By Jenny Gold
This story was produced in collaboration with 

On a Monday night in December, Lauretta Martin, 47, visited the sleep lab at the National Rehabilitation Hospital in Washington, D.C. for the second time.

On her first visit, Martin, a heavyset woman whose husband reports she is a loud snorer, was diagnosed with sleep apnea. This time, she was being fitted for a CPAP machine, which helps keep a snorer’s airway open throughout the night.

The sleep lab has six testing rooms, each of which looks just like a room at a Holiday Inn, with striped wallpaper, a floral bedspread, framed prints of the seaside and free wifi.

“They have a brochure that says it’s just like being in a hotel room, and it is,” says Martin, sitting on the edge of her bed wearing a pair of soft grey pajamas and watching a football game on her flat-screen TV.

Aside from the two-dozen colorful electrodes taped to her body to monitor her every motion and the scuba-style mask on her face to enhance her breathing, she looked ready for a cozy night of slumber.

In the tech room a few doors down, a professional sleep technician observed her over a video monitor, testing the electrodes and preparing to listen in to the sounds of her sleep.

Snoring was once considered a simple annoyance for bed partners, but there is a growing awareness in the medical community that the grunts and snorts of noisy sleepers can also be a sign of sleep apnea, a condition shown to increase the risk of numerous serious illnesses, including heart disease, stroke and dementia.

Testing can be a lucrative business, and labs have popped up in free-standing clinics and hospitals across the country. Over the past decade, the number of accredited sleep labs that test for the disorder has quadrupled, according to the American Academy of Sleep Medicine (AASM).

Sleep apnea occurs when the muscles in the back of the throat relax, causing an airway obstruction that can stop a person’s breathing for several seconds or even minutes.  It causes restless sleep and sometimes dangerously-low blood oxygen levels.

The disorder can be diagnosed by monitoring a snorer’s sleep patterns, either in an overnight visit to a sleep lab or at home using a portable testing device. It is then often treated with a CPAP machine, which helps keep a snorer’s airway open during sleep.

Sleep apnea has likely gotten more common as the population has grown older and more obese, two major risk factors for apnea, and the National Institutes of Health estimates that more than 12 million Americans suffer from the disorder.  Many are never diagnosed.

“I think the medical community is sort of dropping the ball” on apnea, explains Dr. David Gross, medical director of the sleep lab at the National Rehabilitation Hospital. “It’s just sad when you walk through the hospital and you see these patients with heart failure—the person might be 35 years old, he’s 350 lbs — but no one’s thinking that he has sleep apnea, which he statistically does.”

Dr. David Gross, director of the sleep lab at the National Rehabilitation Hospital in Washington, D.C., analyzes a sleep test (Photo by Jenny Gold/KHN)

He says more than three-quarters of the patients who come to the lab are diagnosed with apnea.

But the testing isn’t cheap: each night at a hospital sleep lab can cost $1,900 and is usually mostly covered by a patient’s health insurance. Some patients, including Martin, end up spending two nights at the lab – one to test for apnea, and the second to try the CPAP machine.

Dr. Fred Holt, an expert on fraud and abuse and the medical director of Blue Cross Blue Shield in North Carolina, says some patients aren’t having basic exams done first and are therefore being prescribed expensive tests they don’t need. Not everyone who snores has a chronic disorder, he notes.

In other cases, Holt says the labs prescribe CPAP machines right away without first suggesting other strategies like losing weight of sleeping on your side, which can also reduce apnea.

“We are spending more and more money on sleep testing and treatment, and like anything else in health care, there are unscrupulous people out there who are more than happy to do testing and treatment that might be of questionable value,” says Holt. “This might be because of naiveté on the part of the physician, or unfortunately, it could be done for the sake of improving the cash flow of one’s business.”

It’s no secret that the sleep business can be lucrative for physicians. A website for Aviisha, a sleep testing company, has a section for physicians showing a picture of a doctor with a stack of money in his lab coat pocket.  And in February, the AASM is offering a seminar on the “business of sleep medicine for physicians” at a golf resort in Arizona.

