck and Glaxo Post Losses
• Prescriptions: Rating Heart Risk Tests

Patient Money: Treating Chronic Pain and Managing the Bills Posted: 04 Feb 2011 09:40 PM PST MAYBE the question is not who suffers from some type of chronic pain, but who doesn’t? Enlarge This Image Matt McInnis for The New York Times Ernie Merritt III in his home in Saco, Me., donning a back brace that he must wear to walk around. Well Share your thoughts on this column at the Well blog. Go to Well » Related More Articles in This Series “If you tally up everybody who has chronic, recurring back, headache and musculoskeletal problems, it includes almost everybody by the time people get into their 30s,” said Dr. Perry Fine, a professor of anesthesiology at the Pain Research Center and the University of Utah and incoming chairman of the American Academy of Pain Medicine. Given the prevalence of chronic pain — often defined as recurrent pain that lasts more than three to six months — you might expect that by now medical science would have figured out how to alleviate it and that health insurers would routinely cover its treatment. If only it were that simple. Pain is a sneaky opponent. Invisible, it cannot be detected with a blood test or a scan; sometimes it has no identifiable cause. Pain is perception, and what one person considers intolerable may be only moderately uncomfortable to another. This makes treatment challenging. And insurers often do not make it any easier. For the last 15 years, Ernie Merritt III, 46, has been coping with the aftermath of a back injury he suffered working as a pipefitter in southeastern Maine. At the time, he thought he had just pulled a muscle. But after an M.R.I. revealed a herniated disc pressing on his sciatic nerve, he underwent the first of four operations. Surgery has not been enough. Mr. Merritt’s back still hurts, and now he must wear a brace full time to stabilize it. He has developed carpal tunnel syndrome and shoulder problems. The nerves in his legs are damaged, and doctors cannot figure out why. Because Mr. Merritt is disabled, he qualifies for Medicare, but he says he had to drop the Part B outpatient portion of the coverage. With all of his doctor visits — neurologists, orthopedists and physical therapists, not to mention his regular primary care physician — the 20 percent co-insurance charges were more than he and his wife could afford. Now he pays $3,000 a year for coverage with his wife’s health plan through her job at the county courthouse. Specialist co-payments are a flat $15 per visit, and he can see his primary care doctor free. Given his medical needs, it was the right decision, he said: “I have so many things going on that they can’t explain.” If you have chronic pain, chances are you have discovered that getting the care you need at a price you can afford can be, well, excruciating. These suggestions may help. A MEDICAL ‘HOME’ The most common causes of chronic pain are musculoskeletal conditions — including arthritis, lower back problems and fibromyalgia — and recurrent headaches. Chronic pain also afflicts many patients with such serious illnesses as cancer, AIDS and irritable bowel syndrome. Pain management almost always involves medication, and physical or occupational therapy is common. But there is no one-size-fits-all approach, and patients often see several doctors on a regular basis. It is important to find a primary care provider who will serve as your “medical home” and will work with you to coordinate care. You will avoid duplicative tests and procedures, and you are more likely to find the care you need. In addition, many primary care doctors provide therapies like nerve blocks, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians. A savvy primary care physician can help keep expenses in check. MENTAL HEALTH People with chronic pain are twice as likely to suffer from depression and anxiety as the general population, but insurance coverage for mental health problems often is inadequate for these patients. Fortunately, the recently passed mental health parity law should help make those services more available. Until then, consider some alternate community resources. Stanford University, for instance, has developed a chronic disease self-management program that is available in nearly every state through local area agencies on aging. The six-week program teaches participants relaxation and cognitive behavioral therapy techniques, among other things, and is free in many areas. For a quicker fix, check out the American Chronic Pain Association’s free five-minute relaxation guide. STRETCHING OUT “People in pain don’t exercise,” said Penney Cowan, founder and executive director of the American Chronic Pain Association. Big mistake. Exercise is one of the most effective and most affordable ways to manage chronic pain. Gentle stretching and exercises to increase range of motion and strength training are all helpful. (Get the go-ahead from your doctor before starting, though.) Although physical and occupational therapy are often recommended for people with chronic pain, insurance plans typically cover only a limited number of sessions. Make the most of your visits by asking the therapist to teach you what you can do on your own, said Dennis Turk, a professor of anesthesiology and pain research at the University of Washington. “Eight to 15 sessions of physical therapy may be more than enough if the patient is learning what to do on their own,” he said. INSURANCE APPEALS Insurance coverage for many types of pain management treatment is often inadequate, say advocates and physicians who treat it. Medication and interventional therapies like nerve blocks are more likely to be routinely covered than physical or behavioral therapy. Part of the problem is that pain management is complex, and people respond to therapies differently. “When people keep coming back and saying something’s not working, insurers begin to doubt that reality,” Ms. Cowan said. If your plan turns down your request for physical or behavioral therapy, or any other treatment, get a copy of the policy and read the fine print, said Jennifer C. Jaff, executive director of Advocacy for Patients With Chronic Illness. If the policy says therapies are covered only if they are medically necessary, for example, you may be able to challenge the denial in an appeal. Sometimes insurers say they are denying coverage because you have not shown improvement, a standard that someone with chronic pain may find impossible to meet. Appeal those decisions, too. Ms. Jaff’s organization files free insurance appeals for patients. AFFORDABLE DRUGS Medication is a mainstay for people with chronic pain, and drug therapy is one of the few chronic pain treatments that insurance plans reliably cover, said Mr. Turk. Even if you have coverage, however, it can be tough to figure out which drugs will effectively manage your pain. People with severe chronic pain may take prescription opioids like codeine and oxycodone, as well as antidepressants and muscle relaxants. Some insurers require that patients do “step” therapy: trying to relieve symptoms with aspirin for a few months, for example, before going on to a more powerful painkiller. In addition, some doctors are reluctant to prescribe some analgesics because they fear serious side effects and worry that patients may become dependent on them. It is important to find a doctor who will work with you to find a drug regimen that manages your pain and who will advocate on your behalf with an insurer. As with any drug, it pays to ask your doctor if an older, generic drug might be a reasonable substitute for a brand-name prescription. If you do not have insurance or if a drug you need is not on your plan’s list of covered drugs, check out needymeds.org, a clearinghouse for programs that provide free or discounted drugs to people, generally based on income.

In a Graying Population, Business Opportunity Posted: 05 Feb 2011 12:38 PM PST CAMBRIDGE, Mass. Enlarge This Image C.J. Gunther for The New York Times Calibrated to make the wearer, in this case the student Katii Gullick, experience old age, the Agnes â€" short for the Age Gain Now Empathy System â€" has harnesses and bands that restrict joint and limb movements. Multimedia The AgeLab at M.I.T. The AgeLab at M.I.T. Close Video See More Videos » Interactive Graphic The Aging of America Add to Portfolio Pfizer Inc Bank of America Corp Ford Motor Co Aegon N.V Johnson & Johnson General Electric Co Intel Corp Go to your Portfolio » Enlarge This Image C.J. Gunther for The New York Times Agnes also has a helmet attached to a harness that constrains the neck and spine, plastic gloves that make it harder to open packages, and foam soles on the shoes to throw off balance. IT’S not easy being gray. For the first time ever, getting out of a car is no picnic. My back is hunched. And I’m holding on to handrails as I lurch upstairs. I’m 45. But I feel decades older because I’m wearing an Age Gain Now Empathy System, developed by researchers at the Massachusetts Institute of Technology. Agnes, they call it. At first glance, it may look like a mere souped-up jumpsuit. A helmet, attached by cords to a pelvic harness, cramps my neck and spine. Yellow-paned goggles muddy my vision. Plastic bands, running from the harness to each arm, clip my wingspan. Compression knee bands discourage bending. Plastic shoes, with uneven Styrofoam pads for soles, throw off my center of gravity. Layers of surgical gloves make me all thumbs. The age-empathy suit comes from the M.I.T. AgeLab, where researchers designed Agnes to help product designers and marketers better understand older adults and create innovative products for them. Many industries have traditionally shied away from openly marketing to people 65 and older, viewing them as an unfashionable demographic group that might doom their product with young and hip spenders. But now that Americans are living longer and more actively, a number of companies are recognizing the staying power of the mature market. “Aging is a multidisciplinary phenomenon, and it requires new tools to look at,” Joseph F. Coughlin, director of AgeLab, tells me, encumbered and fatigued after trying to conduct a round of interviews while wearing Agnes. Viewed through yellow goggles, the bright colors of Professor Coughlin’s bow tie appear dim. “Agnes is one of those tools,” he says. AgeLab, like a handful of other research centers at universities and companies around the country, develops technologies to help older adults maintain their health, independence and quality of life. Companies come here to understand their target audience or to have their products, policies and services studied. Often, visitors learn hard truths at AgeLab: many older adults don’t like products, like big-button phones, that telegraph agedness. “The reality is such that you can’t build an old man’s product, because a young man won’t buy it and an old man won’t buy it,” Professor Coughlin says. The idea is to help companies design and sell age-friendly products — with customizable font size, say, or sound speed — much the way they did with environmentally friendly products. That means offering enticing features and packaging to appeal to a certain demographic without alienating other consumer groups. Baked potato chips are just one example of products that appeal to everybody but skew toward older people. Toothpastes that promise whitening or gum health are another. Researchers at AgeLab are studying the stress levels of older adults who operate a hands-free parallel-parking system developed by Ford Motor. Although this ultrasonic-assisted system may make backing up easier for older adults who can’t turn their necks to the same degree they once did, the car’s features — like blind-spot detection and a voice-activated audio system — are intended to appeal to all drivers who enjoy smart technology. “With any luck, if I am successful,” Professor Coughlin says, “retailers won’t know they are putting things on the shelves for older adults.” THE first of about 76 million baby boomers in the United States turned 65 in January. They are looking forward to a life expectancy that is higher than that of any previous generation. The number of people 65 and older is expected to more than double worldwide, to about 1.5 billion by 2050 from 523 million last year, according to estimates from the United Nations. That means people 65 and over will soon outnumber children under 5 for the first time ever. As a consequence, many people may have to defer their retirement — or never entirely retire — in order to maintain sustainable incomes. Many economists view such an exploding population of seventy- and eighty-somethings not as an asset, but as a looming budget crisis. After all, by one estimate, treating dementia worldwide already costs more than $600 billion annually. “No other force is likely to shape the future of national economic health, public finances and policy making,” analysts at Standard & Poor’s wrote in a recent report, “as the irreversible rate at which the world’s population is aging.” 1 2 3 4 Next Page » This posting includes an audio/video/photo media file: Download Now

