Category Archives: Rehabilitation

Opioid treatment model spawns imitators


Two white tabletsBy Christine Vestal

BALTIMORE — Dr. Kenneth Stoller held court on the sidewalk outside the Broadway Center for Addiction on a sunny afternoon last week, chatting with a troop of lingering patients.

He beamed as he patted a young man on the shoulder and said he’d see him tomorrow.

“It’s important for patients to see this as a place that’s safe and accepting,” he said. “For some, it’s the first place they’ve gotten positive reinforcement in their lives.”

Operated by Johns Hopkins Hospital and located two blocks from its main campus, the Broadway Center — or “911” as it’s called because of its address at 911 N. Broadway — has provided methadone maintenance therapy for people with opioid addiction for more than two decades.

But unlike most of the roughly 1,400 methadone clinics across the country, the Broadway Center offers not only methadone, but the two other federally approved addiction medications, buprenorphine and naltrexone, and a full complement of mandatory addiction counseling and group classes. In most other places, addiction treatment is fragmented, leaving patients to shop around for the care they need or settle for whatever is offered at their local opioid treatment clinic.

Unlike most of the roughly 1,400 methadone clinics across the country, the Broadway Center offers not only methadone, but the two other federally approved addiction medications, buprenorphine and naltrexone, and a full complement of mandatory addiction counseling and group classes.

“If you went to a doctor for any other disease, you’d expect to be offered all available treatment options,” said Dr. David Gastfriend, scientific adviser at the Philadelphia-based Treatment Research Institute, which studies substance abuse treatment. “Addiction treatment should be no different.”  Continue reading


Fall prevention essential to preserving health of older adults


Kim, Alice 09 colorBy Alice Kim, MD
Virginia Mason Issaquah Medical Center
Contributing Writer

If you are an older adult a simple thing can change your life, like tripping on uneven pavement or slipping on a slick surface. If you fall, you could break a bone, like thousands of older men and women do every year. Although a broken bone might not sound bad, it could prompt more serious health issues.

Many things can cause a fall. Your eyesight, hearing and reflexes might not be as sharp as they were when you were younger. Diabetes, heart disease or problems with your thyroid, nerves, feet or blood vessels can affect your balance. In addition, some medications can cause you to feel dizzy or sleepy and make you more likely to fall.


Virginia Mason physical therapists working with a patient on gait and stability.

However, it’s important to not allow a fear of falling keep you from being active. Doing things like gathering with friends, gardening, walking or going to the local senior center helps you stay healthy. The good news is there are simple ways to prevent most falls.

Do the right things

If you take care of your overall health, you may be able to lower your chances of falling. Most of the time, falls and accidents don’t just happen. Here are a few tips intended to help you avoid falls and broken bones:

  • Stay physically active. Plan an individualized exercise program that works for you. Regular exercise improves muscle health and makes you stronger. It also helps keep your joints, tendons and ligaments flexible. Mild weight-bearing activities – such as walking or climbing stairs – can help slow bone loss from osteoporosis.

Continue reading


Boston bombing survivors struggle with medical and emotional recovery


Map of BostonBy Martha Bebinger, WBUR

It’s just the crumb of a muffin but Martha Galvis must pick it up. Lips clenched, eyes narrowed, she goes after the morsel, pushing it back and forth, then in circles, across a slick table top.

“I struggle and struggle until,” Galvis pauses, concentrating all her attention on the thumb and middle finger of her left hand. She can’t get them to close. “I try as much as I can. And if I do it I’m so happy, so happy,” she says, giggling.

Martha Galvis has undergone 16 surgeries for her hand, which was injured in the Boston Marathon bombing. (Jesse Costa/WBUR)

Martha Galvis has undergone 16 surgeries for her hand, which was injured in the Boston Marathon bombing. (Jesse Costa/WBUR)

Galvis, 62, has just finished a session of physical therapy at Brigham and Women’s Faulkner Hospital where she goes twice a week.She’s learning to use a hand doctors are still reconstructing.

It’s been two years since she almost lost it.

On April 15th, 2013 Martha and her husband Alvaro Galvis headed for three spots from which they’d enjoy the race and boisterous crowd. Their last stop would be at or near the finish line.

Watching the marathon was a ritual that began in the mid 1970s when the Galvises, who are both from Columbia, met in Boston. Their three children grew up with the marathon as family holiday. The Galvises planned to continue the annual event after retirement.

“But not anymore,” says Martha Galvis, waving both hands in front of her face. “I don’t feel secure to do this.” Continue reading


Getting people back home after a nursing home stay


By Martha Bebinger, WBUR

Dorothy Holmes 300

Dorothy Holmes, back home, with her new dog Jack. (Photo: Martha Bebinger/WBUR).

Two years ago, Dorothy Holmes, then 75, was in the cozy pink bathroom of her mobile home getting ready to shower when she fell.

It’s the type of accident that’s pervasive among older Americans – and it’s often the very thing that triggers the end of independence.

“I got a big spot on my head, it almost conked me out,” Holmes said in her soft voice.

She heard her husband come down the hall, “and when he turned the corner all I heard was, ‘Oh God, honey, what did you do now?’ After that I don’t know anything cause I passed out,” Holmes recalled.

Holmes spent almost three months in a hospital. Her heart stopped a few times, she had breathing and memory problems, and doctors removed an ulcer as big as a grapefruit.

These days, patients are often transferred from a hospital to a nursing home to recover. But, then, some never leave.

“The only thing I worried about was not getting out,” Holmes says now. She kept asking her husband and one daughter: “‘You’re not going to keep me here are you?’ ”

Holmes worried that her children and her husband wouldn’t be able to handle her ongoing need for care at home in Belchertown, Massachusetts.

“That was before Martha [Napierski] came into it and told us all we could get for help,” Holmes said.

Napierski, a case manager at WestMass Elder Care in Holyoke, Mass., drew up a plan for Holmes’s transition.

“We made sure she had home-delivered meals, personal care, homemaking seven days a week, sheets she needed for her bed and skilled nursing,” Napierski explained. “She also had physical therapy and occupational therapy.”

Napierski says Holmes would not have gone home without this help, buoyed by money the federal government is giving states for a Medicaid program called Money Follows the Person.

The program identifies patients, old and young, who’ve been in a nursing home for at least 90 days but don’t really need to be there. Massachusetts is one of 45 states and the District of Columbia in the program, created by the Deficit Reduction Act of 2005.

The program was supposed to end in 2011, but was extended as part of the 2010 federal health law, the Affordable Care Act.

Not ‘One Size Fits All’

Holmes was a relatively easy patient to transition because she had a place to return to and family who could help with her care. In many cases, Napierski starts from scratch.

Finding housing for patients who have given up their homes is the hardest part. Then Napierski shops for appliances, some basic furniture, a few plates and cups.

“Even with that expense, it’s definitely a savings to the state and federal government, as opposed to sometimes $9,000 a month for nursing home care,” explained Priscilla Chalmers, Napierski’s boss and director of WestMass Elder Care in Holyoke. “So it is a success from a humane point of view and also from the point of view of a cost savings to the state.”

That may sound logical, but there’s no proof of savings or happier patients yet. The program is off to a slow start.

Massachusetts had hoped to have more than 1,000 men and women enrolled by now. It has 306. Community agencies are still waiting for final rules for what and how they’ll be paid — what’s covered and which patients will qualify.

The state has to establish connections in the program between housing, mental health, transportation and other departments.

“There is a fairly steep learning curve for most programs” across the country, said Carol Irvin, a senior researcher at Mathematica Policy Research, who is evaluating Money Follows the Person.

And resettling patients who are used to life in a nursing home can be hard.

“It’s a very complicated program for a variety of reasons,” said Dr. Julian Harris, the Medicaid director in Massachusetts. “It’s not a process that’s sort of a one size fits all.”

Putting together all the things a patient may need such as a guard dog, the right home care, home renovations or rides to appointments, is challenging, according to Harris.

But, he added, “this administration has really made a commitment to making home and community based services possible.”

The commitment goes back to a 1999 Supreme Court decision in Olmstead vs. L.C. It said that state Medicaid programs have to pay for home care as long as it doesn’t cost more than a nursing home or some other institution.

It will be several years before supporters of this program will be able to say if it saves Medicaid money and whether participants are better off. But Dorothy Holmes is sure – she’s really glad to be back home.

“It just means everything to me,” Holmes said as a new puppy, Jack, jumped onto her lap. “My life is back, almost the way it always was.”

Holmes is frustrated that a leg she injured in her fall is still not strong enough for walking any distance or climbing stairs. She’s fine at home, but she wants to get out more, especially to visit a new great-granddaughter – her fourth great-grandchild.

This story is part of a collaboration among NPRWBUR and Kaiser Health News.

This article was reprinted from 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.


Life and Death in Assisted Living, Part 4 — “Close the Back Door”


By A.C. THOMPSON, ProPublica and JONATHAN JONES in collaboration with 

A special to ProPublica

Joan4aInside Room 101 at Emerald Hills, a covert campaign was under way in the fall of 2008. Potentially lethal bed sores were spreading across Joan’s body, and workers were trying to improvise help.

The workers at Emerald Hills lacked both the skills and the legal authority to treat Joan. But they were nonetheless determined to try.

