Category Archives: Health Care

Why are we dragging our feet when more automation in health care will save lives?

Thomas Hooven, Columbia University Medical Center

As a neonatologist, I worry about patients with pulmonary hypertension. This unforgiving disease, sometimes seen after premature birth, can end with sudden death from constricting blood vessels in the lungs. One minute a baby in the neonatal ICU may be sleeping comfortably; moments later, doctors and nurses are giving chest compressions and rescue medications. The Conversation

A pulmonary hypertension crisis, as these frightening episodes are called, starts with a drop in the blood oxygen level. That drop triggers a monitor to beep. It’s up to the nurse to hear the sound, come to the bedside and take action.

The first and most effective step in stopping a pulmonary hypertension crisis is simple: Give oxygen. But a nurse caring for another patient might be delayed for 30 seconds, and the loss of that time can lead to brain injury or death.

In an age of self-driving cars and 400-ton airplanes that can land themselves in blinding fog, it makes no sense that hospitalized patients are surrounded by lifesaving machinery that can be activated only by a person pressing a button or turning a knob.

Modern transportation augments human judgment and reaction times with a computer’s superior ability to continuously respond to dozens of fluctuating variables. Yet in medicine, safety remains stubbornly reliant on human intervention.

FDA regulation impedes innovation

My patients with pulmonary hypertension are often attached to a respirator with adjustable oxygen settings. The respirator sits inches below the monitor that indicates how much oxygen is in the blood. But the two machines can’t communicate with each other. If they could, it would be possible to increase the flow of oxygen automatically the moment a crisis is detected.

In 2009, engineers developed just this kind of closed-loop respirator and introduced it in several hospitals as part of a feasibility study. It increased the time premature babies spent at a safe oxygen level by more than two hours per day. But no biotechnology company has marketed the idea.

There are other examples of automated systems with unrealized potential to save lives, and not just in the neonatal ICU. Software that scans an ECG for subtle heartbeat variability can identify patterns – undetectable to the human eye – that indicate an elevated risk of heart attack. Hospital beds that play audible feedback during an emergency promote more effective CPR. Yet patients are not benefiting because neither of these tools has been commercialized.

Why haven’t these innovations attracted the industry backing necessary to make them widely available?

One reason is that the process of getting FDA approval for new devices – particularly those deemed “life-sustaining” – is often even more complicated and expensive than getting approval for drugs. In the Journal of Public Economics, Harvard Business School professor Ariel Dora Stern recently described how FDA hurdles discourage companies from investing in innovation.

Often, the more profitable strategy is to wait for someone else to spend the time and money required to get approval for a new device, and then enter the market later with something similar that will face less scrutiny. Dr. Stern estimates that regulatory obstacles add an average of US$6.7 million to the cost of introducing a new medical device. For a company developing an ICU monitor, for instance, that will ultimately sell for less than $35,000 per unit, this up-front commitment can be prohibitive.

A consequence is that small biotechnology firms (with annual revenue less than $500 million) rarely gamble on getting new inventions approved. Dr. Stern’s paper notes that less than 17 percent of novel device applications to the FDA come from small companies. This is different from new drug applications, the majority of which originate at smaller firms.

What’s behind this discrepancy? Research has shown that while companies pay a steep price for pioneering new medical devices, the first firm to market a new type of drug often gets favorable treatment from the FDA. This raises the incentive for pharmaceutical startups to pursue innovation. In contrast, when it comes to medical devices, the current system discourages all but the biggest players from entering the arena.

And even when a new device has been approved, there is no strong impetus for hospitals and clinics to buy in. Even if they can afford upgrades, medical sites are free to use older equipment, with fewer safety mechanisms, long after improved versions become available.

A chance for Washington to improve health care

In contrast, a variety of government initiatives prod transportation companies to modernize. For example, the Federal Aviation Administration offers rebates to aircraft owners to offset the cost of advanced navigation technology that prevents midair collisions. The Federal Rail Administration is overseeing mandatory, nationwide installation of a GPS-based system to slow down speeding trains automatically.

There is an opportunity here – beyond the messy Obamacare debate – for the White House and congressional Republicans to stimulate economic growth in the biomedical sector while improving patient safety. Streamlining the approval process for new devices and offering financial incentives for early adopters would not threaten anti-regulatory groups, and would allow the new administration to claim progress in health care.

President Trump has expressed interest in expediting pharmaceutical approvals, something FDA commissioner nominee Scott Gottlieb also supports. But most drugs help only a small segment of the population.

Dr. Scott Gottlieb, nominee for FDA commissioner.
J. Scott Applewhite/AP

The president and Dr. Gottlieb should commit to advancing commonsense technology that makes health care better for all.

I’m not suggesting that machines should take over for health professionals. As in the manufacturing industry, the medical field is experiencing mounting anxiety about job displacement. There are many perceived threats, from artificial intelligence X-ray interpretation to robot nurses.

Those things might become commonplace, but they will never supplant the human relationships and insights at the core of medical practice. Neither will the kinds of safety innovations I’m recommending. With help from our leaders, physicians can take better care of patients by bringing more automation into our wards and offices.

Thomas Hooven, Neonatologist, Columbia University Medical Center

Should there be a dress code for doctors?

If you live near a hospital, you’ve probably seen the sight: a young physician in loose blue scrubs, standing in line at the grocery store. You can’t help but wonder if the young physician is lost. After all, it appears that he or she belongs in an emergency room – not the dairy section.