Dr. Nancy Collop, president of the AASM, says that while many sleep centers offer comprehensive care for sleep disorders, others are largely focused on overnight sleep testing.

“A lot of people have gotten into the sleep business specifically to do that procedure,” she explains. The goal of the AASM’s accreditation process, she says, is to make sure sleep labs are offering more because “many patients may not even need a sleep study.”

Helen Darling, president of the National Business Group on Health, which represents large employers offering health insurance to their workers, says the tests are driving up the cost of premiums.

“This is a good example of something where we have technology, we have financial incentives to use more of it then we have historically done, you have enough problems including a growing obesity epidemic, and you sort of put together the so-called perfect storm for driving up overuse and health care cost,” Darling says.

She says doctors should focus instead on common-sense approaches to sleep apnea, like losing weight, before turning to expensive testing and medical devices.

Another option are home sleep tests, which costs less than a fifth of the cost of a lab test, and are considered effective for most patients. Medicare began paying for home sleep tests in 2008, but the tests have had only modest growth.

“I believe lab tests, as opposed to the home tests, are being wildly overprescribed,” says Mike Backus, senior vice president of American Imaging Management, a subsidiary of Wellpoint.

Right now, he says, 99 percent of the sleep tests given to Wellpoint patients are done in the lab, but “it should be 70 percent at home and 30 percent in the lab.”

Backus adds that the majority of patients who are diagnosed with apnea and then given CPAP machines stop using them within the first year.

Some insurers, including Wellpoint, are changing the way they pay for sleep testing to curb the costs. Many now require a special pre-authorization. They also ask the doctor whether a patient qualifies for a home sleep test instead of one at the lab.

Those changes are now widespread among Massachusetts insurers and are having an effect on the sleep industry in the state.

Dr. Lawrence Epstein, the chief medical officer of Sleep Healthcenters in Massachusetts, says the labs have already experienced a 20 percent drop in the number of patients coming in for testing.

While the past decade was focused on industry growth, he says it’s “now going to be about consolidation and provision of better quality, more efficient care.”

Sleep Healthcenters has shut down three of its 15 sleep labs, and more closures may be on the way. Epstein says the company is focusing more on “sleep wellness,” including treating and managing sleep disorders, and less on testing.

The key, he explains, is to become more efficient without decreasing access to care for patients who need it.

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 Richard Knox, NPR News

This story comes from KHN partner ‘s Shots blog.

If a heart attack sends you to an American hospital, you’ll probably go home after only two or three nights. That’s faster than virtually anyplace else in the world.

But your chances of needing to go back into the hospital within the next month are also higher than they are for heart attack patients in 16 other countries.

That’s the finding from a Duke University-led study in this week’sJAMA, the Journal of the American Medical Association.

On the face of it, the results suggest that hurry-up hospital care for U.S. heart attack patients may be pushing them home too quickly.

But, not so fast, says Dr. Manesh Patel, a cardiologist and the senior author of the study, which may be the first to compare international rates of hospital readmission after heart attacks.

“We certainly haven’t shown in this study that U.S. heart attack patients need to be in the hospital longer,” Patel told  Shots.

Rather, he says, the study raises questions about how other countries do post-heart-attack care — both in the hospital and beyond — that results in fewer return stays.

We’ll come back to those questions.

But first, consider the study’s main findings. They involve so-called STEMI heart attacks. The acronym stands for ST-segment Elevation Myocardial Infarction.

Around 1 in 3 heart attacks is a STEMI, and they pose the gravest risk to victims.

The study looked at nearly 5,600 heart attack survivors in 17 nations, including the United States, Canada, Australia, New Zealand and 13 European nations.

Everywhere but the U.S., about 10 percent of the survivors had to be readmitted to the hospital within 30 days of their heart attack.

But in this country, the readmission rate was 15 percent.

The higher U.S. rate wasn’t due to differences in age or the presence of other illnesses.

Some of the higher U.S. readmission rate was from patients who were brought back to the hospital on an non-emergency basis to ream out other clogged arteries discovered at the time of the first admission.