Jenny Hitt, a young woman with no medical training who was in charge of handing out medication in the facility, said she and her coworkers rubbed cream into Joan’s wounds, known as pressure ulcers.

“We knew we weren’t supposed to do it,” said Hitt. “We knew we weren’t licensed or medically trained to do it.”

One ulcer began eroding the skin on Joan’s right buttock.

“At first, it was just like a small, round red spot,” Hitt said. Then, she said, the skin started to deteriorate. “The area started to become like a hole.”

Peggy Stevenson, the lone nurse employed by Emerald Hills, told the workers to act secretly, according to Hitt. “She said, ‘Just don’t let anybody know,’” Hitt recalled.

And so the Boice family was kept in the dark, even her husband, Myron, who lived in another room at the facility; so, too, were the more highly trained nurses who had been sent into the facility to deal with what they had been told was a limited threat: a wound on Joan’s foot.

An ulcer formed on Joan’s right heel. Another on her left heel. The ulcer that had previously erupted on the inside of her right foot opened up again.

Susan Reuther spent a lot of time in Room 101. Her mother was Joan’s roommate.

“They told me, ‘This is the worst — we don’t know what to do,’” Reuther said of the workers. “It would take them maybe an hour, an hour and a half, just to roll her over.”

Officials with Emeritus deny that any such improper care took place. Stevenson, when asked years later about Joan’s care, said she could remember nothing about her treatment, and did not even recall who Joan was.

But records suggest Joan’s situation wasn’t unique. Under California law, seniors with serious bed sores, the kind that require sophisticated and urgent treatment, are not supposed to stay in assisted living facilities.

The reasons aren’t hard to understand: Assisted living facilities, dreamed up three decades ago as a less restrictive and institutional alternative to nursing homes, don’t have the trained personnel or resources to treat potentially life-threatening conditions.

Yet regulators have repeatedly cited Emeritus for housing residents with severe bed sores.

At a facility in Whittier, investigators discovered a person with a bacteria-ridden pressure ulcer near the base of the spine so deep it needed surgery. A wound care expert said the ulcer was teeming with “numerous” strains of bacteria, a sign the person had “probably gone a couple of months” without treatment, according to a state report.

Investigators cited a facility in San Diego for housing a resident with advanced sores on the right hip and both feet. One of the ulcers “was also gangrenous,”state records show. The person was “suffering from severe malnutrition” and was besieged by Clostridium difficile, an aggressive brand of bacteria that can be lethal.

A woman at a facility outside Sacramento was killed by an infection linked to five pressure ulcers. The state fined Emeritus, saying the woman should have been moved to a setting more appropriate to her needs.

Joan Boice, after a career teaching school, had spent the early part of her retirement volunteering with children eager to read and write. Her marriage to Myron had lasted decades, and her children had gone on to lives of accomplishment.

But Eric Boice, one of Joan’s two sons, had few illusions about his mother’s long-term future when he had helped move her into Room 101 at Emerald Hills in September 2008. Her dementia, a problem for years, had become more severe; she could not really talk; moving around was difficult.

Eric had worked for more than a decade as a police officer. He could stare at an unpleasant truth.

“We knew that my mom’s disease was progressive,” he recalled. His chief concern, then, was making sure his mom was “treated with the utmost dignity and honor and respect.”

The Boice family had paid handsomely to make sure that happened. In less than three months, the family had paid more than $12,000 to cover Joan’s room, care and meals.

“Retain the Residents as Long as You Can”

A May 2008 memo from a senior nurse at Emeritus to two other supervising nurses in California included an agenda for an upcoming strategy meeting:

  • Sales
  • Occupancy
  • Back Door

To those outside of Emeritus, a publicly traded company that has expanded dramatically in recent years, the memo’s third agenda item might have been inscrutable. But within the company, people knew what it meant. Emeritus was intensely focused both on persuading people to move into its buildings and dissuading them from moving out. They did not want paying customers to, as they put it, go out the back door.

Around the company, the subject came up regularly. And the emphasis on the policy aim could be explicit and emphatic.

“KEEP THE BACK DOOR SHUT!” shouted a 2009 email from a nurse named Nicole Jackson, who oversaw Emeritus facilities in Northern California.

Joan4bIn an internal 2010 company newsletter, Emeritus touted the success of employees in San Antonio, Texas: “These dynamos really have grown occupancy this year due to closing the back door! They’ve decreased their move outs by 4 per month!”

In an email sent the same year, Budgie Amparo, the nurse who served as head of quality control for the company, thanked Emeritus nurses around the country. “I would like to recognize our nurses for their unbelievable focus” on “the back door,” he wrote.

Emeritus employees at all levels describe a company consumed. Former nurse Doris Marshall said that “closing the back door” was one of her chief responsibilities. “It meant to retain the residents as long as you possibly can,”she said.

The company tracks move-outs closely at each of its hundreds of facilities, gauging the trends and patterns from region to region.

Its officials describe the zeal for retention as benign — nothing more than a good-faith effort to please customers and adjust services and care for residents whose needs change over time. A resident may dislike the meals or squabble with the ornery guy in the apartment down the hall. Perhaps a person can’t quite afford the monthly fees.

Emeritus wants “to ensure that the residents do not choose to move out because they are dissatisfied,” the company said in a written statement. “We do monitor move-outs so that we can identify and correct any issues and enhance resident satisfaction.”

But some people who have worked for the company, as well as some families who have endured painful episodes at Emeritus facilities, said the pressure to “close the back door” has led to dangerous lapses in judgment. In some cases, former employees said, the company failed to move out residents who should have been sent to nursing homes or other medical institutions.

ProPublica and PBS Frontline sifted through thousands of pages of regulatory records from seven states — Texas, California, Iowa, Mississippi, Georgia, Ohio and Florida. Since 2007, inspectors in each state have cited Emeritus for housing seniors who should have been moved out.

Regulators in Iowa faulted an Emeritus facility near Des Moines three times in less than two years. One case involved a 77-year-old with Alzheimer’s who repeatedly attacked other residents, groped female residents, and eventually had to be hauled out of the building by police officers.

Another case centered on a resident with severe dementia who flipped over tables in the dining room and urinated on them, according to a state report. Nearly two months before state investigators showed up, a doctor had determined the resident needed a “higher level of care” and had passed that message on to the facility.

Iowa law bars facilities from renting rooms to people who are “sexually or physically aggressive.”

Regulators in Mississippi, Georgia and Texas have repeatedly cited Emeritus for housing wheelchair-bound seniors who could barely move at all. At a facility in Smyrna, Ga., investigators concluded that 15 of 35 residents shouldn’t have been there. The state labeled the violations an “imminent and serious threat to resident health and safety.” In Clinton, Miss., the number was 10 of 81, according to the state.

Emeritus disputed some of the findings by Mississippi’s regulators.

“We have no interest in preventing people from moving out,” said Emeritus founder and chairman Daniel Baty.

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Emeritus does set precise move-out targets for all of its buildings, however. One such target was articulated by an Emeritus vice president in a 2008 memo sent to employees in California. The executive wanted fewer than 3.5 people to move out of each facility per month, apparently including those who died.

The emphasis left staffers confused and fearful, according to interviews and sworn testimony. Next to none of the workers at a place like Emerald Hills had the medical background to assess the changing conditions of the residents.

Emeritus workers said the corporate push to “close the back door” made them hesitant to transfer patients to nursing homes or hospitals. They understood their decisions were being closely watched and that there could be consequences if they missed their marks on occupancy and revenues.

“Don’t let anybody move out unless they were deceased.”
LISA PAGLIA, former regional sales manager for Emeritus, on what “keep the back door closed” meant.

Nancy Cordova ran the Emerald Hills facility while Joan Boice was there. She later testified that the “close the back door” policy left her feeling pressured into housing “high acuity” clients – those with serious health problems — and uncertain about where the line should be drawn in any given case.

A 2008 email suggests that facility directors like Cordova wound up looking to senior executives to make determinations on who was truly sick or challenging enough to open the back door for.

In the email, Cordova asks her superiors about a small roster of people considering moving out of Emerald Hills. One wanted round-the-clock care. A second was more complicated: The resident had Parkinson’s disease, a degenerative disorder of the central nervous system, and needed three or four people to help get her in and out of bed.

“Just for added fun,” Cordova wrote of the resident, “she has severe hallucinations that are disturbing to her and the staff.”

It is unclear what the supervisors told Cordova to do.

Lisa Paglia, a former regional sales manager, said, in her view, “keep the back door closed” could be translated into another, more blunt, phrase:

“Don’t let anybody move out unless they were deceased.”

“I Don’t Know How She Sat”

Joan4cAt Emerald Hills, Joan, her sores multiplying and worsening, became ever more isolated.

She sat for hours in her wheelchair. She seemed smaller. Depressed. She rarely ate or drank much. Her weight dropped. The muscles in her right arm had seized up due to inactivity, locking at the elbow.

The ulcers on Joan’s heels deepened. They began to blacken as the skin died. The sore on her buttock was chewing through her skin and into the fat beneath.


Joan groaned. She frowned. But she couldn’t speak.

