By Michelle Andrews

Photo by Mad Max

One in 500 kids has an inherited disorder that causes high levels of LDL (“bad”) cholesterol that may require medication to control.However, since the problem doesn’t create observable symptoms, as many as half of these kids don’t know they have the condition.

To help identify these children, late last year an expert panel convened by the National Heart, Lung, and Blood Institute recommended that all children be screened for high cholesterol, once between the ages of 9 and 11 and again between ages 17 and 21.

Reaction to the guidelines, which were included as part of a larger NHLBI report on improving cardiovascular health in children and adolescents, has been mixed.

Some clinicians and researchers say universal screening is an important tool not only to help identify children who are genetically predisposed to high cholesterol, a condition called familial hypercholesterolemia, but also to pinpoint others who could benefit from treatment, including those with high LDL related to being overweight or obese.

Working with these kids to eat more healthfully and to exercise more may reduce the cumulative negative effect of high cholesterol on their cardiovascular systems and lead to fewer heart attacks and strokes later in life, the experts say.

Others, including clinicians who authored a pair of articles in the Journal of the American Medical Association last month, express concerns that screening may do more harm than good.

To learn more read the LocalHealthGuide article: Should kids with high cholesterol be put on drugs? 

To identify the relatively small number of kids who really need medical treatment, doctors cast a wide and expensive net that identifies many children as at risk who will never develop  premature cardiovascular disease, says Matthew Gillman, director of the obesity prevention program at Harvard Medical School, who co-authored one of the articles. Some of those children will probably be needlessly put on cholesterol-lowering medications, he says.

The U.S. Preventive Services Task Force, an independent group of primary-care providers that evaluates the evidence for clinical care, concluded in 2007 that there isn’t enough evidence to recommend for or against routine lipid screening in children and adolescents.

Research has shown that 10 to 13 percent of children have elevated cholesterol levels. Treatment for the vast majority should focus on lifestyle interventions, says Stephen Daniels, chairman of the Department of Pediatrics at the University of Colorado School of Medicine, who led the NHLBI panel. A much smaller number of those children, the ones with a genetic predisposition to high cholesterol, may need to take a statin, he says.

Until the new guidelines were released, the American Academy of Pediatrics recommended cholesterol screening in children primarily based on family history. If a child had a father who had heart disease or a heart attack before age 55, for example, screening would be indicated. Children who had risk factors such as obesity or diabetes were also candidates for screening. The AAP has since endorsed the new NHLBI guidelines.

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“Family history doesn’t really catch everybody” with familial hypercholesterolemia, says Sarah de Ferranti, a member of the AAP committee on nutrition and the director of preventive cardiology at Children’s Hospital Boston.

In addition, she says, “Anecdotally, I can tell you that when someone comes to my office and they know they have high cholesterol values, they’re much more focused.”

That’s the case with the McFeeley family. Bill and Carolyn McFeeley, of Mullica Hill, N.J., had always considered themselves very healthy – until Bill had a heart attack two years ago at age 47.

The pediatrician for their three children checked the kids’ cholesterol and found that while levels for the two girls – Chelsea, now 17, and Chandler, 13 – were normal, Chase, 10, had slightly higher values: His total cholesterol was roughly 210. (In general, anything over 200 is considered high.)

Julie Brothers, medical director of the lipid heart clinic at Children’s Hospital of Philadelphia, sees Chase once a year now and says she hopes they can manage his cholesterol without medication. “None of us wants to slap medication on anyone,” she says.

Maybe not. “But if you’re going to test every child, it’s a sure bet you’re going to be medicating more kids,” says H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, who has written extensively on the problems created by aggressive screening.

Research on the safety and effectiveness of statins in children is scant; studies that have looked at statin use haven’t enrolled more than a few hundred kids, and none has followed them for more than two years, say experts.

“We don’t know what taking a 10- to 11-year-old kid and putting them on statins long term will do,” says Frederick Rivara, division chief of general pediatrics at Seattle Children’s Hospital and co-author of one of the JAMA articles.

Gillman says that while early intervention to prevent heart disease is critical, screening all children may not be the best way to do it. As an example, he cites a study that he co-authored last year examining the cost-effectiveness of blood pressure screening in adolescents.

“The bottom line of that study is that population approaches like taking the salt out of food are more effective and less costly than any screening program,” he says.

PHOTO by Mad Max – GNU Free Documentation License

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

By Michelle Andrews

The 2010 health-care overhaul creates state-based health plans for those who have medical conditions that make them uninsurable in the private market.