Vital Signs: Childhood: Obesity and School Lunches Posted: 04 Feb 2011 11:30 PM PST Researchers say they have identified another risk factor for childhood obesity: school lunch. Related More Vital Signs Columns A study of more than 1,000 sixth graders in several schools in southeastern Michigan found that those who regularly had the school lunch were 29 percent more likely to be obese than those who brought lunch from home. Spending two or more hours a day watching television or playing video games also increased the risk of obesity, but by only 19 percent. Of the 142 obese children in the study for whom dietary information was known, almost half were school-lunch regulars, compared with only one-third of the 787 who were not obese. “Most school lunches rely heavily on high-energy, low-nutrient-value food, because it’s cheaper,” said Dr. Kim A. Eagle, director of the University of Michigan Cardiovascular Center, and senior author of the paper, published in the December issue of American Heart Journal. In some schools where the study was done, lunch programs offered specials like “Tater Tot Day,” he said. Help is on the way, though. Under a federal law passed in December, Department of Agriculture guidelines will limit the number of calories served at every school meal and require programs to offer a broad variety of fruits and vegetables — not just corn and potatoes.

Vital Signs: Disparities: A Growing Gender Gap in Doctors’ Pay Posted: 04 Feb 2011 11:30 PM PST Starting salaries for women who become physicians are significantly lower than men’s, and the pay gap has grown over the past decade, a study reports. Related More Vital Signs Columns The pay differential, which was 12.5 percent in 1999, increased to nearly 17 percent by 2008, according to the report, published Thursday in Health Affairs. The growing gap could not be explained by women’s preferences, the authors said. While women on average do choose lower-paying specialties and shorter workweeks than men, those disparities were less pronounced in 2008 than in 1999. Yet the pay differential has widened. “That was the part that surprised and puzzled us,” said one author, Anthony T. Lo Sasso, a professor of health policy at the University of Illinois at Chicago. “As you start moving forward in time closer to the present day, your ability to explain away that difference between men’s and women’s salaries essentially evaporates.” The research looked at more than 8,000 new physicians in New York State. In 1999, the women earned $151,600 on average, compared with $173,400 for men; by 2008, the figures were $174,000 for women and $209,300 for men. (The study adjusted for inflation.) After accounting for differences in their practices, the study concluded, the pay gap had increased to $16,819 in 2008, from $3,600 in 1999.

$1 Million to Inventor of Tracker for A.L.S. Posted: 04 Feb 2011 07:55 AM PST BOSTON — Tracking the inexorable advance of amyotrophic lateral sclerosis, the deadly neuromuscular ailment better known as Lou Gehrig’s disease or A.L.S., has long been an inexact science — a matter of monitoring weakness and fatigue, making crude measurements of the strength of various muscles. Enlarge This Image Multimedia Interactive Feature Patient Voices: A.L.S. Related Health Guide: Amyotrophic Lateral Sclerosis This imprecision has hindered the search for drugs that could slow or block the disease’s progress. But now a neurologist at Beth Israel Deaconess Medical Center here has won a $1 million prize — reportedly the largest ever for meeting a specific challenge in medical research — for developing a reliable way to quantify the small muscular changes that signal progressive deterioration. The winner, Dr. Seward Rutkove, showed that his method could cut in half the cost of clinical trials to screen potential drugs for the disease, said Melanie Leitner, chief scientific officer of Prize4Life, the nonprofit group that created the competition. The method does not provide a target in the body at which to aim drugs, nor will it help doctors better diagnose the disease. But Dr. Merit Cudkowicz, a professor of neurology at Massachusetts General Hospital and a chairwoman of the Northeast A.L.S. Consortium, compared Dr. Rutkove’s discovery to the way magnetic resonance imaging expedited the development of drugs for multiple sclerosis. “You can use this as a tool to screen drugs to see if they will affect survival,” she said, but added, “The ultimate prize is finding a drug that works for A.L.S.” Dr. Rutkove, 46, who has been treating patients with neuromuscular disease for 16 years, took advantage of the way our muscle fibers change electrical currents. With a hand-held device hooked up to electrodes on the patient’s skin, a doctor can send a painless electrical current into a given muscle, then measure the voltage that results. As A.L.S. spreads, motor neurons die off, causing muscles to atrophy. The deteriorating muscles behave differently from healthy ones, resisting the current more. In studies of humans as well as rats, Dr. Rutkove showed that these variations were closely correlated with disease progression and length of survival. “It’s not like it’s the fanciest technology,” he said. “But I truly believe it will help people.” Dr. Rutkove was inspired to become a doctor when, as a child, he watched his grandfather have an epileptic seizure while fixing a bicycle. Each year, doctors diagnose about 5,000 new cases of A.L.S. in the United States, according to the National Institutes of Health. Despite decades of clinical trials, the diagnosis remains a death sentence. It paralyzes and suffocates patients while their minds remain intact. A few patients live for decades — the physicist Stephen Hawking is the best known — but most survive only three to five years after they first notice symptoms. And riluzole, the only A.L.S. drug approved by the Food and Drug Administration, costs about $10,000 a year and typically extends life by just a few more months. The high cost of clinical trials limits drug companies’ ability to test potential treatments. Researchers must recruit hundreds of patients and run trials that last as long as two years just to eliminate a drug from the running. “One executive told us, ‘For the cost of one A.L.S. drug I can develop two multiple sclerosis drugs, so obviously I go with M.S.,’ ” wrote Avi Kremer, the 35-year-old founder of Prize4Life. Mr. Kremer, who has the disease himself (he was given the diagnosis in 2004, while a student at Harvard Business School), cannot speak or type. He made the remark during a Skype video chat from his apartment in Haifa, Israel, using a sensor that tracks his forehead as he lifts his eyebrows. Dr. Doug Kerr, associate director of experimental neurology at Biogen Idec, which is working on an A.L.S. drug, said more sensitive testing methods “will allow us to test more drugs, more patients, and get an answer earlier.” He called Dr. Rutkove’s method “a powerful new part of the armament to study A.L.S.” Researchers say the $1 million prize, to be presented to Dr. Rutkove in June at a ceremony in New York, is the largest ever awarded for solving a prescribed challenge in medical research. (The Nobel and Lasker awards are given retrospectively, rather than in response to a challenge.) This kind of prize is hardly new. In the 18th century, such a challenge spurred a solution to Newton’s famous problem of how to determine longitude at sea. (A clockmaker, John Harrison, won the competition by inventing the marine chronometer.) And Charles Lindbergh’s nonstop flight across the Atlantic was prompted by a competition, the $25,000 Orteig Prize. Now these sorts of challenges are coming back into fashion. In December, Congress passed a law authorizing federal agencies to use prize competitions as a complement to grants and contracts. Competitions can draw new eyes to old problems; among the Prize4Life contestants was a dermatologist from Buffalo who was driven to look for a skin-based biomarker for A.L.S. after he noticed that patients with the disease did not get bedsores. The danger of a prize competition, on the other hand, is that “if you make the wrong choices, you might be leading people in the wrong direction, or to an R. & D. cul-de-sac,” said Paul A. Wilson, a professor at the Mailman School of Public Health at Columbia University. Dr. Wilson has studied the potential of using a prize to encourage development of a tuberculosis diagnostic tool cheap and simple enough to use in rural Africa. Dr. Rutkove said his work had been under way, and supported by public financing, before he heard of the prize. But he added that the challenge turned his focus toward reducing the cost of clinical trials and sped up his analysis. The lure of a prize competition is that it can set off a race to achieve what is just beyond reach. “It is not unlike President Kennedy succinctly challenging us to put a man on the Moon,” said Dwayne Spradlin, chief executive of InnoCentive, a matchmaking company for problem solvers and seekers of solutions that helped promote the Prize4Life contest. For A.L.S. patients like Mr. Kremer, of course, the biggest challenge remains: to survive.