The oversized bottoms, dangling bright orange pajama knot, deep V-neck and beeper ensemble not only look out of place, but lead to a slew of thoughts. Is he coming from or going to a shift? Could her clothes carry some sort of hospital microbe? What detritus has the outfit picked up on public transit or in line at the ATM that will track back to an operating room or patient? Has the American trend toward casual attire gone too far?

Regardless of profession, we all play out the sartorial ritual of considering colors, textures, and garments for work, school and play.

Clothing for doctors is more than just a matter of personal style: it is an emblem of their specialty, training and culture.

Making a good first impression

In some cases, a physician’s attire is functional. A surgeon’s scrubs protect regular clothes from stains and patients from infection.

Sometimes, it’s about creating a good first impression and projecting the more professional, conservative image often associated with medicine.

Go to a doctor’s office, for instance, and you’re more likely to find physicians donning a shirt and tie, or jacket and blouse when interacting with their patients. In almost all of these cases, the emblematic uniform of physicians – the white coat – is present.

This month, about 20,000 newly minted physicians will enter residency programs across America, to begin their professional journeys. Each will care for and influence the lives of countless patients.

And each has been trained to avoid “anchoring bias,” or to not to take the first thing they learn about a patient as the most important, lest they reach a biased conclusion or incorrect diagnosis. Yet few doctors or medical students consider the first impression they make on patients. And clothes have a lot to do with that.

In an informal survey in our hospital, only two out of 30 medical students said that they actually thought about their dress when caring for hospitalized patients. Yet, over half of the medical students we spoke to agreed that what they wear is likely to influence patient opinions about their doctors. This illustrates a larger discrepancy between what doctors ought to wear and what they do wear – one that may arise from competing concerns or lack of guidance.

Just like the treatment doctors provide, that guidance should be grounded in evidence. For instance, a special report from infection-prevention experts found little evidence that germs on male doctors’ neckties, long sleeves, or white coats actually spread infections in a nonsurgical setting. So bans on such garments, such as those in place in some countries, may go too far.

Looking sharp.
Doctors via

Patients really like white coats

We recently published a study reviewing all available evidence regarding patient preferences for physician attire. We examined more than 30 studies that evaluated how patients viewed physicians’ attire.

In 21 of those studies, we found that patients had strong preferences about what physicians wore. And it looks like patients more often prefer for their doctors to wear formal clothing and white lab coats than not. Indeed, in 18 of the studies we reviewed, patients had a preference or positive association with this style of attire.

But as we reviewed these studies, three keys themes that suggest important variations in what patients may prefer their doctors to wear emerged. First, studies involving older patients or those from Europe or Asia all reported higher satisfaction when physicians wore formal attire.

Second, in emergency, surgical or intensive care settings, scrubs were not only preferred by patients, but also more often equated with professionalism. This makes sense, as in these more “hands-on,” procedure-oriented settings, formal suits, shirts and ties clearly seem out of place.

Finally, in doctors’ offices and outpatient clinics, scrubs were viewed unfavorably and often resulted in negative impressions.

Thus, from the patient’s perspective, a “one size fits all” approach may not work for doctor attire. Rather, the context in which a patient interacts with their doctor influences what they expect to see.

Given the tension between infection risk and patient preferences, it is not surprising that disagreement about dress code also exists among physicians.

After our study came out, the medical news website MedPage Today reported results from an informal, but still telling, online survey of over 2,000 patients and physicians about the “best approach to dressing for patient encounters.”

About 30% of doctors polled stated that they preferred to wear scrubs, casual attire or had no particular preference when caring for patients. However, more than 60% stated that doctors should wear white coats.

The online comments differed widely, with some physicians defiant in stating that they had “never worn a white coat in 30 years,” while others proclaimed, “priests and judges have their robes, we have our white coats.”

And despite clear patient preferences about what doctors wear while working, even the top-ranked hospitals in the nation, only a handful offer formal guidance on attire. Many vaguely recommend that clothes be “professional,” but without defining what professional means?

Keep your scrubs in the OR.
Surgery via

A dress code for docs?

How, then, should doctors dress when caring for patients? Clearly, more evidence is needed to guide members of the medical community. So we have launched a large study that aims to better understand what patients prefer when it comes to physician attire.

We plan to survey thousands of patients from the US, Italy, Switzerland and Japan in settings that span outpatient clinics, doctors offices and hospitals. Because generational effects and familiarity matter, we will specifically assess how factors such as age or how often a person interacts with the health system shape patient opinions.

While we collect data for this study, what best practices can we recommend in the interim, especially those 20,000 brand new residents?

When in doubt, formal attire with long-sleeved shirts and ties for men, and business attire for women, should prevail in nonemergency or nonoperative settings.

This practice should hold true not just for weekdays, but also when physicians are working weekends and after typical business hours. Patients and their expectations remain unchanged, regardless of hour or day.

While scrubs are appropriate for operating or emergency rooms, we suggest changing into more formal attire to visit patients in the hospital or the clinic. Regardless of the occasion, flip-flops, showy jewelry or jeans simply don’t belong in the hospital, just as scrubs do not belong outside the hospital environment. Especially not in the grocery store.

The Conversation

Vineet Chopra is Assistant Professor of Internal Medicine at University of Michigan.
Sanjay Saint is Professor of Internal Medicine at University of Michigan.

This article was originally published on The Conversation.
Read the original article.

Young adults don’t understand health insurance basics – and that makes it hard to shop for a plan

The health and success of the Affordable Care Act (ACA) depends on a lot of factors, and enrolling enough “young invincibles” in health insurance is one of them.