These “preexisting-condition insurance plans” (PCIPs) are intended to act as a bridge until 2014, when insurers will no longer be able to refuse to cover people with medical problems or charge them more than other consumers.

As of November, about 45,000 people had signed up for those plans, far fewer than the up to 400,000 that was originally projected.

However, there is a much larger group, more than 220,000 people, who have coverage through 35 state high-risk pools that were in existence before the overhaul was passed.

Because of restrictions in the new law, they can’t sign up for the PCIP plans, even though the coverage is often cheaper (thanks in part to federal funding) and more comprehensive. For these people, 2014 can’t come soon enough..

Together they pay $1,304 a month for coverage. Chris’s plan has a $2,500 deductible while Kristi’s is $1,000. The plans generally cover 80 percent of their medical bills.

Chris Petersen, who supported the health-care overhaul, nevertheless thinks the law failed him and his wife. “This is the biggest check I write out every month,” he says. “The new federal plan would have been a lot cheaper.”

If the Petersens had been allowed to sign up with the PCIP in Iowa, their combined premium would have been $958 for policies with $1,000 deductibles.

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People such as the Petersens, however, are stuck between a rock and a hard place: To qualify for a PCIP, they must first be uninsured for six months.

Experts say this requirement was included in the law to discourage people in the existing state high-risk pools and other private insurance plans from doing exactly what they would do if better, cheaper coverage became available: switch plans.

It’s clear why they might be tempted. Premiums in the new pools can’t exceed rates for standard individual coverage in the state, while the high-risk pools in some states charge twice that. The new plans must also cover preexisting conditions immediately, in contrast to the older state pools, some of which exclude such coverage for up to a year.

“Much as everybody would like to drop [the six-month requirement], if you did you’d have to increase expenditures,” says Sandy Praeger, the Kansas insurance commissioner, who chairs the health insurance and managed-care committee of the National Association of Insurance Commissioners. Federal funding for the program through 2013 is $5 billion.

Learn about Washington State’s Pre-existing Condition Insurance here.

Although enrollment in the PCIPs has been far lower than originally projected, health-care spending by the individuals who have signed up for coverage has been much higher than anticipated, say experts.

“The people coming into the PCIPs act more like the long-term uninsured,” says Jean Hall, an associate research professor at the University of Kansas who co-authored a report about the PCIPs for the Commonwealth Fund. “They’re not accustomed to managing on a day-to-day basis; they’re accustomed to going to the emergency department when things get bad.”

Nine states have asked the Department of Health and Human Services for more money to fund their PCIPs in 2012. However, it appears the program won’t run out of money soon. Through the end of September 2011, just $386 million of the $5 billion allocated had been spent, according to HHS figures.

(Some experts caution against relying too much on September spending figures, since enrollment has increased since then and claims may take months to clear.)

“As you would expect, some states have exceeded projections and others have not,” says an HHS spokesman. “We have the capacity to accommodate the needs of the program.”

For people who can’t get into the new plans, however, that’s small comfort.

Jill Judy and Mark Brown signed up for the Arkansas high-risk pool a few years ago when Mark’s benefits ran out after his retirement from a management job at a company that repossesses boats. Judy, 49, has mild cerebral palsy, which she hasn’t been treated for since she was a child, and Brown, 62, had an angioplasty 15 years ago and still sees a cardiologist.

Individual insurers wouldn’t cover them, so they ended up in the state’s high-risk pool. Although Judy says she’s grateful that she has coverage, it’s hardly ideal.

The premiums for the two of them come to just under $1,000 a month. But the plan has a $10,000 deductible and a $1 million cap on lifetime benefits. “People like my husband and myself are paying $12,000 a year for nothing,” she says.

She estimates they could get better coverage and save 30 percent in the Arkansas PCIP. “But we don’t qualify because we’re not willing to be uninsured for six months,” she says. “It’s screwy.”

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

Local Resources:

• Statewide Health Insurance Benifits Advisors (SHIBA) provides free, unbiased advice from volunteers: www.oic.wa.gov/shiba/
• Benefits.gov: www.benefits.gov
• King County Project Access: www.kcprojectaccess.org
• Washington Basic Health (insurance assistance): www.basichealth.hca.wa.gov/understanding.shtml
• Washington Health Plan: www.washingtonhealth.hca.wa.gov
• Washington State Office of the Insurance Commissioner: www.insurance.wa.gov
• To search for a community clinic near you go to: http://findahealthcenter.hrsa.gov

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

By Michelle Andrews

If you saw that your doctor had written “SOB” in the notes he took during your latest office visit, you might be offended and wonder what you’d done to give him such a negative impression. But “SOB,” in physicians’ shorthand, simply means “shortness of breath.”