Recipes for Health: Potato and Chard Stalk Gratin Posted: 04 Feb 2011 08:36 AM PST If your Swiss chard has wide stems, keep them handy. You can use them in a number of dishes, including this rich gratin. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Vegetable Casseroles for Frigid Nights (January 31, 2011) Recipes for Health: Cabbage and Red Pepper Gratin (February 1, 2011) Recipes for Health: Slow-Baked Beans With Kale (February 2, 2011) Recipes for Health: Beets, Spiced Quinoa and Yogurt (February 3, 2011) 1 pound small boiling potatoes, scrubbed Salt to taste 1 pound wide Swiss chard stems (from 1 large or 2 smaller bunches), trimmed and cut crosswise into 1/2 inch thick slices 1 garlic clove, halved 2 tablespoons extra virgin olive oil 2 tablespoons finely chopped shallot or onion (optional) 2 tablespoons all-purpose flour 2 cups low-fat (1 percent or 2 percent) milk Freshly ground white or black pepper 1 teaspoon thyme leaves 1 ounce Gruyère, grated (1/4 cup) 1. Place the potatoes in a saucepan, and cover with water. Add 1/2 teaspoon salt, and bring to a boil. Reduce the heat to medium, and boil gently until tender, 10 to 20 minutes, depending on the size of the potatoes. Add the chard stalks to the pot, and simmer for another five minutes until crisp-tender. Drain, and retain the cooking liquid if you prefer to use it instead of milk for the béchamel. Cut the potatoes into quarters or halves, depending on their size. 2. Preheat the oven to 425 degrees. Rub a 2-quart baking dish or gratin with the cut clove of garlic, and brush with olive oil. 3. Make the béchamel. Heat the oil over medium heat in a heavy medium saucepan. Add the shallot or onion, and cook, stirring, until softened, about three minutes. Stir in the flour, and cook, stirring, for about three minutes until smooth and bubbling but not browned. It should have the texture of wet sand. Whisk in the milk all at once, and bring to a simmer, whisking all the while, until the mixture begins to thicken. Turn the heat to very low and simmer, stirring often with a whisk and scraping the bottom and edges of the pan with a rubber spatula, for 10 to 15 minutes until the sauce is thick and has lost its raw flour taste. Season with salt and pepper. Strain while hot into a heatproof bowl or a Pyrex measuring cup. 4. Cut the potatoes into quarters or halves, depending on their size. Combine with the chard stalks and thyme in a large bowl, and season with salt and pepper. Add the béchamel, and stir until the vegetables are coated with sauce. Scrape into the gratin dish. Sprinkle the Gruyère on top. 5. Bake 20 to 25 minutes until bubbling and beginning to brown on the top. Serve hot. Variation: Substitute the stock from the vegetables for some or all of the milk. Yield: Serves four. Advance preparation: You can make a béchamel up to a day ahead of using it; keep it in the refrigerator. If you lay a sheet of plastic or wax paper directly on top, there is less chance that a skin will form. Even if it does, you can get rid of it by whisking vigorously when you reheat the béchamel. Then the sauce should be as smooth as it was when you made it. Thin out if necessary with milk or stock. You can cook the potatoes and chard stalks several hours ahead of serving. Assemble the gratin just before you cook it. Nutritional information per serving (four servings, using 1 percent milk): 265 calories; 11 grams fat (3 grams saturated fat); 14 milligrams cholesterol; 34 grams carbohydrates; 5 grams dietary fiber; 326 milligrams sodium (does not include salt to taste); 11 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

Yoga’s Stress Relief: An Aid for Infertility? Posted: 05 Feb 2011 08:47 AM PST KIMBERLY SORANNO, a 39-year-old Brooklynite undergoing an in vitro fertilization cycle as part of her quest to become pregnant, had gone to her share of yoga classes, but never one like that held on a recent Tuesday night in a reception area of the New York University Fertility Center. There were no deep twists or headstands; just easy “restorative” poses as the teacher, Tracy Toon Spencer, guided the participants — most of them women struggling to conceive — to let go of their worries. Enlarge This Image Sally Ryan for The New York Times In Chicago, Beth Heller, left, and Tami Quinn, founders of Pulling Down the Moon. “Verbally, she brings you to a relaxation place in your mind,” Mrs. Soranno said, adding, “It’s great to do the poses, get energy out and feel strong. But the most important part for me was the connection to the other women.” Besides taxing the mind, body and wallet, infertility can be lonely. Support groups have long existed for infertile couples, but in recent years, so-called “yoga for fertility” classes have become increasingly popular. They are the latest in a succession of holistic approaches to fertility treatment that have included acupuncture and mind-body programs (whose effectiveness for infertility patients is backed by research); massage (which doesn’t have specific data to support it); and Chinese herbs (which some say may be detrimental). No study has proved that yoga has increased pregnancy rates in infertility patients. But students of yoga-for-fertility classes say that the coping skills they learn help reduce stress on and off the mat. For many, it’s a support group in motion (or lotus). “As important as the yoga postures was the idea that women could come out of the closet with their infertility and be supported in a group,” said Tami Quinn, the founder, with Beth Heller, of Pulling Down the Moon, a company with holistic fertility centers in Chicago and the Washington area. “If you say come to my support group, women going through infertility are like, ‘I don’t need some hokey support group’ or ‘I’m not that bad.’ But with yoga they are getting support and they don’t even realize it.” Holly Dougherty, 42, didn’t want to talk about her drug-infused slog through fertility treatment that began seven years ago. “I didn’t tell anyone,” said Ms. Dougherty, with the exception of her parents. This changed after she started going to yoga-for-fertility classes taught by Ms. Spencer at World Yoga Center in Manhattan in 2005. The gentle poses helped take her mind off her setbacks, and each week, she found the community that she hadn’t realized she needed. “Being able to open up in a safe environment with support and encouragement of others on the journey, everyone became each other’s cheerleader,” said Ms. Dougherty, now a mother of two who still socializes with students from Ms. Spencer’s class. “I learned to become so open about it.” SMOKING, alcohol, caffeine and some medications can hurt fertility, as can being overweight or underweight, said Dr. William Schoolcraft, a medical director of the Colorado Center for Reproductive Medicine, whose main branch is in Lone Tree. As for improving one’s chances with massage, diet or yoga? “That’s where the data gets murkier,” he said. “We will never promise that you will get pregnant by doing yoga,” Ms. Quinn said. “We can tell you many women who have done yoga have gotten pregnant. But there’s no clinical data supporting the fact that yoga increases conception rates. The last thing we would want to do is give false hope.” Stress, however, has been shown to reduce the probability of conception. Alice Domar, who has a Ph.D. in health psychology and is the director of mind-body services at the Harvard-affiliated center Boston IVF, said of yoga: “It’s a very effective relaxation technique, and a great way to get women in the door to get support. It’s a way to get them to like their bodies again.” A handful of prominent medical centers have partnered with yoga teachers to offer classes. Pulling Down the Moon now holds its $210 six-week Yoga for Fertility programs at Fertility Centers of Illinois in Chicago (since 2002), and Shady Grove Fertility in the Washington area (since 2008.) Recently, Dr. Domar, a psychologist whose research has shown that participation in a mind-body program can positively affect fertility, joined with Ms. Quinn and Ms. Heller to take wellness programs, including yoga and acupuncture, to infertility clinics nationwide. They have formed a new company, Integrative Care for Fertility: A Domar Center, and plan to open seven branches this year. In 2009, the New York University Fertility Center in Manhattan brought in two yoga instructors to help patients. “We really do push it,” Dr. Frederick Licciardi, a founding partner of the center, said of its wellness programs that include mind-body work and acupuncture along with yoga. “We put it up front. We know they are doing it anyway. We want to show we are supportive that they are doing it.” Some infertility clinics advise patients not to do vigorous exercise like running for fear of twisting their drug-stimulated enlarged ovaries. (This excruciating condition, called torsion, is rare, but surgery is often required if it happens with the possibility of losing the ovary, said Dr. Brian Kaplan, a partner at the Fertility Centers of Illinois, who advises his patients to limit exercise while taking stimulating drugs.) 1 2 Next Page »