Under the ACA, insurers in the individual market have to cover everyone who wants to enroll. Insurers are also restricted in how much they can vary premiums based on age. That means that older people who have higher medical costs (on average) pay premiums lower than what might cover their care, and young people with lower medical costs (on average) pay premiums sometimes above their expected medical costs. So enrolling young people in health insurance helps keep costs stable. In addition, young adults have historically been highly represented when looking at the uninsured population.

And so millions of young adults were targeted for enrollment in the ACA’s health insurance marketplaces during the first open enrollment period in early 2014.

Enrolling in health insurance can be hard; choosing a health insurance plan that provides the amount of coverage you’ll likely need at the right cost is a difficult task. It’s challenging for consumers who have been through the process several times before, and likely even more so for young people who may be selecting from plan options for the first time.

Choosing the right insurance can be tough.
Mike Segar/Reuters

What young adults want in a health insurance plan

I led a research team at the University of Pennsylvania that examined the experience of young people when they enroll in health insurance on, the federal insurance marketplace. At the time of our study, Pennsylvania was one of 34 states that did not have a state-run health insurance exchange. If you don’t have employer-sponsored health insurance, or are too old to remain on a parent’s health insurance, in states like Pennsylvania you have the opportunity to go on to choose a plan.

We studied 33 highly educated young adults aged 19-30 in Philadelphia during the first year of Some of the people we followed had health insurance at the beginning of the study, but wanted to look at insurance options on because they’d heard from friends that they might get better, cheaper coverage on the marketplace. In fact, one of the findings of our study is that young adults were often not only shopping for coverage on, but also comparing those plans to options outside the marketplace, like plans offered by schools, employers or their parents’ health insurance.

From January to March of 2014, we observed the young adults as they shopped for insurance plans on, asking them to “think aloud” to capture their reactions in real time. We then interviewed participants about their thoughts on health insurance in general and what they saw on

One said:

I just wasn’t able to comprehend all of the things on the – I got confused. I’m not a person to give up, not at all – but with the system, I just wanted to quit.

The young adults we followed were looking for an affordable health insurance option. They placed a lot of emphasis on the monthly premium cost and the amount of plan deductible (though see below on their confusion about what deductible actually means).

Most considered a monthly premium of over US$100 unaffordable, yet the least expensive plan without tax credits in Philadelphia was closer to $200 per month. Luckily several of the participants qualified for tax credits, which brought their premiums as low as $0.13 per month. Others, however, did not qualify for any discounts and chose to remain uninsured, stating that they could not afford any of the options, even though they may have to pay a penalty for not having insurance.

One said:

I will just pay whatever that tax consequence is, $95 or something, right?, because $200 a month right now is way too much. I don’t know how my friends with student loans do it.

Topping the list of coverage benefits they wanted was access to affordable primary and preventative care. One participant said:

I would really like to get a physical to just see where I’m at. I haven’t been to a doctor in a long time, but I wanna see if there’s anything I should be concerned about – blood pressure, cholesterol…

Interestingly, however, many participants in the study did not realize that preventive care was included in all plans at no additional cost under the ACA. Hence, one of the recommendations coming out of this study was that plans should emphasize the availability of no-cost preventive care, like birth control and routine visits, especially in efforts targeting enrollment of young adults.

‘What’s a deductible?’ – young adults aren’t familiar with insurance terms

As one of the young adults was looking at his plan options, he said:

This plan is $20 to see a primary doctor, and this one is 10% coinsurance after deductible – and I just don’t understand that. What is the deductible to see my primary doctor?

It became clear early in the study that one of the biggest challenges the young people faced in choosing a plan was their lack of familiarity with basic health insurance terms like “deductible” or “coinsurance.”

Only half of the participants could correctly define “deductible,” while less than one in five could define “coinsurance.” These concepts are fundamental to understand for anyone who hopes to make an informed health insurance choice. And misunderstanding these terms can lead to a rude awakening after purchasing and trying to use the insurance. This happened to one participant who said:

Before I signed up for it, I didn’t really know what deductible meant. I thought it was saying it would cover $6,000 worth of stuff, and anything over that, then I would have to pay the rest. But I found out it was the other way around.

Preventative care is included.
stethoscope via

More support needed for young beneficiaries

While this is a small study that was conducted in a single city and state that uses, it shows that even the highly educated young people in our study had difficulty making health insurance choices. However, our findings on the confusion over health insurance terms have also been demonstrated in studies of consumers across a variety of demographic groups. Other researchers have also verified, mostly in experimental settings, that people have a hard time making optimal health insurance choices, even after ensuring that they understand basic health insurance concepts or conducting their insurance experiments in a population of MBA students.

Their findings and ours help describe how young adults navigate the insurance selection process, and point to many areas where consumers could be better supported in the health insurance selection process.

In the area of health insurance literacy, tools to help consumers could be as simple as providing pop-up explanations of key terms, like “deductible,” when you hover your cursor over the term on the screen. Other tools might include total cost estimators that do the math for the consumer. This could provide an estimate that takes into account a plan’s deductible, coinsurance, copay and premium amounts, as well as how often that person predicts they’ll use their insurance (such as how many times they visit the doctor and how many medications they take).

We are sharing our findings with those getting and the other state-run health insurance marketplaces ready for the next open enrollment period in November 2015.

The Conversation

Charlene Wong is Clinical scholar and pediatrician at University of Pennsylvania.

This article was originally published on The Conversation.
Read the original article.