Danielle Woodlee, who served as a kind of concierge at Emerald Hills, was struck by Joan’s deterioration. “It was almost like a movie,” she remembered. “I mean, the decline, it was just horrible.”

And Emerald Hills still hadn’t told the family what was going on underneath Joan’s clothing.

Joan’s physician would later say that Emerald Hills never informed her of many aspects of Joan’s deterioration – that she had fallen and been taken to the hospital, that she had become confined to her wheelchair, or that she was losing so much weight.

“It was almost like a movie. I mean, the decline, it was just horrible.”
DANIELLE WOODLEE, who worked at Emerald Hills, on Joan Boice’s health.

One Saturday morning, Eric showed up at Emerald Hills with Joan’s morphine, prescribed for the pain caused by a problem with her spine. He couldn’t find any Emeritus employees save Woodlee. He stalked through the memory care unit. He looked in the medication room, and the nurse’s office.

“I couldn’t find anybody,” he said.

After 20 or 30 minutes, Eric Boice left the drug with Woodlee, the concierge. The episode made him furious.

If he had seen Joan’s medication charts, his fury likely would have been exacerbated. The charts showed that on some days nobody gave Joan her morphine at all.

Eric began looking for the facility’s nurse and managing director every time he came to Emerald Hills. He could never find them. Woodlee later said there was a reason for it: She helped the senior officials hide out in her office when they knew a Boice family member was coming for a visit.

November became December. It was then that Emerald Hills formally notified the Boices of Joan’s true and now dire condition. Peggy Stevenson contacted Kathleen Boice, Eric’s wife. In an email, Stevenson said that because of Joan’s deteriorating health, she needed to be transferred to a nursing home.

Kathleen was stunned. “This was the very first time we had ever heard anything like that,” she said.

Three days later, Joan was admitted to a nursing home about a half-mile from Emerald Hills. Kathleen sat with her as a nurse examined her skin.

The nurse started with the first ulcer Joan had developed, on the side of her right foot. “It was an oozing, open sore,” Kathleen said. “There was another sore on that foot, back by the heel, and it was black. Then they took off her other sock.”

“There was a sore. It took up her whole heel. And it was black and oozing red. And not to be rude, but it smelled so bad. It was putrid. You could tell it was decaying.”

The nurse put Joan in a hospital gown. Kathleen saw more wounds, including a fluid-laden blister bulging on the inside of one arm. “Then they took off her diaper. And there were two spots on her right hip that were red. It looked like the skin was starting to come off. There was a similar spot on the left side,” Kathleen said.

Joan grimaced when the nurse touched her. Kathleen held her hand.

“I thought we were about done,” Kathleen said. “And they rolled her over and then we found the one that was on her sit bone.”

It was huge. And black. And oozing.

“It was more putrid than the one on her heel,” Kathleen said. “I don’t know how she sat. It was horrible.”

Kathleen phoned her husband, who had left the nursing home to drive his father back to Emerald Hills. “She scared me,” Eric Boice said of his wife. “She couldn’t talk. She was just sobbing. And I — and I didn’t know if she had been in an accident. I didn’t know what happened. She just started to say like, ‘The sores … the sores are all over her.’”

On Valentine’s Day, 2009, Joan died. Myron, her husband of some 50 years, was dead nine months later.

California regulators eventually cited Emeritus for improperly housing Joandespite her serious bed sores.

Joan’s death set off some agonizing soul-searching for her family.

Eric Boice was haunted for years. His mother visited him frequently in his dreams, he said. In those dreams, she was healthy and lucid and able to communicate. They talked. And Eric told her he was sorry “for not being the voice that she needed, for not demanding more of the people that we trusted with her care.”

Eric also heard from Emeritus.

Its collections department sent him a bill. Apparently, Eric hadn’t given the company sufficient notice when his mother went to the nursing home at the beginning of December. Emeritus wanted $14,175 to cover Joan’s rent and fees for December, January and February.

“Malice, Oppression, Fraud”

The Boice family sued Emeritus not long after Joan’s death, and in late 2012 the trial was looming. It was then, the family says, that Emeritus made an offer to settle the case: more than $3 million.

There were several standards terms in the proposed deal. According to Eric Boice, the company demanded that the family return the extraordinary array of internal records their attorney, Lesley Clement, had obtained from Emeritus: spreadsheets, memos, emails, policy directives, budgets, personnel files.

Emeritus would admit no wrongdoing under the proposed settlement. None of Joan’s relatives would ever be able to talk publicly about the case. And the transcripts of 160 hours of depositions of company officials would remain under seal forever.

Eric Boice said the family ultimately decided to reject the offer. “We would not have been able to share my mom’s story,” Eric said, adding: “That was part of the bargain for the money.”

Joan4dEmeritus declined to discuss details of any proposal but did not deny its existence.

Weeks later, the case went to trial and Joan’s story unspooled over two acrimonious months inside Courtroom 45 in downtown Sacramento. Nearly 40 witnesses took the stand. There were dozens of exhibits. The Boice family was there throughout, as were a team of Emeritus lawyers and two senior executives.

“Emeritus is not a health care provider. Emeritus is a real estate acquisition company,” Clement said in her opening statement on Jan. 7, 2013. “Emeritus should never take any elders into the buildings that it acquires because they don’t have the staff, they don’t have the training, and they don’t have the supervision to provide the care that Emeritus advertises.”

For Emeritus, the risks were not confined to the trial inside Courtroom 45. Headlines about an unfavorable jury verdict can linger on the Internet for years, scaring off would-be customers across the country. Emeritus mounted a vigorous defense.

“The diseases of aging are despicable sometimes,” Bryan Reid, the lead lawyer for Emeritus, told the jury that day in January. “There will be no dispute that what the Boice family had to go through was not pleasant.”

Joan Boice’s death, he argued, was not caused by neglect, but by the very serious illnesses she suffered from when she arrived at Emerald Hills, including dementia. If Joan had been neglected, why hadn’t her family taken action? Why hadn’t they reported any alleged neglect to the authorities? Why had they not moved her out?

“It will be clear at the end of this trial, I believe, ladies and gentlemen, that Emerald Hills fulfilled its obligations,” Reid said in his opening statement. “Its staff did what they were able to do as part of this team that was shepherding her through her journey.”

As Clement called witnesses and introduced internal company memos and emails, she hammered at what she argued were the company’s broken promises: Emeritus didn’t have the adequate staff it had advertised; that staff wasn’t properly trained, as the company had boasted; the company’s fixation was with occupancy rates, sales and containing costs, and not on care.

Dorothy Ting, who had run an Emeritus facility in Fairfield, Calif., testified that the seniors in her facility’s memory care unit ate out of metal dog bowls because the company would not spend the money on more appropriate dishes.

Nancy Cordova, who ran the Emerald Hills facility during Joan’s stay, was asked a pointed question by a member of the jury. Was it fair to say, the juror asked, that Cordova, responsible for 80 or so residents, many of them with dementia, was “in over her head”? “I think that would be fair to say,” answered Cordova.

One of the trial’s most dramatic episodes involved the testimony of Budgie Amparo, a senior Emeritus executive and the highest-ranking company official with any kind of medical background. Amparo, a registered nurse, had described himself as the person ultimately accountable for the safety and well-being of the thousands of elderly men and women living in the company’s vast portfolio of buildings.

However, Clement’s questioning of him, both before the trial and on the stand, called into question whether his career experiences in nursing were sufficient to shoulder that responsibility.

Amparo, who earlier under oath had described himself as the “pillar of quality” at Emeritus, testified that he had earned a master’s degree in nursing by takingonline classes offered by the University of Phoenix. He had done no clinical work as a part of the program. Amparo also had to admit that he had failed his board exams at least twice before finally gaining his accreditation as a registered nurse.

In Courtroom 45, Clement explored with Amparo one of the aspects of Emeritus’s operations that she regarded as particularly questionable: the requirement that nurses who worked for Emeritus were responsible not only for medical care, but for filling its buildings with new residents through sales.

“Since when were nurses supposed to be sales and marketers, sir?” Clement asked Amparo.

“They are not,” he said.

“Since when are nurses supposed to be worried about meeting financial goals of Emeritus?” Clement persisted.

“They are not supposed to,” Amparo said.

“Isn’t that what Emeritus requires, according to their job description?” Clement asked, referring to one of her exhibits.

“That’s what the document says, yes,” Amparo replied.

In the end, the two sides fought most bitterly over the question of Joan’s death — what had caused it and who was responsible.

Clement hired Dr. Kathryn Locatell, a forensic geriatrician, to provide expert testimony. Locatell pointed to Joan’s dramatic decline at Emerald Hills — in particular her dramatic weight loss and festering bed sores, which can be prevented or minimized with proper attention — as signs of neglect. Locatell testified that these factors had been critical in Joan’s demise. She estimated that Joan could have lived another three to five years if she had been properly treated at Emerald Hills.

Emeritus’s lawyers countered that the staff at Emerald Hills had worked tirelessly to tend to Joan. And they pointedly asked why, if Joan had been so neglected, no one ever made a formal complaint about it – not the Boice family, not the outside nurses who saw her, not her own doctor.

A neurologist hired by Emeritus ascribed Joan’s death to her advancing Alzheimer’s and a string of strokes. “She was having a series of small and accumulating strokes” in the left side of her brain, Dr. Richard Tindall testified, “leading to progressive weakness and inability to use her right side.” “This was one stroke on top of another, on top of another,” he added.