Returning the Blessings of an Immortal Life Posted: 04 Feb 2011 08:51 PM PST If there was one thing Rebecca Skloot was certain of when writing “The Immortal Life of Henrietta Lacks,” it was that she did not want to profit from the Lacks family without giving something in return. Enlarge This Image Monica Lopossay for The New York Times Jeri Lacks Whye and her two daughters, Jabrea, left, and Aiyana are among the descendants of Henrietta Lacks. Related Excerpt: ‘The Immortal Life of Henrietta Lacks’ (March 3, 2010) Books of The Times: ‘The Immortal Life of Henrietta Lacks’ by Rebecca Skloot (February 3, 2010) Sunday Book Review: ‘The Immortal Life of Henrietta Lacks’ by Rebecca Skloot (February 7, 2010) Enlarge This Image Andrew Councill for The New York Times Victoria Baptiste, with her children, Brian and Bria, is studying nursing with support from the Henrietta Lacks Foundation. Enlarge This Image Matt Roth for The New York Times Kimberly Lacks has had dental work thanks to grants from the Henrietta Lacks Foundation. For half a century, biotechnology companies and scientists have used the astonishingly hardy cancer cells that killed Henrietta Lacks to develop countless medical breakthroughs and establish a multimillion-dollar industry selling her cell line, known as HeLa. Poor, uneducated and black, Mrs. Lacks was not asked about allowing her tissue to be used for research before she died in 1951, at just 31, and no one bothered to explain the medical revolution that her cells produced to the family she left behind. Since the book’s debut a year ago, it has earned rave reviews, prizes, a movie deal with HBO and a steady spot on best-seller lists. And Ms. Skloot is making good on her pledge to share the financial windfall with the Lackses. Soon after the book came out, she created the Henrietta Lacks Foundation to help Mrs. Lacks’s descendants, some of whom suffered from the whirlwind of publicity, misinformation and scam artists surrounding HeLa cells, not to mention a lack of insurance to pay for any of the medical advances Mrs. Lacks’s cells made possible. “I first envisioned it as a foundation for education, but I realized that the people who were affected the most were her kids, and they needed some medical care and dental care,” Ms. Skloot said from her home in Chicago. Mrs. Lacks had three sons and two daughters, both of whom have died. The foundation — which is still in the process of applying for nonprofit status — is paying for a high-tech hearing aid for Mrs. Lacks’s youngest son, Zakariyya; truck repairs for her middle son, Sonny; new teeth for her granddaughter Kimberly; braces for her great-granddaughter Aiyana Rodgers; and, yes, tuition, books and fees for five of her grandchildren and great-grandchildren. Sonny Lacks’s daughter Kimberly was the first to notice the phrase “other needs” in the grant guidelines. She applied for money to replace cracked and missing teeth and to care for a painful, untreated root canal. “Now I can smile and I can eat,” said Kimberly Lacks, who received $3,000 for the dental work after she lost her job. Her sister Jeri then applied for a grant to cover the cost of her 12-year-old daughter’s orthodontic work. To aid Henrietta Lacks’s three surviving sons, Ms. Skloot said that she made sure that they were hired as consultants for the HBO film, which is being produced by Oprah Winfrey’s Harpo Films and the screenwriter Alan Ball (“American Beauty,” “True Blood”). She is also working to raise money to cover more than $125,000 in medical bills that Sonny Lacks incurred after having quadruple-bypass surgery. Ms. Skloot, however, has stayed focused on education — precisely the advantage that Henrietta Lacks never had. Although Mrs. Lacks never made it past the sixth grade, her great-granddaughter Victoria Baptiste is studying nursing at Baltimore City Community College at night, thanks to a $2,400 grant from the foundation. “Last semester I made straight A’s,” Ms. Baptiste, 29, proudly said in a telephone interview. Between working full time, shuttling her children to scout meetings and repaying a hefty $18,000 loan from a previous educational stint, Ms. Baptiste said she couldn’t afford tuition without help. “I know my great-grandmother would want all her children to be educated, since she didn’t have that herself,” she said. HeLa, the first human cells to grow outside the body, have been used in more than 60,000 experiments involving leukemia, Parkinson’s disease and AIDS. They were instrumental in developing the polio vaccine, chemotherapy, cloning, gene mapping and in vitro fertilization. Ms. Skloot contributes some of her royalties and speaking fees to the foundation, though she does not follow any particular formula. Much of the $50,000 that the foundation has received from readers has come from cancer survivors and scientists who have written to say, “I owe my career to,” or “I wrote my dissertation on,” HeLa cells, she said. Ms. Skloot said that she expected a hefty donation from Harpo Films, but that none of the large biotech companies that continue to profit from HeLa have yet to contribute. Johns Hopkins, where Mrs. Lacks was given state-of-the-art care in its colored ward as her cells were being harvested, has not donated to the foundation, but it has established a lecture series in her name; a $10,000-a-year scholarship for students from an East Baltimore high school; and a $15,000 annual award for community health groups. As Ms. Skloot makes clear in her book, both the law and the ethics regarding medical research were different back then, and Hopkins did nothing illegal by taking a cell sample from Mrs. Lacks. If the institution has not come forward, many individuals connected to it have privately supported efforts to obtain health insurance for the Lackses and to eliminate Sonny Lacks’s debt, Ms. Skloot said. Others there share Ms. Skloot’s interest in education, holding events like Microscope Day every month, when younger members of the sprawling Lacks clan and their friends can come in to look at the cells and talk about science. Ms. Skloot’s hope is that the foundation will soon enlarge its mission to help other needy families in similar situations, particularly those used in research without their consent. “I don’t want to be an activist and I’m not a philanthropist,” said Ms. Skloot, who has been consumed by the details of setting up the foundation over the last year. She is one of three board members; her aim is to enlarge the board and reduce her own involvement so that she can get back to what she really wants to do: write. As a New York Times editor, Patricia Cohen edited an article by Rebecca Skloot on Henrietta Lacks in 2001 and is acknowledged in the book.

World Briefing | AFRICA: Health Fund Adds Fraud Checks Posted: 04 Feb 2011 09:50 PM PST The Global Fund to Fight AIDS, Tuberculosis and Malaria announced steps on Friday to strengthen antifraud safeguards, including doubling the budget for internal investigations. The group acted after a Jan. 23 article by The Associated Press described corruption in grants to Mali, Mauritania, Zambia and Djibouti. The fund said it was seeking to recover $34 million from those and other countries, an amount it said was less than 1 percent of the $13 billion in aid it has disbursed in 145 countries.

Governors Get Advice for Saving on Medicaid Posted: 04 Feb 2011 10:44 AM PST WASHINGTON — Fearing wholesale cuts in Medicaid by states with severe budget problems, the Obama administration told governors on Thursday how they could save money by selectively and judiciously reducing benefits, curbing overuse of costly prescription drugs and attacking fraud. Related For Governors, Medicaid Looks Ripe for Slashing (January 29, 2011) Times Topic: Medicaid Blogs The Caucus The latest on President Obama, the new Congress and other news from Washington and around the nation. Join the discussion. FiveThirtyEight: Nate Silver's Political Calculus More Politics News However, the administration refused to say whether it would allow states to adopt stricter eligibility standards that would, in effect, throw low-income people off the Medicaid rolls and eliminate their insurance coverage. Kathleen Sebelius, the secretary of health and human services, said she was still studying that question. Governors said the ideas, though constructive, were not nearly enough. They said they wanted waivers of some federal requirements and relief from Congress, and they noted that the new health care law would greatly increase Medicaid rolls in 2014. In a letter to governors on Thursday, Ms. Sebelius said, “I have heard the urgency of your state budget concerns.” Ms. Sebelius emphasized that states already had substantial discretion to alter benefits and establish or increase co-payments. While state Medicaid programs must cover hospital and doctors’ services, Ms. Sebelius said, many other services are classified as optional. The optional services, she said, include prescription drugs, physical therapy, respiratory care, optometry services and eyeglasses, dental services and dentures. An administration official, discussing the letter on condition of anonymity, said: “Cuts can hurt people. We certainly see that.” The official said that, instead of taking an ax to Medicaid, states should find ways to save money and improve care at the same time. For example, the official said, states should more aggressively manage the care of the sickest Medicaid recipients. “Just 1 percent of all Medicaid beneficiaries account for 25 percent of all expenditures,” Ms. Sebelius said, and 5 percent of the recipients account for more than half of Medicaid spending. In addition, Ms. Sebelius said, states could save large sums by reducing premature births and medically unnecessary Caesarean sections, by reducing hospital admissions and by using proven techniques to improve the care of children with asthma. Republicans in Congress are introducing bills to give states much more latitude in Medicaid and to block the provision of the new health care law that vastly expands eligibility. The law, with some exceptions, generally bans states from restricting eligibility. In Arizona, Gov. Jan Brewer, a Republican, has asked the federal government for permission to remove 280,000 people from the rolls. Despite painful cuts in benefits and in payment rates for health care providers, Ms. Brewer said, the Arizona Medicaid program “is still growing at an astounding rate.” The 29 Republican governors recently asked President Obama for relief from the Medicaid eligibility requirements, which they said tied their hands. Mike Schrimpf, a spokesman for the Republican Governors Association, said, “Secretary Sebelius’s cleverly buried response to governors is that she is still studying the issue.” Gov. Haley Barbour of Mississippi, a Republican, said, “Secretary Sebelius’s letter fails to provide solutions that immediately address the exploding state budget problems posed by the Medicaid program.” Governors of both parties want the administration to remove the “burdensome constraints” on states’ ability to change Medicaid eligibility rules, Mr. Barbour said. In 2003, when President George W. Bush proposed to give states new power to reduce or eliminate optional Medicaid benefits, advocates for poor people and the disabled denounced the idea. They expressed similar concerns on Thursday. “ ‘Optional services’ is a misnomer,” said Peter W. Thomas, a lawyer for the Consortium for Citizens with Disabilities, a national advocacy group. “These items and services, which include artificial limbs, wheelchairs and kidney dialysis, are life-saving and life-sustaining. They improve functional abilities and the quality of life for millions of people.”