Concern about such misunderstandings is one of several reasons doctors are reluctant to share their notes with patients, according to a study published in December in the Annals of Internal Medicine.

The study surveyed 173 doctors and nearly 38,000 patients at primary-care practices about sharing information with patients. After the survey, the practices joined a project called OpenNotes, in which patients were give electronic access to their files.

Although federal law guarantees patients the right to examine and get copies of their medical records, providers haven’t always made it easy to do so.

But the movement to give patients direct access to their health information has picked up steam, and policymakers have encouraged it as a way to empower patients to help manage their health and their medical care.

Making lab test results available directly is more common, but it’s not routine, either. Just seven states and the District explicitly allow patients to get test results directly from the lab, and seven others permit it with provider approval.

Last fall, the Department of Health and Human Services proposed a rule giving patients in every state direct access to their lab test results. A comment period ended in November, but there’s no date set for release of a final rule, according to a spokesperson for the Centers for Medicare and Medicaid Services, which would release it.

Patients don’t share clinicians’ ambivalence about getting direct, easy access to their health information. No matter their age, education or health status, more than 90 percent of participants in the OpenNotes survey said they thought being able to see doctors’ notes was a good idea.

“In a way, that was the biggest surprise of the study,” says Jan Walker, the study’s lead author. Walker is a nurse at Beth Israel Deaconess Medical Center in Boston, whose practice participated in the study along with those at Geisinger Health System in rural Pennsylvania and Harborview Medical Center in Seattle. “It reflects consumers’ universal interest in their own care.”

In 2010, Quest Diagnostics, a large lab services company, introduced a free smartphone application called Gazelle that lets consumers in 33 states and the District download their lab test results directly. Since then, 125,000 patients have used the service, the company says. “[Gazelle] will help you have an educated conversation with your physician,” says Jon Cohen, chief medical officer for Quest.

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John Hadley downloaded the Gazelle app to his iPhone after he developed deep vein thrombosis and was prescribed a blood thinner to help prevent another blood clot.

At first, Hadley had to get a blood test every few days so his physician could adjust the medication dose if necessary; now he’s tested every few weeks.

Gazelle let Hadley, 53, track his results and make adjustments to his diet if they started to drift. (Foods high in Vitamin K can affect the ability of blood to clot.)

“It’s my health and my results, I should be able to get them as easily as possible,” says Hadley, IT manager who lives in Parsippany, N.J.

Giving patients direct access to their medical information may also help catch physician errors and omissions, say experts.

Walker says she has heard of patients in the OpenNotes project who have reviewed their doctor’s notes and realized that a test the physician called for hadn’t been ordered. Even more troubling, studies have indicated that as many as a quarter of abnormal test results don’t receive timely follow-up. If patients can look up their results online, that figure might decline.

On the other hand, increased patient access “has the potential to diffuse responsibility” for following up on test results if patients and their doctors both expect the other to check on the results, says Hardeep Singh, chief of the health policy and quality program at the Houston Veteran Affairs Health Services Research and Development Center of Excellence.

Many clinicians are troubled by the prospect that patients may get bad or confusing news without a physician or other health-care provider on hand to help put the information in context.

Patients who use the Gazelle app can’t get direct results on HIV, cancer or genetic diagnostic tests, says Cohen. There’s a 48-hour delay on releasing all other test results, to give physicians a chance to contact the patient and discuss the findings first.

Likewise, patients who participated in the OpenNotes project can’t access the visit notes until their physician has signed off on their release.

“No one wants to see their diagnosis of cancer on their own without a medical professional,” says Jonathan Darer, chief innovation officer for Geisinger Health System, which makes most patient information available online. “We try to manage that.”

At the same time, however, it’s important to ensure that patients get information promptly. “Not knowing is incredibly anxiety-provoking,” says Darer.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

By Michelle Andrews

Seventy percent of smokers say they’d like to quit, and now, just three days into the new year, many may already be struggling to stick to their resolution to make 2012 a smoke-free year.

If quitting were easy, after all, chances are good that nearly one in five adults wouldn’t still be smokers, a figure that hasn’t budged much in several years.

Smoking is such a familiar health hazard that some experts say it doesn’t get the attention it deserves; the focus is often on other lifestyle-related conditions, especially obesity.