On the last day of February, the lawyers summed up their cases. Clement reminded jurors of the company’s slogan.

“‘Emeritus is committed to your family.’ Remember that? Remember their promise painted on the walls of their buildings, on their website?” she asked. “‘Our family’s committed to yours.’ But the evidence is, the truth is, Emeritus is committed to your family’s money. That’s what they are committed to.”

She continued, “Emeritus told Joan, ‘Trust us,’ and Emeritus told you to trust them. Trust their officers, their directors, their managing agents, and yet when they came into this courtroom they lied to you. They lied to Joan Boice. They lied to her family, and they lied to their own employees.”

Reid staunchly defended Emeritus’s ethics and its record. He said Clement had distorted facts, misrepresented the company’s policies and enlisted a bunch of disgruntled former employees to make false allegations. It amounted to a stock formula for litigating an elder abuse case, he said.

“The tragedy is the vicious allegations,” Reid said. “It’s not the care.”

“I don’t feel that with this loss Emeritus is doing anything different.”
ERIC BOICE on the outcome of his family’s case against Emeritus.

On March 1, the jury got the case, and after two days of deliberations, its members filed back into Courtroom 45. They had reached unanimous verdicts on more than a dozen questions, finding the nation’s largest assisted living company had acted with “malice, oppression and fraud” — and that its negligence had caused Joan’s death. The jury awarded the Boice family $3.875 million for pain and suffering — a figure that was automatically reduced to $250,000 under California law.

There was more work to do, however. The jury convened again to settle on a number, a dollar figure Emeritus would have to pay in punitive damages. The figure came back: $22.9 million. Two jurors had actually wanted to award more.

Emeritus promptly appealed, asking the trial judge, Judy Holzer Hersher, to reduce the punitive damages or order a new trial.

It would be three months before Judge Holzer Hersher handed down her ruling. But on June 10, she denied the company’s appeal in all respects. The award was lawful, she ruled. Clement had proved her case. And the evidence had shown that the company’s most senior officials were well aware of the troubles at their facilities, including Emerald Hills.

Eric said he is glad the family took the case to trial. He is grateful for the $23 million total jury award, but says Emeritus’s refusal to acknowledge any wrongdoing or failure or error has caused a kind of ambivalence to grow in his mind.

“Technically, yeah, we won and Emeritus lost,” Eric said. “But to me it’s bigger than that. It’s more about right and wrong. And I don’t feel that with this loss Emeritus is doing anything different. I honestly don’t think they have changed their practice, their business as usual.”

The jurors, in calculating their award, appear to have sent a message to Emeritus about its business practices. They came to the $22.9 million in punitive damages by adding together the 2011 compensation for Emeritus’s chairman and chief executive officer.

And then the jury took a step to make sure Emeritus didn’t forget Joan Boice, the Illinois farm girl who had come to California to chase a dream, and who, in an effort to hang onto her dignity near the end of her life, signed on with Emeritus Senior Living.

The jury tacked on 81 cents to the award — Joan’s age when she moved into Room 101 at Emerald Hills.

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Osteoarthritis thumbnail

Osteoarthritis – from NIH MedlinePlus magazine


From NIH MedlinePlus magazine 

What Is Osteoarthritis?

Osteoarthritis is the most common type of arthritis. People usually have joint pain and stiffness. Unlike rheumatoid arthritis, it does not affect skin tissue, the lungs, eyes, or blood vessels.

In osteoarthritis, cartilage—the hard, slippery tissue that protects the ends of bones where they meet to form a joint—wears away. The bones rub together, causing pain, swelling, and loss of motion. Over time, the joint also may lose its normal shape. Bone spurs—small deposits of bone—may grow on the edges of the joint. Also, bits of bone or cartilage can break off inside, causing more pain and damage.

Where does osteoarthritis occur?

Hands—Osteoarthritis of the hands seems to run in families. Women are more likely than men to have hand involvement. For most, it develops after menopause. Small, bony knobs may appear on the end joints (those closest to the nails) of the fingers. Fingers can become enlarged and gnarled, and may ache or be stiff and numb. The base of the thumb joint also is commonly affected.

Knees—Symptoms include stiffness, swelling, and pain. This makes it hard to walk, climb, and get in and out of chairs and bathtubs.

Hips—There is pain and stiffness of the joint itself. But sometimes pain is felt in the groin, inner thigh, buttocks, or even the knees. Osteoarthritis of the hip may limit moving and bending. This can make dressing or other daily activities a challenge.

Spine—There is stiffness and pain in the neck or lower back. In some cases, arthritis-related changes in the spine can put pressure on the nerves where they exit the spinal column. This results in weakness, tingling, or numbness of the arms and legs. In severe cases, bladder and bowel function can be affected.

Osteoarthritis Basics: The Joint and Its Parts

Joints allow movement between the bones and absorb the shock from walking or other repetitive motion. Joints are made up of:

Cartilage. A hard, slippery coating on the end of each bone.

Joint capsule. A tough membrane that encloses all the bones and other joint parts.

Synovium (sin-O-vee-um). A thin membrane inside the joint capsule that secretes synovial fluid.

Synovial fluid. A fluid that lubricates the joint and keeps the cartilage smooth and healthy.

Ligaments, tendons, and muscles. Tissues that surround the bones and joints, a llowing the joints to bend and move. Ligaments are tough, cord-like tissues that connect one bone to another. Tendons are tough fibers that connect muscles to bones. Muscles are bundles of specialized cells that, when stimulated by nerves, either relax or contract to produce movement.

A Healthy Joint

Illustration: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

Illustration: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

In a healthy joint, the ends of bones are encased in smooth cartilage. Together, they are protected by a joint capsule lined with a synovial membrane that produces synovial fluid. The capsule and fluid protect the cartilage, muscles, and connective tissues.

A  Joint With Severe Arthritis

A Joint With Severe Osteoarthritis. Illustration: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

A Joint With Severe Osteoarthritis.
Illustration: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

With osteoarthritis, the cartilage wears away. Spurs grow out from the edge of the bone, and synovial fluid increases. The joint feels stiff and sore.

Fast Facts

  • Osteoarthritis is the most common type of arthritis. More common in older people, it is sometimes called degenerative joint disease.
  • Osteoarthritis most often occurs in the hands (at the ends of the fingers and thumbs), spine (neck and lower back), knees, and hips.
  • Some 27 million Americans age 25 and older have osteoarthritis.
  • Osteoarthritis is more likely in overweight people and among those with jobs that stress particular joints.
  • Exercise is one of the best treatments for osteoarthritis.
  • Before age 45, osteoarthritis is more common in men. After 45, it is more common in women.

Warning Signs of Osteoarthritis

  • Pain and stiffness in a joint after getting out of bed or sitting for long.
  • Swelling in one or more joints, especially those at the ends of the fingers (closest to the nail), thumbs, neck, lower back, knees, and hips.
  • Crunching feeling or the sound of bone rubbing on bone
  • Osteoarthritis may progress quickly, but in most people it develops gradually. It is relatively mild and interferes little with daily life in some people. Others have significant pain and disability.
  • If you feel hot or your skin turns red, or if your joint pain is accompanied by a rash, fevers, or other symptoms, you probably do not have osteoarthritis. Check with your health provider about possible other causes, such as rheumatoid arthritis.


A combination of the following methods are used to diagnose osteoarthritis:

Clinical history—You will be asked when the condition started and how your symptoms have changed since. You will also describe any other medical problems you or your family may have, and any medications being taken. This helps your doctor make a diagnosis and understand the disease’s impact on you.

Physical examination—Your doctor checks your strength, reflexes, and general health. She or he also examines bothersome joints and observes your ability to walk, bend, and carry out daily activities, such as dressing.

X rays—X-rays will help determine the form of arthritis and how much damage there is, including cartilage loss, bone damage, and bone spurs.

Magnetic resonance imaging —Magnetic resonance imaging (MRI) provides high-resolution computerized images of internal body tissues. It is used if there is pain, X-rays don’t show much, or there is damage to other joint tissues.

Other tests—Your doctor may order blood tests to rule out other causes of symptoms. Fluid may also be drawn from the joint for microscopic examination to determine whether the pain is from a bacterial infection or uric acid crystals, indicating gout.


Doctors often combine treatments to fit a patient’s needs, lifestyle, and health. Osteoarthritis treatment has four main goals: Improve joint function, keep a healthy body weight, control pain, and achieve a healthy lifestyle. Treatment plans can involve:

Exercise—Research shows that exercise can improve mood and outlook, decrease pain, increase flexibility, strengthen the heart and improve blood flow, maintain weight, and promote general physical fitness. Your doctor and/or physical therapist can recommend the exercises best for you.

Weight control—Weight loss can reduce stress on weight-bearing joints, limit further injury, and increase mobility. A healthy diet and regular exercise help reduce weight. A dietitian can help you develop healthy eating habits.

Rest and relief from stress on joints—Learn to recognize the body’s signals, and know when to stop or slow down. Regularly scheduled rest prevents pain from overexertion. Proper sleep is important for managing arthritis pain. If you have trouble sleeping, relaxation techniques, stress reduction, and biofeedback can help.