Virginia to Ask Supreme Court to Rule on Health Law Posted: 03 Feb 2011 11:10 PM PST Virginia’s attorney general announced on Thursday that he hoped to bypass an initial appellate review by asking the United States Supreme Court to consider the constitutionality of the Obama health care law on an expedited basis. Enlarge This Image Jay Paul for The New York Times Kenneth T. Cuccinelli II, the attorney general of Virginia, spoke with reporters in December after a federal district judge backed the state and struck down a provision of the health care overhaul. Multimedia Interactive Feature The Health Care Law: The Growing Legal and Political Opposition Related Senate Rejects Repeal of Health Care Law (February 3, 2011) Only rarely does the Supreme Court grant such hearings, and it has already rejected a similar request in another legal challenge to the health care act. But the commonwealth’s attorney general, Kenneth T. Cuccinelli II, said the legal and governmental confusion sown by conflicting lower-court opinions demanded a rapid resolution. “Currently, state governments and private businesses are being forced to expend enormous amounts of resources to prepare to implement a law that in the end may be declared unconstitutional,” Mr. Cuccinelli said in a statement. In December, Mr. Cuccinelli became the first plaintiff to win a challenge to the health care act, when Judge Henry E. Hudson of Federal District Court in Richmond, Va., struck down a provision that requires most Americans to obtain insurance. The judge ruled that the insurance requirement exceeded Congress’s authority under the Constitution to regulate interstate commerce. Two other federal judges, including another in Virginia, had previously upheld the law. Then on Monday, Judge Roger Vinson of Federal District Court in Pensacola, Fla., joined Judge Hudson in striking down the insurance mandate. But unlike Judge Hudson, Judge Vinson invalidated the entire law. The law, enacted last year by a Democratic Congress and signed in March by President Obama, aims to cover 32 million uninsured Americans by ending insurer discrimination against those with pre-existing health conditions and by providing government subsidies to make coverage affordable. The Justice Department, which is defending the Obama administration in the health litigation, has already filed a notice of appeal of Judge Hudson’s ruling in the Court of Appeals for the Fourth Circuit in Richmond. Because of the geographic distribution of the four lower court rulings, three different courts of appeal are likely to hear the cases on their way to the Supreme Court. Tracy Schmaler, a spokeswoman for the Justice Department, said the agency continued “to believe this case should follow the ordinary course” so that legal arguments could be fully developed before being presented to the Supreme Court. She pointed out that the insurance mandate does not take effect until 2014 and that the Fourth Circuit has already expedited its schedule by setting oral arguments for May. The Justice Department also is considering whether to seek a stay of the Florida decision in order to clarify confusion about whether the health care act remains in effect in the 26 states that are plaintiffs in the case. Mr. Cuccinelli said he recognized that an expedited Supreme Court review would be exceptional. But he said that this case and the others challenging the constitutionality of the Patient Protection and Affordable Care Act, as the law is known, were “truly exceptional in their own right.” In November, the Supreme Court refused to review another challenge to the health care act that had been dismissed by a California judge on grounds that the plaintiffs did not have standing to sue.

Close Look at a Flu Outbreak Upends Some Common Wisdom Posted: 04 Feb 2011 08:10 AM PST If you or your child came down with influenza during the H1N1, or swine flu, outbreak in 2009, it may not have happened the way you thought it did. Multimedia Graphic Tracking Flu Transmission Related Health Guide: H1N1 (swine) Influenza Vaccine A new study of a 2009 epidemic at a school in Pennsylvania has found that children most likely did not catch it by sitting near an infected classmate, and that adults who got sick were probably not infected by their own children. Closing the school after the epidemic was under way did little to slow the rate of transmission, the study found, and the most common way the disease spread was a through child’s network of friends. Researchers learned all this when they studied an outbreak of H1N1 at an elementary school in a semirural community in spring 2009. They collected data in real time, while the epidemic was going on. With this information on exactly who got sick and when, plus data on seating charts, activities and social networks, they were able to use statistical techniques to trace the spread of the disease from one victim to the next. Their report appears online in the Proceedings of the National Academy of Sciences. The scientists collected data on 370 students from 295 households. Almost 35 percent of the students and more than 15 percent of their household contacts came down with flu. The most detailed information was gathered from fourth-graders, the group most affected by the outbreak. The class and grade structure had a significant effect on transmission rates. Transmission was 25 times as intensive among classmates as between children in different grades. And yet sitting next to a student who was infected did not increase the chances of catching flu. Social networks were apparently a more significant means of transmission than seating arrangements. Students were four times as likely to play with children of the same sex as with those of the opposite sex, and following this pattern, boys were more likely to catch the flu from other boys, and girls from other girls. The progress of the disease from day to day followed these social interactions: from May 7 to 9, the illness spread mostly among boys; from May 10 to 13 mostly among girls. “Our social networks shape disease spread,” said Simon Cauchemez, the lead author. “And we can quantify the role of social networks.” Thirty-eight percent of children 6 to 10 were infected, compared with 23 percent of 11- to 18-year-olds and 13 percent of those older than 18. Adults were only about half as susceptible as children, but when they got sick they were just as likely to transmit the virus to others. The school closed from May 14 to 18, but there was no indication that this slowed transmission. It may already have been too late — May 14 was the 18th day of the outbreak, and 27 percent of the students already had symptoms. The scientists found no difference in transmission rates during the closure and during the rest of the outbreak. This, they write, confirms earlier studies showing that a school has to be closed quite early in an epidemic to have any effect on disease transmission. Only 1 in 5 adults caught the illness from their own children, and this goes against one of the most common arguments for closing schools: that it will prevent the disease from moving from the school to households. “Here we find that most of the infected adults were not infected by one of the children in their household,” said Dr. Cauchemez, a research fellow at Imperial College London. “This information could be used to understand whether it might be better to close a school, or to close individual classes or grades.” Other experts were impressed with the work. “I think it’s a nice step,” said Ira M. Longini Jr., a professor of biostatistics at the Fred Hutchinson Cancer Research Center in Seattle. “It’s a beautiful analysis of an important dataset. This virus spreads very fast among school-age children, so the topic is important.”