But smoking is still the No. 1 cause of preventable death in this country. Nearly half a million people die prematurely because of smoking-related illnesses, including lung cancer, heart disease and chronic obstructive pulmonary disease, according to the Centers for Disease Control and Prevention.

Scrambling to address budget problems, states this year will spend less than 2 percent of their tobacco-tax and tobacco-settlement billions on programs to help people quit smoking or prevent them from starting, according to a recent report by a coalition of public-health organizations.

Local Smoking cessation resources:

• King County’s Tobacco Prevention Web page.
• Seattle Cancer Care Alliance’s Smoke Free Life.
• Washington State Department of Health Tobacco Prevention and Control Program.
• Washington’s Tobacco Quite Line: Free Help for Tobacco Users.
• American Lung Association of Washington.
• American Cancer Society.

In the past four years, state spending on tobacco prevention and cessation has declined by 36 percent, to $457 million.

Tobacco-related health-care spending is nearly $100 billion annually, according to the CDC.

“It’s a travesty,” says Danny McGoldrick, vice president for research at the Campaign for Tobacco-Free Kids. “These programs more than pay for themselves.”

Carrots And Sticks

While public funding falters, a growing number of companies offer smoking-cessation programs to their workers. Last year, two-thirds of companies with 200 or more workers offered such programs, while 31 percent of smaller companies did so, according to the Kaiser Family Foundation’s annual survey of employer-sponsored health benefits. (Kaiser Health News is an editorially independent program of the foundation.)

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At the same time that they offer a helping hand to quit, more companies are also penalizing employees who don’t kick the habit by hitting them with higher health insurance premiums.

At firms with more than 20,000 employees, 24 percent vary premiums based on whether someone smokes, as do 12 percent of companies with 500 or more workers, according to the 2011 survey of employer-sponsored health plans by human resources consultant Mercer.

Public-health advocates generally agree that this punitive approach isn’t ideal. “The issue isn’t smokers, it’s smoking,” says McGoldrick. Charging people higher premiums may just make smokers drop their coverage, he says.

But employers argue that charging smokers more is only fair. “The cost of medical care for smokers is considerably higher,” says Helen Darling, chief executive of the National Business Group on Health, an employer group. “Employers are increasingly saying that if someone costs the pool more, they should pay more.”

Darling points out that companies that go this route typically offer free smoking-cessation services and give employees plenty of notice before implementing the change.

A Quitter’s Story

For Tommy Piver, 59, the combination of pricier cigarettes and looming health insurance penalties finally motivated the two-pack-a-day smoker to give up the habit he’d started at age 13. Increased taxes had caused the price of a pack of cigarettes at the gas station near his home in Naples, Fla., to double within a year, to $5. Then he got a notice that his insurance carrier was going to triple the health insurance premium and reduce the amount it covered for all sorts of care from 90 percent to 70 percent for smokers.

“Kicking and screaming,” Piver quit on Jan. 1, 2010. About a week later, he saw a television ad for an online stop-smoking program developed by Legacy, a nonprofit created under the settlement between the states and the tobacco industry. Piver joined the free EX program and hasn’t had a cigarette in two years.

The EX campaign is an “excellent, science-based tool” for smokers who want to quit, says Thomas Glynn, director of cancer science and trends for the American Cancer Society.

Another option is a national toll-free line, 1-800-QUIT-NOW, which routes callers to free support services, including free medication in the handful of states that provide it, says Glynn.

The 2010 federal health law expanded coverage for smoking cessation, though not to the degree that advocates wanted. Under the law, states must provide tobacco-cessation coverage for all pregnant women in their Medicaid programs at no cost.

But anti-smoking activists would like broader Medicaid coverage requirements: Although 19 percent of adults smoke overall, 31 percent of adults living below the poverty line are smokers.

The health law also requires that new health plans – those that have either just begun or have changed their benefits sufficiently to lose grandfathered status under the law – screen adults for tobacco use and provide free stop-smoking interventions.

Exactly how much intervention is required isn’t spelled out in the law; that will be up to federal rulemakers to decide. Smokers typically make several attempts to quit before they succeed.

Advocates hope that federal guidelines will provide coverage for more than a single four-session counseling module, for example, or a standard 12-week round of medication. “Data is accumulating that 12 weeks is not enough,” says Glynn.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

$6.8 Billion spent yearly on 12 unnecessary tests and treatments

By Michelle Andrews

For many adults, a routine visit to a primary care physician might involve blood tests, a urinalysis, an electrocardiogram, maybe a bone density scan.

Too often, however, these tests are inappropriate and they cost a bundle, according to a recent study,  not only for the health care system but also for individuals, who are increasingly footing more of the bill for their care.