Nondrug pain relief and alternative therapies—You may find relief from:

  • Heat or cold (or a combination of both). Heat—with warm towels, hot packs, or warm bath or shower—can increase blood flow and ease pain and stiffness. Cold packs (bags of ice or frozen vegetables wrapped in a towel) can reduce inflammation, relieving pain or soreness.
  • Massage uses light stroking and/or kneading of the muscles to increase blood flow and warm the stressed joint.
  • Complementary and alternative therapies—Some people have found relief from such therapies as acupuncture. A large study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the National Center for Complementary and Alternative Medicine (NCCAM) showed that acupuncture can relieve pain and improve function in knee osteoarthritis.
  • Nutritional supplements—such as glucosamine and chondroitin sulfate have been reported to improve osteoarthritis symptoms in some people.


When selecting medicines, your doctor will consider the intensity of pain, potential side effects of the medication, your medical history, and other medications you are taking. By working together, you and she or he can find the medication that best relieves your pain with the least risk of side effects.

The following medicines are commonly used to treat osteoarthritis:

Acetaminophen—A common over-the-counter pain reliever. It is often the first choice for osteoarthritis patients because of its safety and effectiveness compared to some other drugs.

NSAIDs (non-steroidal anti-inflammatory drugs)—A large class of medications for both pain and inflammation. It includes aspirin, ibuprofen, naproxen, and others. Some NSAIDs are available over the counter, while more than a dozen others are available only with a prescription. NSAIDs can have significant side effects. Anyone taking NSAIDs regularly should be monitored by a doctor.

Narcotic or central acting agents—Mild narcotic painkillers containing codeine or hydrocodone are often effective against osteoarthritis pain. But because of their potential for physical and psychological dependence, they are generally for short-term use.

Corticosteroids—Powerful anti-inflammatory hormones that may be injected into the affected joints for temporary relief. No more than four treatments per year are recommended.

Hyaluronic acid substitutes—These medications are injected to help lubricate and nourish joints. They are approved only for osteoarthritis of the knee.

Other medications—Doctors also may prescribe topical pain-relieving creams, rubs, and sprays, which are applied directly to the skin over painful joints. Because most medicines used to treat osteoarthritis have side effects, it is important to learn as much as possible about the medications you take, even the ones available without a prescription.


For many people, surgery helps relieve the pain and disability of osteoarthritis. You may have surgery to:

  • remove loose pieces of bone and cartilage (arthroscopy)
  • reposition bones (osteotomy)
  • resurface bones (joint resurfacing).

Surgeons also may replace affected joints with artificial ones called prostheses. These can last up to 15 years or longer. The surgeon chooses the prosthesis according to the patient’s weight, sex, age, activity level, and other medical conditions.

After surgery and rehabilitation, the patient typically feels less pain and moves more easily.

No pills, yet . . .

“There are no pills yet for osteoarthritis, but we’re working on it . . . “

“There are no pills yet for osteoarthritis, but we’re working on it,” says Linda Sandell, Ph.D., professor of Orthopaedic Surgery and of Cell Biology at the Washington University School of Medicine, in St. Louis. In osteoarthritis, the soft tissue called cartilage, which cushions the knees and other joints of the body, wears away, causing pain and loss of mobility.

“It’s a huge and growing public health issue,” says Sandell, who points out that more than 50 percent of people age 65 and over have osteoarthritis. “But it is not just a disease of old age; people get it when they’re young, too.”

Under a multi-year grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), she and her colleagues are studying stem cells in specially bred mice to determine whether there is a correlation between injury and healing.

“Every person has stem cells, and some people are better at repairing than others,” Sandell observes. “We need to find the gene, or genes, for cartilage repair and osteoarthritis in these mice, and target these genes in the development of medications that could be used in humans.

“Every person has stem cells, and some people are better at repairing than others.”

“But like heart disease or obesity, osteoarthritis is a complex disease; the research is difficult and expensive, and improvements are hard to measure. We need to change its image as an inevitable result of old age. It has a molecular start, and it takes a long time to develop. People often don’t realize that their joints are degenerating until late in the process when they begin to hurt.”

Sandell says people can’t change their age but they can reduce the risks of osteoarthritis, which, in addition to genetics, include prior joint injuries and being overweight, through exercise and a healthy diet. “First,” she urges, “no more couch potato. Check with your doctor, then start walking a couple of miles a day. Use—but don’t overuse—your joints.

“Pay attention to what your body is telling you. If your cartilage is okay but your knee is inflamed, ice it,” she advises. “Keeping fit is one of the keys to delaying arthritis.”

Ongoing research

Osteoarthritis is not simply “wear and tear” in joints as people get older.

Researchers are studying:

  • Tools to detect osteoarthritis earlier
  • Genes
  • Tissue engineering—special ways to grow cartilage to replace damaged cartilage
  • Medicines to prevent, slow, or reverse joint damage
  • Complementary and alternative therapies
  • Vitamins and other supplements
  • Education to help people better manage their osteoarthritis
  • Exercise and weight loss to improve mobility and decrease pain
  • Researchers are learning about sex differences that explain why women are more susceptible than men to anterior cruciate ligament (ACL) injuries, which can lead to osteoarthritis. These include structural differences of the knee joint and thigh muscles and differences in the ways male and female athletes move. They are also developing ways to protect young female athletes from these injuries.
  • Discovery of the various genetic mutations leading to osteoarthritis could lead to new treatments.
  • Longer-lasting materials and designs that more closely mimic natural knee movement are making total joint replacements more suitable for younger, more active osteoarthritis patients.
  • Despite the benefits, African American and Asian American patients are less likely than their white counterparts to choose total knee replacement. Also, researchers have found that race is more important than socioeconomic status in these decisions. That is an important first step toward improving access to knee surgery, and to help all patients make informed decisions about their treatment.
  • Surgical advances have made hip replacements safer for older patients. This helps older patients who have other conditions that previously would not have allowed them to have the procedure.
  • Less invasive surgical approaches and preoperative exercise programs have led to decreased hospital stays and faster recovery. If adopted nationwide, they could lead to major cost savings.

Articles in NIH MedlinePlus magazine are written by professional journalists. All scientific and medical information is reviewed for accuracy by representatives of the National Institutes of Health. However, personal decisions regarding health, finance, exercise, and other matters should be made only after consultation with the reader’s physician or professional advisor. Opinions expressed herein are not necessarily those of the National Library of Medicine. Photos and other images without credit lines are provided by NIH.


Cancer rehab begins to bridge a gap for patients



By Rachel Gotbaum

This story was produced in collaboration with NPR

It was her own experience with debilitating side effects after cancer treatment that led Dr. Julie Silver to realize there is a huge gap in care that keeps cancer patients from getting rehabilitation services.

Silver was 38 in 2003 when she was diagnosed with breast cancer. Even though she is a physician, she was shocked at the toll chemotherapy and radiation took on her body. Silver was dealing with extreme fatigue, weakness and pain.

“I was really, really sick, sicker than I ever imagined,” says Silver, who is an assistant professor at Harvard Medical School. “I did some exercise testing and I tested out as a woman in my 60s. So I had aged three decades in a matter of months through cancer treatment.”

Silver went to her oncology team for help. They told her to go home and heal. “The conversation should have been, ‘We’re going send you to cancer rehab to help you get stronger,’” she says. But that’s not what happened, and after Silver came to realize that her experience was typical, she set out to change the system for other patients.

In 2009 she started a program designed to offer cancer survivors rehabilitation therapy after treatment. It’s called STAR and is now offered in almost all 50 states. The program is growing, as is research showing that many of the quality-of-life problems cancer survivors have are physical and can be helped with rehab.

But even with the awareness of its benefits growing, there is still a disconnect for patients.

“Patients are getting stuck, and they don’t know where to go,” says Dr. Rebecca Lansky, a rehabilitation specialist at the University of Massachusetts Medical Center. She says the focus on cancer care is on treatment and that cancer patients suffering from major side effects often fall through the cracks. She recalls one patient who struggled with the side effects of tongue cancer treatment.

“He had radiation to the whole jaw and neck so he couldn’t open up his mouth for six months,” Lansky said. “He had a feeding tube, and he kept going to his oncologist saying, ‘How can I get better? What I can do? He finally got referred to me and we are now opening up his jaw six months after he has been unable to move.”

Dr. Rebecca Lansky examines a patient (Photo by Rachel Gotbaum/For KHN)

Dr. Rebecca Lansky examines a patient (Photo by Rachel Gotbaum/For KHN)

A 2008 study of breast cancer patients in the Journal of Clinical Oncology found that 90 percent of the patients needed rehab but only about one third were getting the therapy.

“I’ve seen cases where someone has had a lot of pain, and they’ve done scans and it’s not a malignancy and maybe they have done exploratory surgery to see what is happening and not really finding much except a lot of scar tissue,” says physical therapist Jennifer Goyette, a STAR trained therapist who works with cancer patients in Worcester, Massachusetts. “I am able to get them a lot of relief and a lot of times patients don’t need to have further intervention. They don’t want to be on the narcotics for the pain management. They would rather come here.”