Two Teams Show Divide in Debate on Safety Posted: 03 Feb 2011 11:48 PM PST DALLAS — Aaron Rodgers sat woozily on the Green Bay Packers’ bench after a hard hit from the Detroit Lions on Dec. 12. Midway through a ghastly loss, with the Packers’ playoff hopes in the balance, the veteran receiver Donald Driver decided that Rodgers, his star quarterback, needed some encouragement. Enlarge This Image Paul Sancya/Associated Press Aaron Rodgers was kept out of the rest of the Detroit game and a loss to the Patriots before being declared healthy. Multimedia Interactive Feature Who Will Win Super Bowl XLV? Related Union Leader Addresses Differences With League (February 4, 2011) The Fifth Down: Injured Steeler Is Overlooked for Rookie of Year (February 4, 2011) The latest news, notes and analysis of the N.F.L. playoffs. Go to The Fifth Down Blog N.F.L. Live Scoreboard Standings Stats | Injuries Giants Schedule/Results Stats | Roster Depth Chart Jets Schedule/Results Stats | Roster Depth Chart Enlarge This Image Rick Osentoski/Associated Press Aaron Rodgers sustained a concussion from a hit by the Lions’ Landon Johnson on Dec. 12. Receiver Donald Driver encouraged him to put his health first. “I went behind him and told him that this game is just a game,” Driver recalled this week. “Your life is more important than the game.” A professional player telling another to put his long-term health ahead of the team — a once and, to some, still-heretical idea — thrilled those who are trying to temper the sport’s win-now, regret-later ideology. Neurologists nodded. Parents cheered. As for the rebuttal in football’s continuing debate, that was gladly delivered this week by none other than the Packers’ opponent in Sunday’s Super Bowl — the Pittsburgh Steelers, whose stars stumped as football’s defiant traditionalists. The hard-hitting linebacker James Harrison mocked the N.F.L.’s crackdown on head-to-head tackles, suggesting that the league “lay a pillow down where I’m going to tackle them, so they don’t hit the ground too hard.” Receiver Hines Ward questioned all the fuss about brain injuries, and said that advising his own oft-concussed quarterback, Ben Roethlisberger, about health was all but preposterous. “I know players are under pressure to perform, but these guys are modeling behavior,” said Dr. John P. Sullivan, the University of Rhode Island’s sports psychologist. “If the Steelers players do what they’re saying, high school and youth athletes will do the same thing. If you have someone at the top of the game say not to risk it, like the Packers guys did, that’s powerful.” Dustin Fink, an athletic trainer for Shelbyville High School in Illinois with a special interest in concussions, said he was rooting for the Packers on Sunday primarily because of the messages delivered by each team’s players. “We want people to say the right things whether they believe it or not, because kids are listening,” Fink said. “The Packers have handled this wonderfully. Meanwhile, Hines Ward makes fun of the people trying to protect him.” The Packers might have saved their season through their handling of Rodgers’s concussion, his second of the year. Doctors kept him out of the Lions game and also Green Bay’s subsequent loss to New England, before ruling him recovered. The healthy Rodgers has not lost since: he helped rout the Giants, 45-17, in his first game back; secured the Packers’ playoff spot with a win over Chicago; and ripped through Philadelphia, Atlanta and Chicago again to reach the Super Bowl. Had Rodgers returned too soon and sustained another concussion, his season, and his team’s, could very well have been over. While many concussions go unnoticed, Rodgers’s injury against Detroit was no secret to his teammates. But the speed of football kept him from receiving immediate treatment. Tackled after an 18-yard scramble near halftime, Rodgers hit his head hard on the turf and rose slowly, requiring a few Packers to pull him up by the arms. He walked to the huddle and called a 30-second timeout — not long enough for any medical personnel to examine him — before returning to the huddle. “I noticed he wasn’t right,” center Scott Wells said. “He called a play that we didn’t have in that week. We had it the previous week.” Rodgers ran two plays before going to the sideline again for the two-minute warning. As Rodgers talked strategy with Coach Mike McCarthy, all the Packers’ athletic trainer, Pepper Burruss, said he had time to ask was, “Are you all right?” Rodgers looked him straight in the eye and said yes. Burruss said he also asked McCarthy if Rodgers was fine, and the coach said yes, although Burruss knew that no coach could truly know. “It’s not like I can put my hand up and say: ‘That’s it! I need an injury timeout!’ ” Burruss said. “There’s a red flag for a video review, but I don’t have anything to throw out there to check a player out.” Only after another play brought on the punting unit did Burruss and Dr. John Gray, the Packers’ team physician, get to administer the memory, balance and other tests that determined Rodgers indeed had a concussion. That meant Rodgers could not return to the game, according to new N.F.L. guidelines. Whether before or after that decision — no one quite remembers — Driver sidled up to Rodgers and told him not to come back, to take care of himself first. Those words did not influence the team’s decision — as Burruss put it, “It’s not like Aaron was diagnosed by Dr. Driver” — but they did resonate among concussion-awareness advocates a few days later when the exchange was reported publicly. “I felt an affirmation of the things we have been arguing all along,” said Gerry Gioia, chief of pediatric neuropsychology at Children’s National Medical Center in Washington. “We keep telling kids that they have responsibility not only to your health, but that of your teammates. To hear an N.F.L. player say that is huge for us.” The Packers kept that message strong this week. Even when the Packers lost to the Lions and then to New England, Driver said, “There wasn’t any regret; you make a decision, and you live with it.” He and Rodgers used the same words to describe what they would do under the same circumstances in the Super Bowl: “It’s the same decision” as before, they said. The Steelers are no strangers to concussions. Tight end Heath Miller missed time this season with a serious one, safety Troy Polamalu has a long history of brain injury, and Roethlisberger has sustained several concussions, including one from a motorcycle crash. Ward was asked if he would ever encourage Roethlisberger to look after himself, as Driver did with Rodgers, rather than play through a concussion. His answer was just as clear as Driver’s. “For me, I’ve been in that situation,” Ward said. “I wanted to be out there fighting. To each his own. Who am I to tell somebody what not to do?”

Doctor and Patient: How Aggressive Is Your Hospital? Posted: 03 Feb 2011 10:48 AM PST One morning during my training, I noticed that the belly of a patient in the I.C.U. had grown rounder and tighter overnight. The patient had gone through a difficult liver transplant a day earlier and was bleeding, it seemed, into his abdomen. I was the newest member of the transplant team, but even so, I knew what had to be done right away: We had to take this man back to the operating room. Enlarge This Image Can aggressive care be better? Well Share your thoughts on this column at the Well blog. Go to Well » Related More Doctor and Patient Columns But I hesitated for a moment. Not because I was unsure of whom to call or how to go about scheduling an emergency operation at the hospital. I paused because I wanted to brace myself for what I imagined would be the reaction of the surgeon in charge. Wiry and impeccable in his person, the head surgeon of the transplant team was considered one of the finest, and most fearless, in his field. Patients whom others would have considered too far gone or who would have normally just lingered and died made Lazarean recoveries under this doctor’s meticulous care. But my guess was that he wouldn’t be happy to hear about a complication. Particularly one serious enough to require an urgent return to the operating room. I was wrong. The doctor barely flinched when I told him the news. Instead of the blast of angry expletives I’d feared, I was greeted with a calm and simple request: “Book him for a take-back to the operating room.” When I later relayed the morning’s events to a friend, another surgeon-in-training who was ahead of me in the same program by a year, he laughed. “It’s not a lack of complications that makes a great surgeon,” he said. “It’s being aggressive about taking care of those complications.” Over the last few years, no other aspect of the health care system has lost its luster as much as aggressive care. Once considered a point of pride and a source of strength, aggressive care has now been transformed into the whipping boy for health care reformers of all stripes. Armed with data that shows geographic variations in spending and the outcomes of patients who have recently died, politicians from both sides of the aisle, administration officials and even insurers have transformed the nuanced caveats of the research into a broad “more-is-worse” rallying cry. In this heated environment, restricting payments to hospitals whose total expenditures, total I.C.U. days and total hospital days exceed the norm has become a foregone conclusion so appealing that even usually wary consumer watchdog groups have enthusiastically added their own licks. The notion that aggressive care leads to worse outcomes has been easy to buy into because it seems to offer an easy remedy for spiraling costs while playing into our worst fears about overzealous health care providers. But in journals and in newspapers there have been a few brave voices issuing cautions. And most recently one group of researchers has gone so far as to say that at least for one group of patients, hospitals that offer aggressive care are better than those that don’t. Analyzing the insurance claims data of more than four million Medicare patients admitted for vascular, orthopedic or general surgery operations, researchers from the University of Pennsylvania in Philadelphia and the University of Illinois in Chicago found no difference in the rate of complications for aggressive and nonaggressive hospitals. But when they looked at all the patients who had complications and examined their outcomes, the researchers found that regardless of the urgency of their operations, those patients who were cared for at more aggressive hospitals were significantly more likely to survive their complications than those who had their operations at less aggressive hospitals. “There is something that is going right at those more aggressive hospitals,” said Dr. Jeffrey H. Silber, lead author and a professor of pediatrics and health care management at the University of Pennsylvania and the Children’s Hospital of Philadelphia. “Aggressive hospitals don’t increase your chance of complications, but they decrease your chance of dying if you get a complication because you survive those complications better.” Referred to as “failure to rescue,” the inability of a hospital to help its patients survive surgical complications may be a more accurate measure of quality than traditional indicators. Mortality rates, for example, are as dependent on the general health of a hospital’s patient population as they are on the quality of care delivered. “The best hospitals are going to attract the sickest and most complicated patients, and that will inevitably taint mortality rates,” Dr. Silber noted. While Dr. Silber and his co-investigators found that a hospital’s failure or success in treating surgical complications correlated consistently with factors that also characterized intensity of care — general expenditures, intensive care unit use and the total days of hospitalization — they found that benefits of this more aggressive care extended well beyond the time of the operation. “It’s not like these patients were filled up with antibiotics only to die later,” Dr. Silber said. Clearly, lowering health care costs and increasing quality and efficiency will require approaches far more complex than broad penalties for hospitals that offer more aggressive care. “Most people have been saying that the health care system is too aggressive, implying that aggressiveness is bad because people are being operated on unnecessarily or too much stuff is being done on them and can harm them,” Dr. Silber said. “But we have to do detailed research that compares the effectiveness of different treatment approaches, because aggressiveness is not necessarily bad and may in fact be sometimes associated with better outcomes.” He added, “We need to rein in expenditures, but we need to do it very carefully.” Join the discussion on the Well blog.