Even small co-pays for contraception can be a big deal

On May 11 the Obama admin released updated guidance on insurance coverage of contraception. The announcement provides much-needed clarification for insurance plans regulated by the Affordable Care Act (ACA).

Before this announcement, the guidance for what insurers were supposed to do was vague.

The ACA requires insurers to provide women access to the full range of FDA-approved contraceptive methods at no cost. But insurers could use “reasonable medical management” to introduce cost-containment measures like providing generics at no-cost, while requiring co-pays for a branded equivalent.

Some insurers used reasonable medical management to restrict access to some forms of contraception – often the more expensive, but longer-lasting forms. And that lead to variation among insurance plans about which contraceptives required a co-pay and which did not.

The new guidance specifies that at least one birth control method from each of 18 different categories must be covered without cost-sharing in all eligible plans. Reasonable medical management and cost-containment strategies can still be used, as long as methods in each category are offered.

So why does it matter than some insurers were restricting access to some forms of contraception?

About half of pregnancies in the US are unintended – and that has much to do with access and use of contraception. Unintended pregnancies lead to an estimated US$5 billion in costs for the US health-care system per year, while birth control use provides cost-savings of $19 billion each year. Even small improvements in contraceptive use could result in a meaningful reduction in the number of unintended pregnancies.

Why are co-pays such an important issue?

Relative to other forms of health care, the low cost of so many contraceptive methods may make the individual out-of-pocket expense seem unimportant. But to many women, these costs are real. Cost is a big factor in choosing to use one form of contraception over another, using it consistently or even the likelihood of using contraception at all.

Notably, the most effective methods (such as long-acting reversible contraceptives, like intrauterine devices (IUDs) or hormone implants) have the highest up-front cost. And if women must share the cost, that discourages them from using these highly effective methods.

We studied the relationship between out-of-pocket costs and contraception use among almost 1.7 million women enrolled in the types of plans regulated by the ACA rules between January 1 and December 31, 2011. Women in plans with the highest level of cost-sharing were 35% less likely to have an IUD placed than women with the lowest level of cost-sharing – suggesting that even higher income women are sensitive to the price of contraceptives.

The Contraceptive Choice study, which offered almost 10,000 women free birth control, demonstrated that low-income and uninsured women will select the most effective (and most expensive) birth control methods at high rates when cost is not a factor.

This is why the new White House guidelines are so important. The broader menu of options available will increase women’s access to their preferred method, which may in turn improve contraception use patterns and decrease unintended pregnancy.

There’s more to contraception than the pill.
Contraceptive pills via

One contraceptive is not like another

All contraceptives aim to prevent pregnancy, but there are a variety of ways they can do so. They aren’t interchangeable and the method that may work best for one woman may not be suitable for another.

Under previous guidance, many insurers interpreted the law to mean they must cover at least one – but not all – option from each of five categories: hormonal contraception (like birth control pills, vaginal rings or patches), barrier methods (diaphragm), emergency contraception, implanted devices (like IUDs or hormone implants) and sterilization.

But this approach to grouping methods doesn’t reflect the clinical uses for each type of contraception. For instance, the contraceptive ring was considered a “hormonal” method, and since there is a generic pill containing the same hormones as the ring, insurers have often not covered it because they consider them equivalent. But the ring lasts for three weeks before needing to be replaced, while the pill needs to be taken every day. And this distinction is important for women who know that they will sometimes forget to take a pill every day.

Even methods that are similar – such as the copper IUD and the hormone-containing IUD – are not, in medical parlance, therapeutic equivalents. This means that they have different medical uses, health benefits or side effects. These products aren’t interchangeable – the best one for an individual woman will depend on her menstrual patterns, tolerance of side effects and prior birth control experience. Clinicians, therefore, use them in different situations

When physicians help women choose the “best” choice, we look at her medical history, lifestyle and a product’s unique characteristics. In contraception, it’s important to never underestimate the importance of side effects or ease of use, since they can drive how consistently a woman uses a particular method. If our goal is consistent, effective use, we must remove barriers to an individual’s choice of birth control method.

Not the same.
Pills and IUD via

How much of a difference will the new guidelines make?

In the months before the White House released the new guidelines, three different reports captured the coverage variations between insurance plans.

A report from the Guttmacher Institute, a non-profit organization focused on reproductive health, in September 2014 found that women continued to report out-of-pocket costs, especially for the most effective methods, like the IUD.

In April, a report from the Kaiser Family Foundation looked at coverage for 12 contraceptive methods among 20 different insurance carriers in five states. The organization found significant variation in interpretation and coverage among the plans. They also found that methods such as the vaginal ring and patch (which don’t need to be taken daily) and the most-effective methods like the implant and IUD, were less likely to be covered without cost-sharing.

Further gaps were identified by the National Women’s Law Center in an analysis of more than 100 insurance plans in 15 states. They concluded that 33 plans in 13 states did not comply with the ACA. These plans were not covering all FDA-approved methods. They imposed cost-sharing, only covering generic methods or were not covering associated services, such as counseling or administration visits.

If our nation wishes to reduce the high number of unintended pregnancies – and the costs and abortions that result from them – improving women’s access to the contraceptive methods they prefer, and that they will use consistently, is key. The updated guidelines from the White House mean that American women face fewer barriers to use the contraceptive method of their choice.

The Conversation

Vanessa K Dalton is Associate Professor at University of Michigan.
Lauren MacAfee is Fellow, Family Planning at University of Michigan.

This article was originally published on The Conversation.
Read the original article.