The study, led by physicians from the Mount Sinai Medical Center and the Weill Cornell Medical College in New York, was published online in October in the Archives of Internal Medicine.

The researchers examined the cost of common primary care practices that were identified as being overused earlier this year in a study by another group of physicians, known as the Good Stewardship Working Group. .

The working group, for example, had noted that blood and other diagnostic tests were often ordered even for patients who had no related symptoms or risk factors and said they should be discontinued in those cases.

Also included on its list were imaging studies such as CT scans or MRIs for low back pain and Pap tests to screen for cervical cancer in teenagers.

Among the frequently inappropriate pediatric practices were writing prescriptions for antibiotics for children with sore throats who didn’t have a strep infection; recommending cough medicines for children with upper respiratory infections and ordering imaging tests for the heads of kids who took a spill but didn’t exhibit red-flag symptoms such as dizziness or loss of consciousness.

Photo by Mikael Häggström via Wikipedia Commons

The newest study, using data from federal medical surveys, estimated that 12 of those unnecessary treatments and screenings accounted for $6.8 billion in medical costs in 2009.

The activity most frequently performed without need was a complete blood cell count at a routine physical exam. In 56 percent of routine physicals, doctors inappropriately ordered such tests, accounting for $32.7 million in unnecessary costs.

In terms of dollars, the biggest-ticket item by far was physicians ordering brand-name statins before trying patients on a generic drug first: That accounted for a whopping $5.8 billion of the $6.8 billion total.

Minal Kale, an internist at Mount Sinai School of Medicine and lead author of the study, says $6.8 billion was a conservative estimate of the cost of the inappropriate care.

She notes, for example, that the study didn’t evaluate the cost of additional testing or procedures that result from an abnormal blood test reading result or imaging scan, even though in the absence of symptoms or risk factors the follow-up may be unnecessary and even cause harm.

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“The financial and other emotional results of that can be significant,” she says.

The original list of primary care activities upon which Kale and her colleagues based their financial analysis was developed by the Good Stewardship Working Group under a grant from the American Board of Internal Medicine Foundation and published first online in May.

Working group members were composed of internists, family physicians and pediatricians who are part of the National Physicians Alliance, a group of 22,000 doctors that advocates universal, affordable health care.

The working group focused on common activities that no physician would argue against, says Stephen Smith, a family physician and professor emeritus at Brown University’s Alpert Medical School, who co-authored that group’s paper.

That’s why you don’t see more controversial practices like the PSA blood test for prostate cancer, which was recently removed from the U.S. Preventive Services Task Force‘s list of recommended screenings for most men.

“What we were trying to do was change [physicians'] mindset, not cause firestorms of controversy,” says Smith.

So why would physicians continue to order tests and prescribe pricey drugs when there’s clear evidence that they’re not necessary in many cases and may even cause harm by exposing people to unneeded care?

One of the main reasons is the way doctors are trained, Smith says. “I think all of us practicing in the U.S. were raised in an educational environment where we got dinged if we didn’t order certain tests,” he says.

Defensive medicine also plays a role. “Nobody ever gets sued for ordering unnecessary tests,” says Doug Campos-Outcalt, a family physician in Phoenix and a past president of the Arizona Academy of Family Physicians.

And patient expectations drive some of the spending as well, say physicians, who note that sometimes simple directives, such as drinking less alcohol or getting more exercise, aren’t what patients want to hear. “If a doctor says, ‘Let’s talk about weight control,’ patients aren’t usually too happy,” says Campos-Outcalt. “They feel like there should be some testing.”

Doctors alone can’t turn the tide. Improving patient education and communication with doctors is key to helping change practice patterns, says Smith.

Still, one expert is encouraged that doctors came up with this list of wasteful spending, rather than leaving it to government bean counters. “It’s only the doctors that can get into the clinical detail and find out what sorts of things are not producing a benefit and might cause harm,” says H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, whose work has questioned whether much of the preventive screening people receive is helpful.

The dollar amounts identified in the current study may be a good start, but they don’t even begin to address the country’s spending issues, he says. In 2009, health spending grew to $2.5 trillion and accounted for 17.6 percent of the gross domestic product.

Kale suggests that specialist care be the next target that physicians take aim at to identify inappropriate, overused activities. Specialist income, after all, is primarily generated through procedures, while primary care is often conversation-based. “We have more to gain by examining [specialist care] more closely,” she says.

KHN wants to hear from you: Contact Kaiser Health News

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.