Many heart specialists hope that will lessen the chances of a subsequent heart attack, although the evidence for that isn’t clear, Patel says.

But even when these elective hospitalizations are taken out, the U.S. still has the highest rate of post-heart attack readmissions.

Since the U.S. has the shortest hospital lengths-of-stay, it would be tempting to conclude that the pressure to cut costs here has compromised quality. Early readmission is considered a marker of poor quality of care.

Readmission also imposes an additional cost burden, so policymakers also consider it a red flag for inefficient care.

But Patel says it’s simplistic to blame high U.S. readmission rates on short U.S. lengths-of-stay. As a case in point, he cites Canada — perhaps the closest comparison with U.S. medical culture.

“In the U.S., the 30-day readmission rate was 14.4 percent. In Canada it’s in the 5 percent range,” Patel notes. “The U.S. length-of-stay is three days, in Canada it’s five.”

But in all of Canada there are only 45 hospitals that provide the kind of acute heart attack care available in hundreds of U.S. centers — clearing of the clogged coronary artery within hours, followed by placement of a metal stent to keep it open.

“In Canada,” Patel says, “patients are often transferred back to the hospital from where they were initially referred, and then they’re linked up with their primary care physicians and local cardiologists so their rehabilitation can start.”

He says the U.S. often falls down on that post-hospital coordination.

“I think we both do very well from when the patient has chest pain to getting the clogged artery open,” Patel says. “But it looks like Canada does better in going from the hospital to home.”

That involves things like making sure the patient knows all the things he or she needs to do to prevent a subsequent heart attack, such as stopping smoking; setting up a followup visit with a primary care physician who has access to the hospital records; and ensuring the patient knows what to do if new cardiac symptoms arise.

Importantly, the study found no difference in 30-day death rates following STEMI heart attacks between the United States and the 16 other developed countries.

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.

The report, America’s Health Rankings, is published jointly by United Health Foundation, American Public Health Association and Partnership for Prevention.

Top-ranked states:

1. Vermont
2. New Hampshire
3. Connecticut
4. Hawaii
5. Massachusetts

Bottom-ranked states:

Washington State Trends:

Among the trends that drove down Washington State’s rankings this year were rises in the rates of obesity, diabetes, and smoking and a decline in high school graduation rates.

The annual study, America’s Health Rankings, assesses a state’s health using not only standard measures of health, such as infant mortality rates, but also by such measures as smoking, obesity, and high school graduation rates — all of which provide indications of a population’s overall health status.

High school graduation rates are considered in the ranking because, in general, graduates tend to go on to have fewer health problems later in life.

Among the trends in Washingtion the report found troubling were:

• A marked increase in obesity rates among the state’s residents over the past decade from 18.8 percent to 26.2 percent, meaning that 1.6 million of Washington state’s adults are now obese.

• A steady increase in the the rate of diabetes, which rose from 6.3 percent five years to 7.3 percent in 2011, meaning that 391,000 adults in the state now have the disease.

• And a decline in the number of students graduating from high school in four years to the lowest rate in seven years, 71.9 percent, placing the state 38th in the nation for high school graduation.

Other challenges facing the state identified by the report were a low immunization rate among children, 88.6 percent. That rate makes the state 39th in the nation.

National progress stagnates

The report found that the nation made no progress in improving its overall health this year with modest improvements being offset by a number of troubling trends.

Among improvements were declines in smoking, cardiovascular deaths and preventable hospitalizations:

• Smoking cessation: 17.3 percent of the population smoked in 2011, down from 17.9 percent in 2010 – a 3.4 percent decline since 2010; a 25.4 percent decline since 2001.

• Cardiovascular deaths: 270.4 deaths per 100,000 in 2011, down from 278.2 deaths per 100,000 in 2010 – a 2.8 percent decline since 2010; a 22.2 percent decline since 2001.

• Preventable hospitalizations: 68.2 preventable hospitalizations per 1,000 Medicare enrollees in 2011, down from 70.6 preventable hospitalizations in 2010 – a 3.4 percent decline since 2010; a 17.3 percent decline since 2001.