Few Consumers Are Using Quality, Price Information To Make Health Decisions

Despite the government’s push to make health information more available, few people use concrete information about doctors or hospitals to obtain better care at lower prices, according to a poll released Tuesday.

Prices for the health care industry have historically been concealed and convoluted, unlike those for most other businesses. The 2010 health law aimed to make such information more transparent. People shopping for insurance can now compare the prices of competing plans through online marketplaces, including premiums, deductibles and their share of any medical expenses. The federal government also publishes more than 100 quality ratings about hospitals, as do some large private insurers. Private groups such as Consumer Reports and U.S. News & World Report also rate providers, and Internet forums such as Yelp are now littered with easily accessible opinions.

The poll from the Kaiser Family Foundation found that about two of three people say it is still difficult to know how much specific doctors or hospitals charge for medical treatments or procedures. (KHN is an independent program of the foundation.) Only about one in five people said they had seen specific cost or quality information about a hospital, insurer or doctor.

The poll found that this information rarely makes a difference. About 6 percent of people ever used quality information in making a decision regarding an insurer, hospital or doctor. And fewer than 9 percent used information about prices, most commonly in relation to health plans. Only 3 percent said they used price information about physicians, the poll found.

This lack of practical information may be related to another major finding from the poll: people are overconfident about their ability to pay medical bills without financial strain.

A majority of people told pollsters they had enough insurance coverage or money to pay for their usual medical costs or for an unplanned hospitalization. A majority also said paying insurance premiums, deductibles and their share of medical costs was relatively easy.

However, when asked how they would handle an unanticipated $500 medical bill, only 47 percent of insured adults under 65 said they would pay the bill in full immediately. The others said they would put it on a credit card and pay it out over time, borrow money or not be able to pay the bill at all. Not surprisingly, those bills would be a bigger problem for those who lacked insurance.

If the medical bill were $1,500—a sum that is less than the deductible in many insurance plans— 25 percent of people with insurance thought they could pay it off immediately. Another 29 percent said they would add it to their credit card debt, and 25 percent said they could not pay it at all.

The poll was conducted April 8 through 14 among 1,506 adults. It has a +/- 3 percentage point margin of error.

Kaiser Health Tracking Poll: April 2015

How Getting Married Affects Health Insurance Tax Credits

This week I answered questions from people about health insurance cost and coverage rules, including how getting married or working here as a foreign national may affect them.

Q. Last year, I had single coverage through the marketplace from January through May. Then I got married and canceled my policy because I had coverage through my husband’s job for the rest of the year. When I filed my 2014 taxes, we had to repay half of the premium tax credits for the months when I had a marketplace plan. Why? Those first five months I was single and relying on my own income. Why should my husband’s income be counted?

uninsured 570A. The Internal Revenue Service has a special rule to handle situations like yours when people get married during the tax year. Though not a perfect solution, without it, chances are you would have had to repay even more of your tax credit.

First, some background: The premium tax credits that people can qualify for if their income is under 400 percent of the federal poverty level (about $46,000 for one person) make coverage purchased on the health insurance marketplace more affordable. Like you, many people opt to receive the credit in advance and have it sent directly to their insurer, which reduces their monthly bill.

The amount of the tax credit is based on your annual household income, which you estimated when you signed up for coverage. At tax time, your estimated income is reconciled against your actual income and, if the estimate was too low, you have you repay the excess, up to a cap.

That’s the situation you found yourself in. However, when people marry during the tax year, the IRS offers an alternative way of calculating household income that for many reduces the excess premium tax credit they have to repay.

Under the IRS rule, the tax credit for the months when you were single is computed as if your annual household income were half of what it actually was. So if your joint income was $70,000 for the year, your tax credit will be computed on a $35,000 income rather than the whole $70,000.

Using that alternative calculation will generally reduce how much people have to repay.

Though not a precise income adjustment, “this creates at least some rough justice, in giving people a chance to simulate what they made when they were single,” says Judith Solomon, vice president at the Center on Budget and Policy Priorities.

IRS publication 974 has step-by-step instructions on how to do the alternative calculation, and tax preparation software generally incorporates that option.

Q. I am on a H1B visa, legally working in the United States. My employer provided my husband and me with health insurance, but it is costing us a lot. My husband is here on an H4 visa as my spouse. My question: Is it mandatory to have health insurance for him? What are my options?

A. In general, people who are living in the United States legally are subject to the health law requirement that they have health insurance. There are some exceptions for foreign nationals who are here only briefly, but as someone who is living and working here and has employer-sponsored health insurance you likely pass the IRS test for having a “substantial presence” in the U.S., says Sonal Ambegaokar, a senior attorney at the National Health Law Program, an advocacy group for low-income and underserved people.

To avoid the penalty for not having health insurance, you and your husband must have coverage unless you qualify for an exemption. Since you say that coverage is expensive, one possibility might be an exemption based on affordability, says Matthew Lopas, a health policy fellow at the National Immigration Law Center.

If the cost of your plan is more than 8 percent of your income you’d be exempt from the requirement to have coverage.

Q. If a person does not pay the premium and is charged a penalty for not having health insurance, is that penalty considered to be a partial payment of the premium and does it provide any health benefits?

A. No on both counts. The penalty for not having health insurance, which you pay when you file your federal income taxes, is completely separate from the health insurance premium you would pay to an insurer to provide coverage. The penalty can’t be applied to insurance in any way and provides no health benefits.