One of Goyette’s clients is 56-year-old cancer survivor Deborah Leonard. For two years after her treatment for early stage breast cancer, Leonard had swelling, pain and a large mass in her breast –which was not cancer.

“Clearly I didn’t have that before the surgery, because the tumor was so small and this was much bigger, and it just kept getting bigger,” says Leonard. “By nighttime my breast was extremely swollen and very painful.”

At first doctors thought Leonard might have an infection and gave her antibiotics. When that didn’t work they did another surgery to remove scar tissue. But the problem returned. Her doctors were suggesting a third surgery when Leonard finally found Goyette.

After three sessions with Goyette doing what is called lymphatic drainage, Leonard felt much better. Goyette uses manual pressure to clear Leonard’s lymphatic system, allowing the build up of fluid causing Leonard’s pain and swelling to subside.

“I had a 6-inch mass that is now down to half its size,” says Leonard.

“I’m sleeping at night, I have energy again. More people need to know about this because you don’t have to be a martyr and grin and bear it. This works.”

The issues are different for every type of cancer – head and neck cancer patients may need swallowing and speech therapy; blood cancer patients may need therapy similar to cardiac rehab to rebuild their strength and stamina; and patients treated for colon cancer can get help from physical therapists with back pain and abdominal swelling.

Most insurers do cover rehab for cancer patients, but sometimes patients must battle to get more than the standard 9 to 12 sessions covered. Another barrier to care is that too few oncologists and cancer surgeons refer their patients to rehab.

The Commission on Cancer, the arm of the American College of Surgeons that accredits cancer programs in U.S. hospitals, recently announced new requirements aimed at improving care for survivors of cancer including better access to rehabilitation therapy.

This article was reprinted from 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.

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Hip replacement  - thumb

Need a price for a hip replacement? Good luck with that . . .


Hip replacement  - thumbBy Scott Hensley, NPR News
This story comes from our partner ‘s Shots blog.

Let’s say your 62-year-old granny is feeling creaky. One of her hips has been giving her trouble, and her doctor tells her it’s time to get it replaced with an implant.

There’s a catch. Grandma isn’t old enough for Medicare and she doesn’t have health insurance. She does, however, have a stack of cash in the bank and is willing to pay for surgery right away.

So how much will it cost her?

Who knows. Seriously.

Researchers from Iowa called 20 top-rated orthopedic hospitals across the country using a script based on Grandma’s predicament. They asked for the lowest price (everything included) for a total hip replacement.

The researchers also asked two other hospitals in each state and Washington, D.C., for good measure.

Getting an answer wasn’t easy.

Of the top 20 hospitals, only 9, or 45 percent, provided a bundled price that included fees for both the doctors and the facilities.

But that response looks terrific compared with how the other hospitals did.

The researchers were able to get a bundled price estimate from only 10, or about 10 percent, of the other 102 hospitals they queried.

The researchers were able to piece together prices in quite a few instances by contacting doctor groups when hospitals provided only their fees.

Even after incorporating those figures, however, total pricing information was available for only 60 percent of the top hospitals and 63 percent of the others.

The prices obtained varied widely: from a low of $11,100 to more than $125,000.

The findings were just published online by JAMA Internal Medicine.

Why couldn’t more hospitals comply? Some said a doctor would need to see a patient before an estimate could be given. Others said they didn’t give out prices over the phone. Some just said there was no way they could do it.

“Our calls to hospitals were often greeted by uncertainty and confusion by the hospital representatives about how to assist us,” the researchers wrote. “It is sobering to compare our experience with the best practices we have come to expect from other service industries.”

Buying a car used to be like this, an accompanying editorial points out: “A 2013 hip replacement looks a lot like a 1954 Buick.” But a 1958 federal law that required dealers to post sticker prices on vehicles began a long road to fuller disclosure about prices and specifications that have changed the marketplace for automobiles.

Now it’s time for hospitals and doctors to do a better job, the authors of the editorial write. “There is no justification for the inability to report a fee estimate, or a 12-fold price variation for a common elective procedure,” they declare.

As a matter of fact, they argue, the health care business is even worse off than the car business was. Many doctors and hospitals don’t know the price of their products, unlike car dealers.

Still, there’s hope, the editorialists say.

“The history of the automobile industry shows that information asymmetry is treatable,” they write. “Health care will need to travel down a similar path. It is time we stop forcing people to buy health care services blindfolded — and then blame them for not seeing.”

This article was reprinted from 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 ‘Matrix’ meets medicine: surveillance swoops into health care


By Michael L. Millenson

Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age.


In an inconspicuous control room at the Sioux Falls, S.D., headquarters of the Evangelical Lutheran Good Samaritan Society, nurses keep round-the-clock watch on motion and humidity sensors in the living rooms, bedrooms and bathrooms of elderly men and women in five states.

The seniors — a handful in their own homes and the rest in assisted living facilities owned by Good Samaritan — are part of one of the most comprehensive remote health monitoring efforts anywhere.

Using sophisticated sensors, computerized pattern recognition and human responders, Good Samaritan hopes to show it can detect and head off health threats to the elderly and thereby accomplish two important goals.

Whether this costly technology will ultimately prove clinically or economically effective remains uncertain.

The first is saving money on medical costs.

The second is helping seniors feel secure enough to “age in place” at home or avoid moving from assisted living to a skilled nursing facility.

Whether this costly technology will ultimately prove clinically or economically effective remains uncertain. So, too, is whether a benign health care purpose can help overcome the unsettling “Big Brother” overtones for some potential users.

What is clear, however, is that health care is joining a national trend toward greater surveillance of everyday life.

For example, more than 70 U.S. cities now use ShotSpotter sensors to pick up the sound of gunfire and alert authorities even before 9-1-1 is dialed. Auto insurers are hooking up sensors to a car’s computer system to monitor driving habits and, with the driver’s permission, calculate premiums accordingly.

Even some farmers are equipping cow collars with monitors allowing automated milking systems to track the cow’s milk production, amount of feed eaten and even how long it chews its cud. If the system detects a problem, it can call the farmer on his phone.

What benefits bovines might also help humans, albeit with appropriate modifications. Good Samaritan is the nation’s largest nonprofit provider of senior services, operating more than 240 facilities in 24 states.

Working with the University of Minnesota, the system recruited 1,600 seniors in North Dakota, South Dakota, Minnesota, Nebraska and Iowa to test the impact on cost, quality of care and senior independence of a comprehensive set of monitoring tools.

With an $8.1 million grant from the Leona M. and Harry B. Helmsley Charitable Trust, the LivingWell@Home study began collecting data at 40 of its assisted living facilities in January 2011, and will stop at the end of June 2013.

LivingWell@Home comprises three technologies. First, sensors from WellAware Systems are distributed throughout the living space. (The company stresses that no cameras or microphones are involved.)

“Unless you gather, integrate and interpret that data in a meaningful way to the client and to their formal and informal caregivers, a sensor hanging on a wall isn’t going to help anyone.”

When a senior is sleeping a motion sensor records how often he or she moves in bed. Showering, toileting and other activities of daily living are also analyzed by WellAware algorithms and scrutinized by nurses for changes that might signal health problems.

The second piece is a medical alert button from Philips Lifeline that includes an auto-alert function designed to detect a fall and call for help even if the user is incapacitated.

Lastly, remote monitoring is provided by the telehealth unit of Honeywell through a clock radio-sized console in each apartment. It turns on each morning and prompts seniors to strap on a special blood pressure cuff, step on a special scale and transmit that and other information back to the monitors in Sioux Falls.

Jacci Nickell, who is Good Samaritan’s vice president of development and operation delivery systems, emphasizes that the technology is just a tool.

“Unless you gather, integrate and interpret that data in a meaningful way to the client and to their formal and informal caregivers, a sensor hanging on a wall isn’t going to help anyone,” she says. “It’s what you do with that data, and how you optimize wellbeing.”

Good Samaritan isn’t waiting for the study results to be finalized to roll out the LivingWell@Home service, in which the system has a financial stake, as an option in all its assisted living facilities. It’s also putting parts of the technology into some skilled nursing facilities and even into seniors’ own homes.

The organization’s website tells the story of an elderly woman who agreed to have the sensors installed in the South Dakota farmhouse where she lived alone.

Not long afterwards, the sensors detected a change in her toileting that prompted a call from a nurse. In response, the woman sought out her doctor, who discovered a bladder infection.

“Maybe it was God talking to me,” says 83-year-old Carol Tipton in a website video, seemingly near tears.

“We think the use of the technology can reduce the need for physical visits and will save expense and time,” Nickell says. Still, the high-tech security blanket doesn’t come cheap.

The technology costs $500 to $750 per month per person at home and about $175 a month for residents in Good Samaritan assisted living facilities that already have a personal emergency response button service.

By comparison, notes Mary Cain, managing director of consulting firm HC3, conventional disease management costs well under $100 per month per patient.

“It’s a very small percent of the population that’s going to benefit from [the Good Samaritan] level of monitoring,” Cain says. “How many will you monitor, and who is paying?”

A similar cautionary note comes from a spokeswoman for United Healthcare, the nation’s largest health plan. United already covers devices such as those used to detect abnormal heart rhythms or measure blood sugar.

But “health insurers typically rely on guidance from the clinical community in making coverage decisions,” says the spokeswoman, and with sensors and similar technology “it’s too early to do so at this time.”