Senate Rejects Repeal of Health Care Law Posted: 03 Feb 2011 03:40 PM PST WASHINGTON — Senate Democrats on Wednesday defeated a bid by Republicans to repeal last year’s sweeping health care overhaul, as they successfully mounted a party-line defense of President Obama’s signature domestic policy achievement. Enlarge This Image Drew Angerer/The New York Times Senators Charles E. Schumer and Sherrod Brown, both Democrats, spoke with reporters on Wednesday in Washington. Multimedia Senate Vote 9 Fails to Repeal Health Care Law Interactive Feature The Growing Legal and Political Opposition Related Officials Consider Requiring Insurers to Offer Free Contraceptives (February 3, 2011) States Diverge on How to Deal With Health Care Ruling (February 2, 2011) Enlarge This Image Drew Angerer/The New York Times Senators Mitch McConnell, from left, John Cornyn and John Barrasso, all Republicans, at a news conference on Wednesday. Challenges to the law will continue, however, on Capitol Hill and in the courts, with the United States Supreme Court ultimately expected to decide if the law is constitutional. The vote was 47 to 51, with all Republicans voting unanimously for repeal but falling 13 votes short of the 60 needed to advance their proposal. Lawmakers in both parties joined forces, however, to repeal a tax provision in the law that would impose a huge information-reporting requirement on small businesses. That vote was 81 to 17, with 34 Democrats and all 47 Republicans in favor. Senators Joseph I. Lieberman, independent of Connecticut, and Mark Warner, Democrat of Virginia, were absent. Republicans said after the votes that they would persist in their efforts to overturn the law. Rejecting assertions that the repeal vote was a “futile act,” Senator John Cornyn of Texas, the chairman of the Republican Senatorial Campaign Committee, declared, “These are the first steps in a long road that will culminate in 2012.” Senator John Thune, Republican of South Dakota and a potential presidential candidate in 2012, noted that Republicans had just 40 votes when they opposed the health care bill last year, but that they had 47 as a result of winning seats in November. “Elections do have consequences,” Mr. Thune said. The vote to eliminate the tax provision offered a brief moment of consensus on a day otherwise characterized by angry partisan disagreement. In the latest reprise of last year’s fierce debate over the health care law, senators crossed rhetorical swords for hours of floor debate. Republicans denounced the overhaul as impeding job creation and giving the government too big a role in the health care system. Democrats highlighted the law’s benefits, especially for the uninsured, and noted that the nonpartisan Congressional Budget Office had projected that the law would reduce future deficits. Senator Rand Paul, Republican of Kentucky, who is an ophthalmologist, cited the law’s requirement that nearly all Americans obtain insurance as evidence that it was unconstitutional and overly intrusive. “If you can regulate inactivity, basically the non-act of not buying insurance, then there is no aspect to our life that would left free from government regulation and intrusion,” Mr. Paul said. He added, “From my perspective as a physician, I saw that we already had too much government involvement in health care.” But Democrats hit back hard. “The Republicans’ obsession with repealing the new health reform law is not based on budgetary considerations,” said Senator Tom Harkin, Democrat of Iowa, the chairman of the Health, Education, Labor and Pensions Committee. “It is based strictly on ideology. They oppose the law’s crackdown on abuses by health insurance companies and they oppose any serious effort by the federal government to secure health insurance coverage for tens of millions of Americans who currently have none.” And Senator Charles E. Schumer of New York, the No. 3 Democrat, lambasted Republicans for seeking repeal of the law without proposing an alternative. “If my colleagues on the other side of the aisle said: ‘You know, you’re right. We have to reduce costs. We have a better way,’ and they offered a bill on the floor, well maybe we’d take a look at it,” Mr. Schumer said. “But they’re silent.” He added: “Easy to sit there and say, ‘repeal.’ What would you put in its place?” The repeal measure, which was adopted overwhelmingly by the Republican-controlled House last month, was put forward by the Senate Republican leader, Mitch McConnell of Kentucky, as an amendment to an aviation industry bill that is now on the Senate floor. The willingness of the majority Senate Democrats to allow a vote on the amendment reflected a deal among leaders of both parties to limit the parliamentary warfare and ease the procedural stalemates that have bogged down the Senate in recent years. The openness to a vote also reflected confidence among Democrats that they would be able to defeat the amendment. And they did, challenging the amendment on the grounds that it violated the budget resolution by increasing the deficit. To overcome that challenge, and win approval, Mr. McConnell needed the votes of 60 senators. On the repeal of the tax provision, a similar challenge on budget grounds was easily surmounted. Republicans had criticized the provision, which would require businesses to file a 1099 tax form identifying anyone to whom they paid $600 or more for goods or merchandise in a year. Businesses would also be required to send copies of the form to their vendors, suppliers and contractors. The House is expected to support its repeal. Because the tax provision was expected to result in increased tax revenue, Democrats had to come up with another way to generate the same money. The plan that was approved, sponsored by Senator Debbie Stabenow, Democrat of Michigan, rescinds $44 billion in unspent money appropriated by Congress. But it exempts the Pentagon, the Department of Veterans Affairs and the Social Security Administration from those cuts.

Medical Detectives Find Their First New Disease Posted: 02 Feb 2011 11:50 PM PST Louise Benge’s medical problems started when she was 25. Walking became excruciating. Her calves got hard as rocks, and every step was agony. Her hands started hurting too. And the condition, whatever it was, only got worse over the next two decades. Enlarge This Image Brendan Smialowski for The New York Times Paula Allen's legs and feet were checked for blood flow on Tuesday in a clinic in Bethesda, Md. She and her two sisters and two brothers have all suffered from similar pain in their extremities. Ms. Benge’s family doctor in Mount Vernon, Ky., was at a loss, as were a vascular specialist, a hand specialist and a kidney specialist. Her two sisters and two brothers had the problem too, but no doctor could figure out why. It was clear from X-rays why Ms. Benge could barely walk: The blood vessels in her legs, feet and hands were accumulating calcium deposits like the scale that sometimes forms inside water pipes. The deposits had grown so thick that blood could hardly squeeze through. But calcium was only in those blood vessels of her legs and hands; her heart’s vessels were spared, so she was not in immediate danger of dying. A doctor prescribed weekly infusions of a drug, sodium thiosulfate, Ms. Benge said, thinking it might bind to the calcium so her body could flush it out. But the drug did not work — it only made her vomit. Finally, Ms. Benge’s family doctor sent her medical history to a detective agency of sorts, the Undiagnosed Diseases Program at the National Institutes of Health. Set up in the spring of 2008, the program relies on teams of specialists who use the most advanced tools of medicine and genomics to try to figure out the causes of diseases that have baffled doctors. The idea was that understanding rare diseases can give insights into more common ones, said Dr. William A. Gahl, director of the program. And, he said, there was another reason. “Patients who have rare diseases are often abandoned by the medical community,” Dr. Gahl said. “We don’t know how to treat if we don’t have a diagnosis. The way our society treats abandoned individuals is a measure of our society. It speaks to how our society treats the poorest among us.” With Ms. Benge and her siblings, the researchers have their first newly discovered disease. It is caused, they report on Thursday in The New England Journal of Medicine, by a mutation in a gene that prevents calcium from depositing in blood vessels. Now that they know the cause of the disease, the researchers have ideas for how to treat it. And the discovery also has implications for more common diseases, like heart disease and osteoporosis, in which calcium is deposited inappropriately. The unraveling of Ms. Benge’s mystery disease began the week of May 11, 2009, when Ms. Benge, who is 56, and her sister Paula Allen, who is 51, arrived at the tall red-brick clinical center on the campus of the National Institutes of Health. The Office of Undiagnosed Diseases had been hearing from thousands of patients, Dr. Gahl said, 1,700 of whom sent their medical records. “Many had been to Hopkins, the Mayo Clinic and the Cleveland Clinic, and some had been to all three and been there more than once,” he said. Dr. Gahl and his colleagues were looking for people with unusual symptoms or unusual clues to what might be wrong. For example, they are now investigating a mystery disease in a young girl with uncontrollable muscle contractions that make it hard for her to talk, walk and use her hands; one that gave a young boy symptoms that look like Parkinson’s disease; and one that gives a middle-aged woman shards of keratin, a hair protein, coming out of her hair follicles. Ms. Benge and her sister had symptoms like no one had ever seen before. X-rays and M.R.I. images of their legs, hands and feet showed blood vessels so clogged with calcium that blood could get through only by squeezing into tiny vessels that had sprouted to circumvent the blockages. And those tiny vessels just were not able to supply enough blood. Because there were five affected siblings, the researchers decided to take a genetic approach, using techniques not available at most major medical centers. The parents were fine, and that indicated the disease might be caused by a recessive gene — each parent would have one copy of the mutated gene and one copy of the intact gene, and each child with the disease would have two copies of the mutated gene, one inherited from each parent. That led the investigators to a stretch of DNA with 92 genes. From there, the researchers zoomed in on the gene that was the culprit. A mutation had stopped it from functioning. Cells use the gene to make extracellular adenosine, a common compound that, in this case, was needed to suppress calcification. No one had known about this metabolic pathway, said Dr. Manfred Boehm, a vascular biologist at the National Heart, Lung and Blood Institute. The discovery is very important, said Dr. Dwight Towler, a bone endocrinologist at Washington University in St. Louis who was not part of the study, because it can help researchers understand signals for calcification in different parts of the body. “You notice they don’t have problems everywhere,” he said of Ms. Benge and her siblings. That is because bone calcification and blood vessel formation are exquisitely coordinated, and different parts of the body use similar, yet subtly distinct, mechanisms. The disease also fits in with a growing understanding of the close relationship between blood vessel cells and bone cells. Researchers say it could lead to new insights into heart disease, in which calcium deposits in coronary arteries, and heart valve disease, in which calcium can deposit in heart valves. Sometimes, said Dr. Towler, actual bone, with marrow, forms in valves. It also could help illuminate the relationship between osteoporosis, in which bone is lost, and heart disease. In osteoporosis, as people lose bone, calcium often accumulates in arteries. It is as if the calcium that is not being deposited in bones is going into blood vessels instead. “I think it has to do with the fact that the cells that make up our blood vessels are of the same origin as the cells that make up bone,” said Dr. Gahl, who is also clinical director of the National Human Genome Research Institute. The researchers have now identified nine people from three families who have the newly discovered disease: Ms. Benge’s family, a patient in San Francisco and a family in Italy. Now they are working on treatments. The simplest might be to give a bisphosphonate, an osteoporosis drug. With the gene mutation and decreased levels of adenosine, patients end up with high levels of an enzyme, alkaline phosphatase, needed to make calcium deposits. Bisphosphonates bring down levels of that enzyme. The investigators are putting together plans to test bisphosphonates and submitting them to ethics boards for approval. “We hope to know in three or four months whether we can go forward,” Dr. Gahl said.