For 2014, the penalty is $95 or 1 percent of your income, whichever is greater. If you’re uninsured and didn’t realize you would owe a penalty for last year, you may still be able to sign up for 2015 coverage, says Cheryl Fish-Parcham, private insurance program director at Families USA, an advocacy organization. You’d still owe the fine for 2014 but you could avoid it for this year, and you’d have insurance that could provide benefits that the penalty cannot.

If this scenario fits you, better get cracking. The special enrollment period ends April 30.

Hospitals Increasingly Turn To Patients For Advice

Members of a Spectrum Health patient and family advisory council visit a newly constructed hospital facility. (Photo courtesy of Spectrum Health)
Members of a Spectrum Health patient and family advisory council visit a newly constructed hospital facility. (Photo courtesy of Spectrum Health)

Jane Maier was one of a select group of patients invited in early 2012 to help Partners HealthCare, Massachusetts’ largest health system, pick its new electronic health record system – a critical investment of close to $700 million.

The system, which is now being phased in, will help coordinate services and reshape how patients and doctors find and read medical information. The fact that Partners sought the perspective of patients highlights how hospitals increasingly care about what their customers think.

“It’s such a great experience,” Maier said. “They treat us as a member – a partner – in their review process.”

Patient advisory councils, like the one Maier belongs to, often serve as sounding boards for hospital leaders – offering advice on a range of issues. Members are usually patients and relatives who had bad hospital experiences and want to change how things work, or who liked their stay and want to remain involved.

For Maier, it all started in 2009 when she had surgery at Brigham and Women’s Faulkner Hospital, a Partners facility. Her husband wrote to the hospital’s CEO, praising her experience. The couple was then invited to speak at a hospital leadership retreat, sharing with top executives both the good and the not-so-good, and Maier was recruited to serve on a new patient advisory panel.

This hunt for patient perspective, which is becoming more and more common, is fueled in part by the health law’s quality-improvement provisions and other federal financial incentives, such as the link between Medicare payments and patient satisfaction scores.

“It’s a change in culture,” said Jayne Hart Chambers, senior vice president for quality at the Federation of American Hospitals, which represents for-profit hospitals.

Data from 2013 suggested that 40 percent of hospitals had some kind of patient council, said Mary Minniti, a program and resource specialist at the Institute for Patient and Family Centered Care, a Maryland-based nonprofit organization. Though councils appear to have become more common in the past few years, experts say it’s too early to know whether they typically improve hospital practices.

“A lot of hospitals right now are very concerned because of the direction of [Medicare] payments,” said Carol Cronin, executive director of the nonprofit Informed Patient Institute, an advocacy group. “They’re very concerned about patient experience and patient satisfaction.”

But it’s not just federal incentives. Patients have greater expectations as they shoulder larger shares of health care costs, said Richard Evans, chief experience officer at Massachusetts General Hospital, another Partners facility. This, he added, leads hospitals to focus on customer service.

Cronin, who has had a relative stay for an extended time in the hospital, volunteers on the patient advisory council at Johns Hopkins Hospital in Baltimore. She was struck, she said, by the “meaty” topics the group addresses. Hopkins’ medical researchers have even pitched their projects to the council to find out what patients and families think are worthy of scientific investigation.

To have an impact, though, these groups can’t operate in isolation.

Patient and family advisory councils are useful if they have the ear of hospital leaders, Minniti said. But the groups also have to be integrated into decision making.

Andy DeVries joined the first patient advisory council at Michigan’s Spectrum Health about 10 years ago, after he was hospitalized with life-threatening injuries from a motorcycle accident.

“Initially, nobody knew who we were and we had to sell ourselves,” said DeVries, who now serves on one of Spectrum Health’s 13 patient groups. Now, by contrast, his group offers input “any time there’s something new that involves patient or family care,” adding that the panel of patient advisers has tackled issues ranging from beefing up the facility’s security to how the hospital should give patients billing information. He’s even worked with the human resources department on what to look for when hiring doctors and nurses.

Such feedback led to marked increases in patient satisfaction scores, said Deborah Sprague, Spectrum Health’s program manager for patient and family services.

For instance, she said, a member of the orthopedics and neuroscience patient council noticed slow responses when he pushed the call button in his hospital room, a problem staff hadn’t noticed. The council worked with hospital employees to speed up response times. After the fix, positive patient assessments of the hospital jumped.

Maier, from the Faulkner council, recalled a time when hospital executives asked for help with patient complaints regarding nighttime noise levels. Late-night talking by staff was keeping patients awake.

The group discussed potential nighttime “quiet times” and other strategies to minimize noise without keeping doctors from doing their jobs. Once changes were made, patient satisfaction scores went up, Maier said — and a council member noticed a definite improvement the next time he was a patient.

Meanwhile, MedStar Health, which serves the District of Columbia and Maryland, has targeted advisory panels’ efforts to improve both the quality and safety of its care. The system has emerged as a model for finding ways to incorporate patients’ opinions, which was noted in a report from the American Hospital Association.

In one recent case, said David Mayer, MedStar’s vice president of quality and safety, patient advisers helped brainstorm ways to soothe the confusion and stress that often sets in when people have been in the ICU for more than a day. When implemented, the ideas led to reduced instances of patient confusion – known as delirium – which is linked to more destructive behavior, like patients trying to leave the room or bed before they should.

But even as the role of patient advisory committees grows, recruiting members continues to be a challenge. Finding people from diverse backgrounds with both the inclination and time to serve can be tricky, Cronin said. As a result, council members are often “middle-aged and older, white and English-speaking, and a lot of women,” said Deb Wachenheim, health quality manager at the Massachusetts-based advocacy group Health Care For All.