This story comes from our partner ‘s Shots blog.

It’s here. The cholesterol-fighter Liptor, the biggest hit in the history of the pharmaceutical industry, is now widely available in generic form.

The Pfizer drug finally lost its U.S. patent protection at the end of November, opening the door for cheaper substitutes (atorvastatin, generically) and ending the monopoly for one of the most profitable brand-name products of any kind.

So how much might you save on Lipitor now? If you have insurance, you should be able to get atorvastatin for the price of a generic copayment. Around $10 is typical.

For the next few months Pfizer is looking to keep people using brand-name Lipitor with subsidized copays. Depending on your insurance, you might get a month’s supply for as little as $4 out of your wallet with the Pfizer deal. Without the card, the average copay for the brand is around $25.

What are the actual prices of Lipitor and the generic copycats?

That question isn’t easy to answer. The bottom-line price paid for prescription drugs by insurers, pharmacy benefits managers and drugstore chains is practically a state secret. There are incentives and rebates that aren’t made public.

But you can get a sense of the cost difference from the cash price someone without insurance would pay.

My neighborhood CVS said a 30-day supply of the 10 milligram dose of Lipitor would cost $150.99. The generic: $117.99.

How about Wal-Mart? One nearby quoted a $119.78 price for the same strength of the brand and $105.46 for the generic.

At the nearest Costco, a month’s worth of 10 mg Lipitor goes for $116.74 while the generic is $87.14.

Are Pfizer’s $4 copay card and some other deals to help it hang on to market share working out? Sort of.

For the week that ended Dec. 9 (the first full week generic atorvastatin was available in the U.S.), brand-name Lipitor accounted for 41 percent of prescriptions for the statin, according to Goldman Sachs. Generics (there are two right now) already claimed 59 percent.

Drug industry analyst Richard Evans says the real price breaks should come in the second half of 2012, when more companies start making and selling generic atorvastatin. Don’t be surprised if the generic costs as little as $4 a month during the second half of next year, he says.

Cleveland Clinic cardiologist Steven Nissen says Lipitor’s transition to generic status marks the end of an era in the pharmaceutical industry. “But a new era is beginning,” he tells Shots. “Many of the tremendous benefits [for heart health] we’ve seen can now be achieved at much lower prices.”

To learn more:

• Read the National Library of Medicine’s PubMed page on Atorvastatin(a tore’ va sta tin)

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.

In the previous five years, the 7 percent of retailers were caught selling tobacco to underage teens. This year the number caught jumped to 15 percent of the time.

Overall, there were 70 sales (from 63 establishments) to minors across Seattle over 468 retailer inspections this year, Public Health – Seattle King County officials said.

King County saw a similar jump in illegal sales to minors, from an average of six percent between 2006 and 2010 to 12 percent in 2011, officials said.

The Law

In Washington State, selling tobacco to a minor is prohibited by law and results in a fine for retailers of $100 for the first offense, the officials said. The fine for a clerk is $50.

Repeat offenders within a two year window are fined up to $1,500 and may have their license to sell tobacco products suspended.

Retailer compliance checks are conducted throughout the year by Public Health and the Washington State Liquor Control Board, as well as the U.S. Food and Drug Administration (FDA) due to new federal laws around tobacco and cigarettes.

Fast Facts About Teen Smoking:

• 90 percent of current smokers became addicted before they were 19 years old.

• About a third of all kids who become regular smokers before adulthood will eventually die from smoking.

• Tobacco use is the leading cause of death in King County, leading to 1,990 deaths per year and $343 million in medical care costs, lost productivity and other expenses.

Public health officials encourage anyone who witnesses a merchant or other adults providing tobacco to a minor is encouraged to call Public Health’s Tobacco Prevention Program at 206-296-7613 to file a confidential complaint or text the information to 206-745-2548.

To learn more:

• Visit Public Health – Seattle & King County’s web site at www.kingcounty.gov/health/tobacco