Privacy also remains a concern. Some critics may detect overtones of a 1983 song by The Police that warns, “Every breath you take, every move you make, we’ll be watching you.”

As Christine Sublett, a health privacy and security consultant, put it: “Individuals should have the right to know exactly what information is being transmitted and that appropriate controls are in place.” Good Samaritan says it takes appropriate precautions, but the research study may not provide a rigorous test of protection against hackers.

Nor has Good Samaritan or its vendors yet encountered patients demanding their own data feed, as has happened to makers of defibrillator monitors and similar technologies.


BodyMedia monitor

Still, other companies are jumping into this market. For instance, StealthHealth offers a radar beam to provide in-home monitoring of vital signs, activities of daily living and falls. The company suggests its equipment be placed inconspicuously behind a picture frame.

And GrandCare Systems offers to collect data from motion, temperature, door, chair and bed sensors, in addition to pill box sensors for monitoring medication use and caller ID information to keep an eye out for telephone scams.

Choices are also proliferating for consumers willing to pay out of pocket for detailed quantification of their diet, exercise and sleep patterns. In just one example, BodyMedia sells wearable sensors said to gather 5,000 data points a minute on skin temperature, heat flux and galvanic skin response. The company says its aim is to provide users with a personalized assessment of health issues such as stress, fatigue and depression.

This article was reprinted from 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.


Ten things you didn’t know were in the Affordable Care Act


By David Schultz and Christian Torres

So you think the Supreme Court upheld a law that requires most people to buy health insurance?

That’s only part of it.

The measure’s hundreds of pages touch on a variety of issues and initiatives that have, for the most part, remained under the public’s radar.

Here’s a sampling:

Postpartum Depression (Sec. 2952)

Urges the National Institute of Mental Health to conduct a multi-year study into the causes and effects of postpartum depression. It authorized $3 million in 2010 and such sums as necessary in 2011 and 2012 to provide services to women at risk of postpartum depression.

Abstinence Education (Sec. 2954)

Reauthorizes funding through 2014 for states to provide abstinence-only sex education programs that teach students abstinence is “the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems.” Federal funding for these programs expired in 2003.

Power-Driven Wheelchairs (Sec. 3136)

Revises Medicare payment levels for power-driven wheelchairs and makes it so that only “complex” and “rehabilitative” wheelchairs can be purchased; all others must be rented.

Oral Health Care (Sec. 4102)

Instructs the Centers for Disease Control and Prevention to embark on a five-year national public education campaign to promote oral health care measures such as “community water fluoridation and dental sealants.”

Privacy Breaks for Nursing Mothers (Sec. 4207)

Requires employers with 50 or more employees to provide a private location at their worksites where nursing mothers “can express breast milk.” Employers must also provide employees with “a reasonable break time” to do this, though employers are not required to pay their employees during these nursing breaks.

Transparency on Drug Samples (Sec. 6004)

Requires pharmaceutical manufacturers that provide doctors or hospitals with samples of their drugs to submit to the Department of Health and Human Services the names and addresses of the providers that requested the samples, as well as the amount of drugs they received.

Face-to-Face Encounters (Sec. 6407)

Changes eligibility for home health services and durable medical equipment, requiring Medicare beneficiaries to have a “face-to-face” encounter with their physician or a similarly qualified individual within six months of when the health professional writes the order for such services or equipment.

Diabetes & Death Certificates (Sec. 10407)

Directs the CDC and the HHS Secretary to encourage states to adopt new standards for issuing death certificates that include information about whether the deceased had diabetes.

Breast Cancer Awareness (Sec. 10413)

Instructs the CDC to conduct an education campaign to raise young women’s awareness regarding “the occurrence of breast cancer and the general and specific risk factors in women who may be at high risk for breast cancer based on familial, racial, ethnic, and cultural backgrounds such as Ashkenazi Jewish populations.”

Assisted Suicide (Sec. 1553)

Forbids the federal government or anyone receiving federal health funds from discriminating against any health care entity that won’t provide an “item or service furnished for the purpose of causing … the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.”

This article was reprinted from 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.


How to find the right drug treatment program


The National Institutes of Health has issued an 8-page guide to help you pick the right drug abuse treatment program.

The booklet, Seeking Drug Abuse Treatment: Know What to Ask, says there are five key questions you should ask about a program:

Five Key Questions:

  • Does the program use treatments backed by scientific evidence?
  • Does the program tailor treatment to the needs of each patient?
  • Does the program adapt treatment as the patient’s needs change
  • Is the duration of treatment sufficient?
  • How do 12-step or similar recovery programs fit into drug addiction treatment?

To learn more:

Additional Resources:


Online Video: Breakthroughs in Spine Surgery


UWTV is offering the Ninth Annual Harborview Spine Symposium: Breakthroughs in Spine Surgery.

Learn about care and recovery from complicated spinal cord injuries, with case studies and in-depth research. From vertebroplasty to disc replacement, this series delivers the most recent developments in spine treatment from national experts as well as doctors at with UW Medicine.

To view:

Three red and white capsules

When pain doesn’t end


By Maia Szalavitz, Contributing Writer
Health Behavior News Service 

Living Beyond Pain

For people with severe chronic pain like Kelly Young and Teresa Shaffer–both of whom have become patient advocates–coping with agony is a fact of life. Young suffers from rheumatoid arthritis while Shaffer’s pain is linked primarily to another degenerative bone disease.

Chronic pain is one of the most difficult-and common-medical conditions. Estimated to affect 76 million Americans–more than diabetes, cancer and heart disease combined–it accompanies illnesses and injuries ranging from cancer to various forms of arthritis, multiple sclerosis and physical trauma.

Acute pain or chronic pain?

Acute pain is pain from an injury or illness, typically lasting only hours or days-and definitely not continuing once the original cause has cleared up. By contrast, chronic pain lasts months or years and continues even when the initial problem has been resolved.

Chronic pain is itself considered a disease because it reflects pathology in the brain and nervous system — which transmits pain — that persists and affects all aspects of life functioning.

Pain is defined as chronic when it persists after an injury or illness has otherwise healed, or when it lasts three months or longer. The experience of pain can vary dramatically, depending in part on whether it is affecting bones, muscles, nerves, joints or skin.

Untreated pain can itself become a disease when the brain wrongly signals agony when there is no new injury or discernable other cause.

Fibromyalgia–a disease in which pain in joints, muscles and other soft tissues is the primary symptom–is believed to be linked to incorrect signaling in the brain’s pain regions.

Finding a Doctor

The first step to deal with chronic pain is to find a physician or medical team who can accurately diagnose your condition and work with you to lessen pain.

“It’s not easy,” says Shaffer. “You have to find someone [with whom you can] build a relationship of trust and open communication.”

Dr. Russell Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center, agrees. “You need to identify someone with a high level of knowledge and competence, good communication skills and a network of professionals with whom they work, someone who has compassion,” he says.

Dr. Paul Christo, director of the multidisciplinary pain fellowship program at Johns Hopkins School of Medicine, also suggests looking for someone who has completed at least a year-long certification in pain management. This information can usually be obtained on the doctor’s website or by asking about his or her qualifications.

Comprehensive Treatment

Experts agree that comprehensive care–which can involve medications, exercise, psychological therapy, massage, physical therapy, injections and complementary treatments, depending on the patient and condition-is essential.

“The reason we now call chronic pain an illness is that we recognize that it is more than just a sensation in the body,” Portenoy says. “It affects your ability to function as a human being, your relationships, your ability to be productive, to think straight.”

Unfortunately, because they have so often been dismissed as having a problem that’s “all in your head,” many people with chronic pain resist considering talk therapy as a part of treatment.

“A lot of people have the misconception that what I’m telling them [when recommending therapy] is that their pain is a figment of their imagination,” Christo says. “That’s not what we mean. Pain has such an emotional component and psychotherapy is extremely useful in terms of helping patients reorganize and rethink how they interpret it and how it affects their lives.”

Says Shaffer, “Pain encompasses the entire person. It’s not just in your leg or back. It encompasses the entire being of who you are and what you can do and don’t do. So physically, mentally psychologically: you have to take care of all of those things.”

The Opioid Question

Although drugs like aspirin, ibuprofen and even some antidepressants can help relieve pain, the most effective medications for most severe pain remain the opioids, like Oxycontin and morphine. Both doctors and patients tend to fear these drugs because of concerns about addiction and overdose.

However, of patients without a prior history of addiction, less than 3 percent of patients who take opioids regularly for pain will become addicted to the drugs, according to a Cochrane review of studies. Opioids are currently under a cloud because of a sharp rise in overdose death and addiction, mostly resulting from misuse by people who aren’t pain patients. The majority of overdoses occur in people who abuse the drugs along with alcohol and depressants like benzodiazepines (for example, Xanax).

Virtually everyone who takes opioids on a daily basis will become physically dependent, however: They will suffer withdrawal if the drugs are not slowly tapered. But that is not the same as addiction, which is defined by craving, negative consequences, reduced ability to function and compulsive drug-related behavior.