For some hospitals and health systems, though, these panels are just the beginning. Massachusetts General puts patients on various policy setting committees, and Faulkner has a non-voting patient board member.

“As we continue to evolve,” Maier said, “the hospital looks to us more and more.”

What’s At Stake In Supreme Court Obamacare Case

The Affordable Care Act mandates that all Americans get health coverage or pay a penalty. To help people pay for that insurance, the federal government subsidizes insurance premiums for millions of Americans.

In just a couple of months, the Supreme Court will rule in a major case concerning those subsidies. The question is whether the law allowed for them across the country or just in the minority of states that set up their own insurance exchanges. A decision to take away those subsidies could leave millions without insurance.

Attorney Tom Goldstein, who runs SCOTUSblog, has been following the case and says the law is ambiguous. “This is a real, serious question,” he says. “The law doesn’t tell you whether Congress wanted to limit the subsidies only to those states where the state itself went to the trouble of setting up the exchange or whether Congress wanted everybody who needed the help to be able to get the subsidies.”

Louisiana is a state where a lot of people could be affected. It runs and about 186,000 people there have used the site to buy health insurance. Nearly 90 percent of them in Louisiana get subsidies.

We traveled to the state to interview many of these people who could lose subsidies if the Supreme Court rules against them. Here are our first three profiles:

Carlton Scott, 63, at his house in Prairieville, Louisiana. Scott is too young for Medicare and Louisiana hasn't expanded Medicaid, so Obamacare was a good option for him (Photo by Jeff Cohen/WNPR).

Carlton Scott
Carlton Scott is 63. Sitting at his kitchen table at the house he owns in Prairieville, near Baton Rouge, he says he worked at a chemical plant for 30 years before he retired. He found out last fall that his company was scaling back his retiree benefits.

“’Round October they wrote me a letter saying, in December we’ll no longer be covered,” he says.

That included his health insurance, which he was really counting on.

“I thought they would take me to my grave. I really thought the company would take me to my grave,” he says. When it went away, “That pissed me off. Because, god——, I been through 30 years and you come with this bullsh–? That pissed me off.”

And he was in a bind. At 63 he is too young for Medicare and Louisiana hasn’t expanded Medicaid. Obamacare was a good option for him.

He signed up for a BlueCross BlueShield of Louisiana plan. He says he pays $266.99 per month, “to the penny.” Like a lot of people, he could rattle off the exact amount. Money is tight and people track their expenses carefully.

Scott could be in a position to lose his subsidy and his health insurance. He says if he had to pay more, he could for a while. He gets $2,600 a month between Social Security and his pension. But he worries about his friends.

“Everybody don’t make the same amount of money, that’s what I’m saying. I got a friend of mine, stay down the street. He gets Social Security and pension, too. But it’s not as much as mine, not half as [much].”

When asked about the case in front of the Supreme Court, he laughs.

“They all got insurance, too. I guarantee you that. They all got insurance.”

He says the court should, “Leave it like it is. I mean, what are people going to do? Get sick, go to the hospital, ‘I don’t have insurance. Won’t you please help me anyway?’ Hell, no. That ain’t going to happen,” he says.

LaTasha Perry
LaTasha Perry is at the other end of her career. She’s 31 and works at the front desk of a community health center in Plaquemine, La. She got covered under Obamacare because it was cheaper than paying the penalty.

LaTasha Perry, 31, works at a community health center in Plaquemine, Louisiana.  Perry says getting insured under Obamacare was cheaper than paying the penalty (Photo by Jeff Cohen/WNPR).

She says her children have Medicaid as their health coverage. Her job offers health insurance, but she says she can’t afford to buy it.

“I would pay at least $100 a month for the insurance here,” she says. “With my subsidy, I pay $13.”

Now she’s got money left over for necessities: “Food for my kids. I’m a single parent, so it’s hard.”
Charles Dalton
Charles Dalton wanted health coverage. He’s 64 and after he retired as a paramedic, he didn’t have health insurance. Then he got sick. He says his condition is too personal to talk about. “I’m disabled,” he says. “But I would be totally incapacitated without seeing this doctor.”

Charles Dalton, 64, a retired paramedic says losing his insurance was not an option (Photo by Jeff Cohen/WNPR).

The Affordable Care Act says insurers can’t take into account whether somebody is sick, like they used to. That made insurance unavailable or unaffordable for many sick people. And now — with subsidies — Dalton says he pays $149 a month. He hopes the Supreme Court doesn’t touch the subsidies.

“They’re just going to make a difficult situation more difficult,” he explains. “Because of the Affordable Care Act, it’s helping me to be able to make this existence more livable. You’re not asking for a handout. But if you get a helping hand, the last thing you need is for it to be snatched out from under you.”

Regardless of the politics, there are a lot of people like Dalton who could feel that the Supreme Court would be taking something away. Goldstein of SCOTUSblog says the court has a tough job.

“This is a case that requires the justices to be both lawyers and try and look at the words that Congress used, but also to struggle with the human dimension of the case,” he says. “The consequences are so real and so powerful that, if the challengers win here — and maybe they deserve to win, maybe it’s what Congress intended — but it’s hard to avoid the conclusion that millions of people would lose access to health insurance.”

biomimicry and the search for new tech

Biomimicry is the study of nature as inspiration for human designs in effort to fit  human technology into a more efficient and workable, sustainable model. Each organism alive today has the potential to teach humankind about the systems and rules it follows. Natural solutions aren’t just about having better materials.