Officials Consider Requiring Insurers to Offer Free Contraceptives Posted: 03 Feb 2011 01:15 PM PST WASHINGTON — The Obama administration is examining whether the new health care law can be used to require insurance plans to offer contraceptives and other family planning services to women free of charge. Enlarge This Image Jacquelyn Martin/Associated Press An amendment from Senator Barbara A. Mikulski requires officials to weigh the “unique health needs of women.” Multimedia Interactive Feature The Growing Legal and Political Opposition Such a requirement could remove cost as a barrier to birth control, a longtime goal of advocates for women’s rights and experts on women’s health. But it is likely to reignite debate over the federal role in health care, especially reproductive health, at a time when Republicans in Congress have vowed to repeal the law or dismantle it piece by piece. It is also raising objections from the Roman Catholic Church and is expected to generate a robust debate about privacy. The law says insurers must cover “preventive health services” and cannot charge for them. The administration has asked a panel of outside experts to help identify the specific preventive services that must be covered for women. Administration officials said they expected the list to include contraception and family planning because a large body of scientific evidence showed the effectiveness of those services. But the officials said they preferred to have the panel of independent experts make the initial recommendations so the public would see them as based on science, not politics. Many obstetricians, gynecologists, pediatricians and public health experts have called for coverage of family planning services, including contraceptives, without co-payments, deductibles or other cost-sharing requirements. Dr. Hal C. Lawrence III, vice president of the American Congress of Obstetricians and Gynecologists, said contraceptives fit any reasonable definition of preventive health care because they averted unintended pregnancies and allowed women to control the timing, number and spacing of births. This, in turn, improves maternal and child health by reducing infant mortality, complications of pregnancy and even birth defects, said Dr. Lawrence, who is in charge of the group’s practice guidelines. But the United States Conference of Catholic Bishops and some conservative groups, including the Family Research Council, say birth control is not a preventive service in the usual sense of the term. “Pregnancy is not a disease to be prevented, nor is fertility a pathological condition,” said Deirdre A. McQuade, a spokeswoman for the bishops’ Pro-Life Secretariat. “So birth control is not preventive care, and it should not be mandated.” About one-half of pregnancies in the United States are unintended. Kathleen Sebelius, the secretary of health and human services, last month unveiled a 10-year plan to improve the nation’s health. One goal of the initiative is to “increase the proportion of health insurance plans that cover contraceptive supplies and services.” The Department of Health and Human Services commissioned the Institute of Medicine, an arm of the National Academy of Sciences, to help identify preventive services for women that must be covered at no cost under the health care law. The institute, a nonpartisan, nongovernmental organization, seeks to provide unbiased advice to decision makers and the public. Using this advice, the department expects to issue “comprehensive guidelines” for women’s preventive care by Aug. 1. A White House spokesman, Nick Papas, said it was too early to comment. “We will wait and see what the study returns,” he said. Congress left it to the administration to define the preventive care benefit and adopted an amendment by Senator Barbara A. Mikulski, Democrat of Maryland, requiring officials to pay special attention to the “unique health needs of women.” Lawmakers said they also meant to require coverage of annual checkups and health assessments known as well-woman visits; screening for domestic violence, heart disease and breast and cervical cancer; and doctor visits for women intending to become pregnant. In a report more than 15 years ago, the Institute of Medicine said financial barriers to contraception “should be reduced by increasing the proportion of all health insurance policies that cover contraceptive services and supplies, including both male and female sterilization, with no co-payments or other cost-sharing requirements.” Brand-name versions of oral contraceptives can cost $45 to $60 a month or more, not including the cost of a doctor visit for a prescription. In recent years, many health plans have increased co-payments for prescription drugs, so even women with insurance may end up paying half the cost of birth-control pills. Administration officials and Democrats in Congress said free preventive care was just one of the health care law’s benefits for women. It also prohibits insurers from charging women more than men of the same age for the same coverage. Such disparities have been common. As a result, premiums for women have often been 25 percent to 50 percent higher than those for men. Advocates for women’s health, including the Planned Parenthood Federation of America and the American Congress of Obstetricians and Gynecologists, have urged the administration to require coverage at no cost for family planning, including contraceptive drugs and devices. Likewise, the American Academy of Pediatrics said, “Adolescents and adult women need to have access to the full menu of contraceptive methods without cost-sharing,” along with counseling and education. This recommendation is supported by the American Civil Liberties Union, the March of Dimes, Naral Pro-Choice America, the National Partnership for Women and Families, the National Women’s Law Center and scores of Democrats in Congress. But Ms. McQuade of the Catholic bishops’ conference said any requirement for coverage of contraception could violate the “rights of conscience” of religious employers and others who had moral or religious objections to it. This concern is amplified, she said, by the fact that some emergency contraceptives can act like abortion-inducing drugs. Jeanne Monahan, the director of the Center for Human Dignity at the Family Research Council, said: “The government should focus on services that prevent disease. Fertility and babies are not diseases. Fertility occurs in healthy women.” The issue is also complicated by privacy concerns. Dr. Margaret J. Blythe, a professor of pediatrics at the Indiana University School of Medicine, said some adolescents would be reluctant to use a preventive care benefit unless the government and insurers guaranteed the confidentiality of family planning services and screening for sexually transmitted infections. When a doctor or a clinic files a claim, the insurer is often required to send an explanation of benefits to the policyholder, often a parent, describing the services provided. Parents sometimes learn from such notices that their children are sexually active. Doctors said the need for confidentiality was even greater now because, under the new law, many young adults could stay on their parents’ policies until age 26. Isabel V. Sawhill, an economist at the Brookings Institution who has studied unintended pregnancy for three decades, said: “It’s absolutely critical that family planning be considered a preventive service. It could prevent all kinds of health problems, and it would actually save taxpayers money.” “We have rigorous evidence that every dollar invested in family planning saves more than a dollar in welfare and social service costs for children that result from unintended births,” Ms. Sawhill said.

Smoking Ban for Beaches and Parks Is Approved Posted: 02 Feb 2011 10:20 PM PST After a bitter debate over individual liberties and the role of government, the City Council on Wednesday handily approved a bill to ban smoking in 1,700 city parks and along 14 miles of city beaches. Enlarge This Image Eirini Vourloumis for The New York Times Smoking would be banned in places like Bryant Park under a bill the City Council passed on Wednesday by a 36-to-12 vote. By a 36-to-12 vote, the Council passed the most significant expansion of antismoking laws since Mayor Michael R. Bloomberg pushed to prohibit smoking in restaurants and bars in 2002. The Council speaker, Christine C. Quinn, said the ban was an affirmation of the rights of nonsmokers. “Their health and their lives should not be negatively impacted because other people have decided to smoke,” Ms. Quinn said at a news conference. Opponents of the bill spoke strongly against it; several members derided it as an overly broad law that would infringe on individual liberties. “We’re moving towards a totalitarian society if in fact we’re going to have those kinds of restrictions on New Yorkers,” said Councilman Robert Jackson of Manhattan, who described himself as a marathon runner and nonsmoker. Others said the ban would set a dangerous precedent. Councilman Daniel J. Halloran III of Queens said, “Once we pass this, we will next be banning smoking on sidewalks, and then in the cars of people who are driving minors and then in the homes.” A compromise that would establish designated smoking areas outdoors was scuttled by Council leaders in favor of an all-out ban. The bill will become law 90 days after Mr. Bloomberg signs it, which he is expected to do this month. “This summer, New Yorkers who go to our parks and beaches for some fresh air and fun will be able to breathe even cleaner air and sit on a beach not littered with cigarette butts,” Mr. Bloomberg said in a statement. Enforcement of the law will fall to the Department of Parks and Recreation, which can impose $50 fines. Councilwoman Gale A. Brewer of Manhattan, a longtime advocate for stricter antismoking laws, said increasing revenue for the city was not the goal. “I’m not interested in arrests; I’m not interested in revenue,” she said. “I’m just interested in public health.” Ms. Quinn said she would look for more ways to reduce exposure to secondhand smoke but declined to provide specifics. A city health department study published in 2009 found that 57 percent of nonsmoking adult New Yorkers had an elevated level of a nicotine byproduct in their blood indicating recent exposure to cigarette smoke. The comparable nationwide figure was 45 percent. City health officials say that people seated within three feet of a smoker are exposed to roughly the same levels of secondhand smoke, regardless of whether they are indoors or outdoors. The ban is also intended to help reduce trash in public places. In addition to applying to parks and beaches, the ban approved on Wednesday would extend to pedestrian malls and plazas like those in and around Times Square. One group will be exempted from the restrictions: actors lighting up a cigarette in a park or on a beach for the purposes of a theatrical production.

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