Kelly Young avoided opioids for years, relying on high doses of ibuprofen (Advil) and similar drugs. But when the pain became excruciating, her doctor suggested she try an opioid. “I was afraid of side effects,” she says. “One night it was really bad so I took it.” At first, she felt severe dizziness. “But in 30 minutes, the pain started going away and I thought, ‘This is amazing, this is the first time in 4-5 years that I’ve been without pain,'” she says.

To reduce the dizziness, she cut the dose, starting with a liquid usually given to children so that she could find a level that allowed her to be most comfortable. Neither Young nor Shaffer, who also manages her pain with opioids, has ever developed addiction.

Two-Way Trust

Because doctors can lose their licenses or go to prison if they don’t detect addicts who fake pain, patients find themselves in a difficult position when they want to discuss opioid medications. Asking for a drug by name, for example, which might be fine with other conditions, is seen as a “red flag.”

“When you initially go to an appointment, you don’t want to go in there saying I need medication; that’s the worst thing you can do,” Shaffer says. “You want to ask for relief. Explain to the health care provider, ‘This is my life. I can’t get out of bed. I can’t do laundry. I can’t pick up my child. I need quality of life, that’s why I’m here.'”

Shaffer adds, “You have to be upfront and honest and build that relationship of trust with your doctor.”

Shaffer also notes that it is the patients’ responsibility to store opioids in a locked box safely: Many people who abuse and overdose on these medications get them from friends and relatives who do not secure them.

Acceptance and Hope

Shaffer and Young both recommend a mix of realism, mutual support and fighting spirit when it comes to facing pain. Young runs her Rheumatoid Arthritis Warrior website and Shaffer moderates online discussion groups for people in pain at the American Pain Foundation site Experts agree that support from family, friends and people facing similar problems-so long as there’s some type of social support-is essential.

“You have to accept what your life is going to be, but you don’t have to give up,” says Shaffer, “OK, yes I have pain but that pain doesn’t own me or define who I am today.”

 Pain Management Resources

American Pain Society is a “multidisciplinary community that brings together a diverse group of scientists, clinicians and other professionals to increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering,” their website says.

American Academy of Pain Medicine This is a directory of physicians whose practice is primarily devoted to pain and offers its membercontinuing medical education in pain. The site’s Patient’s Center page provides general information and helps patients locate pain specialists in their area.


Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.


Rep. Giffords could receive brain injury treatment thousands of troops do not


As Congresswoman Gabrielle Giffords begins rehabilitative therapy in Houston after being shot in the head in Tucson earlier this month, she was transferred today to TIRR Memorial Hermann, a premier rehabilitation hospital renowned for its treatment of traumatic brain injuries.

On its website, the hospital calls itself “one of very few hospitals in the country designated as a model system for traumatic brain injury.” Among the techniques it relies on is cognitive rehabilitation therapy, a tailored type of medical treatment designed to retrain the brain to do basic tasks.

It’s a treatment that Rep. Giffords will likely end up receiving, if doctors’ general descriptions of her care plan are any indication. Dr. John Holcomb, a retired Army colonel and trauma surgeon at Memorial Hermann, has described Giffords’ treatment as a “tailored and comprehensive

rehab plan” that includes “speech, cognitive, physical rehabilitation.”

If Giffords does end up receiving it, she’ll be getting a treatment that many troops don’t. As we’ve reported, the Pentagon’s health program, Tricare, has refused to cover cognitive rehabilitation therapy for the tens of thousands of service members who have suffered brain injuries in the line of duty. Tricare, which provides insurance-style coverage to troops and many veterans, does cover speech and occupational therapy, which are often part of cognitive rehabilitation.

We’ve called the hospital to get further details about Giffords’ treatment plan but have not yet received that information. News reports have described her treatment as using “high-tech tools to push the brain to rewire itself,” with a focus on her physical abilities, speech, vision, cognitive skills and behavior.

Traumatic brain injuries have different types and levels of severity, according to the Office of the Surgeon General. They can include penetrating injuries—like Giffords’—or mild brain trauma like the kind often sustained by troops in an explosion.

The latter, as we’ve reported, has been called one of the signature wounds of the Iraq and Afghanistan wars, and tens of thousands of cases have been left undiagnosed by the military’s medical system.

Though top brain specialists have endorsed cognitive rehabilitation as an effective treatment for brain injury, Tricare officials have said that scientific evidence does not justify providing it comprehensively to troops.

To support that position, officials cite a 2009 Tricare-funded assessment of cognitive rehabilitation therapy—an assessment that internal and external reviewers have called “deeply flawed,” “unacceptable” and “dismaying,” as we reported last month with our partners at NPR.

Last week, Sen. Claire McCaskill, chairman of the subcommittee on contracting oversight, cited our findings while announcing an investigation into the Pentagon’s decision to deny treatment of traumatic brain injuries to troops. In 2008, McCaskill was one of 10 senators—including then-Senator Barack Obama—who signed a letter to Defense Secretary Robert Gates urging the military to provide Tricare coverage of cognitive rehabilitation “so that all returning service personnel can benefit from the best brain injury care this country has to offer.”

Inform our investigations: Do you have information or expertise relevant to this story? Help us and journalists around the country by sharing your stories and experiences.

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Business gears up to battle new Obama workplace safety rule


by Joaquin Sapien, ProPublica

This story was co-published with Politico.

As the U.S. Chamber of Commerce and the White House are trying to minimize their differences, a brewing battle at OSHA over a workplace injury reporting rule illustrates how tough that could become given the administration’s pro-labor leanings.

While bureaucratic clashes over subtle rule changes like this one are usually waged outside the public’s view, they can have big ramifications for business and workers.

At issue is a regulation that would force employers to identify when a workplace-related injury or illness is considered a musculoskeletal disorder (MSD), a term broadly used to describe ailments caused by repetitive stress, like carpal tunnel syndrome or strains from frequent heavy lifting.

Figures gathered by the Bureau of Labor Statistics show that MSD-related problems accounted for nearly a third of the 1.1 million workplace injuries and illnesses in the private sector that led to days off work in 2008.

The Occupational Safety and Health Administration wants to include an additional column on the federal surveys employers are required to fill out, to identify when a worker’s injury is musculoskeletal in nature.

Currently, these injuries are recorded in the same category as problems like hearing loss, making it difficult for OSHA to collect accurate data. Union representatives and OSHA officials say the data could help the agency find opportunities to reduce injuries.

But business representatives, including the U.S. Chamber of Commerce, say the move is the Obama administration’s first step toward developing sweeping regulation of ergonomic safety, which could cost employers millions.

The spat harks back to the final days of former President Bill Clinton’s administration, when, on Nov. 13, 2000, OSHA released more than 1,600 pages of ergonomic rules that took three years to draft.

The rules covered everything from the amount of time a construction worker could spend using a jackhammer to requiring breaks for people using a computer mouse.

The Chamber and other representatives of large employers persuaded Republicans in Congress to pass riders on appropriations bills that would delay the rule’s release.

When the rules were finally issued a week before Clinton left office, employer trade groups responded by persuading the Republican-controlled Congress to shoot them down with the never-before-used Congressional Review Act. ProPublica included this anecdote in its “midnight regulations” coverage.

Now the same groups are worried that with Democratic majorities in both houses of Congress, Obama might try to introduce similar rules.

“Attempts to put this recordkeeping requirement in place represent the first efforts to return to the ergonomics question,” said Marc Freedman, the Chamber’s director of labor law policy. “We will be very involved in this rulemaking as it goes forward. We have a history with this issue.”

The Chamber held a closed-door meeting on Jan. 25 to discuss how to approach the new proposal. Freedman wouldn’t reveal who attended the meeting or discuss the Chamber’s plans. He said the only reason people outside the Chamber’s membership even knew about the meeting is because he accidentally e-mailed an invitation to someone who shouldn’t have been on the list.

The change proposed by the Obama administration is far narrower than the rules Clinton proposed at the end of his term. This one would merely provide OSHA, the public, and employers with a more accurate count of how many MSD injuries are actually occurring, OSHA officials say.

“The industry is just looking for a fight,” argued Peg Seminario, director of safety and health for the AFL-CIO. “As soon as Obama was elected, it was clear that immediately there would be a war on ergonomics. This gives you a sense of how rabid they are that they don’t even want these injuries identified.”

Freedman countered that the Chamber is concerned about how musculoskeletal disorders will be defined and how OSHA will determine whether these injuries actually occurred inside the workplace.

“In the previous regulation, the definition of musculoskeletal was very broad,” Freedman said. “That’s definitely one of the reasons why the regulation was considered so offensive.”

Jordan Barab, OSHA’s deputy assistant secretary of labor, told ProPublica that OSHA will use a definition similar to one the Bureau of Labor Statistics has used for years to record these injuries. But the proposed OSHA definition will also include three problems that aren’t on the Bureau of Labor Statistics’ list — Raynaud’s phenomenon, tarsal tunnel syndrome and herniated spinal discs that aren’t caused by slips, trips and falls.

The Chamber doesn’t have an alternative definition in mind. Freedman said that’s not the Chamber’s job.

OSHA has consistently stated that workplace injuries and death are steadily declining. But in 2008, ProPublica reported that the decline is not so dramatic if incidents involving violent crime or transportation, which are actually overseen by other agencies, are removed.

Write to Joaquin Sapien at

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