They are about making products that might empower mankind against dwindling resources. Ecosystems aren’t just where we all live and consume resources but they are a resource of information as well. The ecosystem is self-replenishing and efficient and can be channeled and worked with in a way that has yet to be attempted. Potential new materials come with  side effects that warrant equal consideration. Biomimicry is a paradigm that fits many emerging techs. Take a look at spider venom’s effect on the drug industry, for example:

A peptide found in spider venom might lead to a safer class of painkillers. What other drugs, chemicals and designs are being inspired by biology and newly-studied species?

Biomimicry is a relatively young term, describing designs that derive inspiration by emulation of designs found in nature. The movement is focused on sustainable human endeavors and projects that will compliment the environment humans share with the rest of the natural world and thus better humanity’s chance for survival. Check out this video, the most recent by Janine Benyus, one of the idea’s most vocal proponents.

You might wonder why these chemicals are found in nature at all? There are many functions and motivations behind the diverse, unfound substances found in the Eco-system. Plants develop poison to discourage predators. some develop drugs to encourage other species to assist with seed dispersal. Evolution has provided the earth with highly diversified species of plants fungi and animals the vast majority of which have yet to be explored.

French researchers discovered a painkiller as powerful as morphine in the venom of e infamous African black mamba snake. Then there is a potential psoriasis treatment derived from the venom of the Caribbean sun anemone, undergoing testing in the U.S. might help sufferers with psoriasis, autoimmune disorders, multiple sclerosis and rheumatoid arthritis.gecko

Textures and surface patterns of geckos have been studied for stickiness. Skin textures of some animals have been proven to possess antimicrobial properties, in that bacterial colonies can’t find a way to attach to surfaces, making water currents and frequent rinsing enough to eliminate infective agents.

Artificial limb design and development has been greatly advanced by designs mimicking the weight-bearing capacity of other animals. New technologies are being developed to grant disabled people the ability to feel touch, as the natural mechanisms controlling pain, touch and movement are further understood.


In recent biomimetic news, we may see a mastery of understanding the human eye lead to a leap in ocular and immersive tech. MHOX is an Italian design firm who would like  synthetic replacement eyes.EYE to become an affordable, regular upgrade people opt for. Their work could restore sight to the blind and be the missing link to allow locative tech and a lot of web 2.0 concepts to become workable mainstream realities.

There is an initial shock in some people when these concepts are explained. Something about the current trends over the last few decades favoring straight, clean lines that are inspired by lifeless geometry over bio-inspired,  flowing shapes.

The drugs and prosthetics discussed, theorized and predicted in the biomimetics industries doesn’t have to turn humans into cyborgs, although some proponents wouldn’t be against that. It is likely that the public will be more inclined to accept these advancements as they are developed. Decades back people might have been less receptive to plastic hip replacements and artificial hearts, but the medical community has become very good at installing these prosthetics as minimally invasive, outpatient procedures.


Jonathan Howard
Jonathan is a freelance writer living in Brooklyn, NY

Spider Venom and the Search for Safer Pain Meds

Some of the most poisonous animals on the planet are found down under. Australian researchers retrieved exciting new data when taking a closer look at spider venom. Biosynthesized chemicals designed to be highly reactive with other organisms could inspire new drugs and, eventually, an entire new class of painkillers.

It can be defensive but the function of spider venom is often to incapacitate or kill prey. University of Queensland academics released their findings in The British Journal of Pharmacology, after they isolated seven unique peptides found in certain spider venoms that can block the molecules that allow pain-sensitive nerve pathways to communicate with the brain. One of the pepetides originated in the physiology of a Borneo orange-fringed tarantula. That peptide possessed the correct chemical structure, combined with a stability and effectiveness to become a non-opiate painkiller.

15% of all adults are in chronic pain, according a study published in 2012 Journal of Pain. Most readers are already aware of the danger of addiction and lagging effetiveness of opiate drugs like morphine, hydrocodone, oxycodone. The medical community is hungry for a change in available medications. Opiates are all derivatives or inspired by opium plants which have been tried and tested for centuries. Venomous spiders are difficult to study but the motivation for new drugs has loosened funding with the help of promising finds like this one.

“Spider venom acts in a different way to standard painkillers,” ~ Dr. Jennifer Smith, research officer @ University of Queensland’s Institute for Molecular Bioscience.

While cessation from pain might in itself create an addictive reaction, this venom is promising, according to Dr. Smith, because it blocks the channel through which the pain would even reach the brain. Opiates merely block the widespread opioid receptors in actual brain cells, deep within and in the surrounding nerve tissue of the brain itself.

What’s the mechanism of action for this spider-drug? Some people are born with a rare genetic defect that renders them unable to feel pain. Geneticists identified the human gene responsible, known as SCN9A. Dr. Smith hopes the peptide will enable the cells of a human without the defect to shut down part of the DNA that manifests this immunity to pain.

There could be other breakthroughs in medicine and chemistry. The findings are awesome in the Australian project but those researchers only documented findings of roughly 200 out of 45,000 known species of spider.  Out of those 200, 40% contained peptides that interacted with the way pain channels communicate. The next step would be to test the painkillers on animals.

“We’ve got a massive library of different venoms from different spider species and we’re branching out into other arachnids: scorpions, centipedes and even assassin bugs,” said Dr. Smith.


Jonathan Howard
Jonathan is a freelance writer living in Brooklyn, NY