Susan Johnson DHHS Region X Director

Health law repeal will fail, administration official tells Seattle conference

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Susan Johnson DHHS Region X DirectorRepeal of the health-care reform law would strip patients of consumer protections already in force, drive up Medicare beneficiaries’ drug costs, and add $1 trillion to the U.S. federal deficit, a senior administration official told attendees at a health-care policy conference in Seattle this week.

The official, Susan Johnson, director of the U.S. Department of Health and Human Services (DHHS) region X, made her comments in a speech to 2011 State of Reform Washington Health Policy Conference held in Seattle last Wednesday.

Johnson’s office oversees DHHS operations in Washington, Oregon, Idaho and Alaska. Before becoming regional DHHS director, Johnson had been director of the King County Health Action Plan for the Public Health Department in Seattle and King County and on Washington State Health Care Policy Board.

Congressional Republicans have vowed to repeal the 2009 Patient Protection and Affordable Care Act and, failing that, to block its implementation by defunding related programs and enforcement.

A vote on repeal of the Act is scheduled in the U.S. House of Representatives this coming week. The bill is expected to pass the Republican-controlled House but fail to pass in the Democratically controlled Senate.

In addition, should repeal pass both chambers of congress, President Barack Obama has vowed to veto the legislation.

“This administration will fight hard for all the people in America who are benefiting now from its implementaion and will benefit in the future,” Johnson told the Seattle audience.

Should repeal succeed, Johnson warned, it would allow insurance companies to again place lifetime limits of key benefits and to deny coverage to people with pre-existing conditions, end help with drug payments that more than 45,000 Washington state seniors now receive through Medicare, and halt programs that will help employers provide health coverage to employees who retire early before their eligible for Medicare.

More than 300 attendees from government, business and consumer organizations participated in the conference, which focused on implementation of the new law, including the state’s efforts to create insurance exchanges, the act’s likely impact on Medicare and Medicaid, and how the law will change the practice of medicine.

Johnson likened the U.S. health system before reform to a cruel board game in which the rules were constantly changing. You would think you had coverage, she said, but then learn you had hit a benefit cap you did not know about; you’d fall ill and then learn your insurance company has dropped you, citing an error in your original application, a common industry practice called rescission.

“The rules would change, and you wouldn’t know why,” Johnson said. It became a “nasty” game that was “unfair and unjust,” Johnson said.

In addition to providing consumer protections, the law will significantly improve healthcare delivery to promote prevention and ensure that consumers will get the “right care, at the right time, in the right place,” Johnson argued.

These and other provisions of the law “make sense to me,” Johnson concluded, and will create “a better board game for all of us to play on.”

Click for Washington State Health Reform Info

Click for Washington State Health Reform Information

To learn more:

  • Visit the State of Reform website: www.stateofreform.com.
  • Visit HealthReform.gov, the government’s website detailing the new laws benefits.
  • Visit the Washington State Office of the Insurance Commissioner’s Health Reform page, which has information about implementation of the new law in Washington State.
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EKG tracing

Talking about medical tests with your health care team

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Becky Ham, HBNS Science Writer

Whether you’re healthy or ill, there are a variety of medical tests your health care team might recommend for you. A yearly checkup often includes routine tests such as blood sugar and cholesterol levels, vision and hearing assessments, tests for heart functioning and others used to monitor a chronic condition—such as a lung function test for those with asthma. You may also be tested to diagnosis or confirm the presence of a disease, or to see how well a particular treatment or medication is working.

But if the wrong test is given, or you fail to receive or understand your results, tests can work against your health. In a 2008 study of testing errors, researchers found that nearly three out of four patients involved in a testing error had their treatment delayed, or suffered additional pain, or had a worse health outcome as a result of the error.

Every time your team orders a test for you, the results become part of your medical history and a potential guide or reference for your future care. But many patients walk away from their doctor’s office with important, unanswered questions:

  • What tests will I take?
  • Why have these tests have been ordered?
  • What will the tests show?
  • What should I do after the test results are in?

Deborah Lewis’s benign spine tumors were mistakenly labeled as cancer after her pain doctor and a technician misinterpreted her MRI scan. After that, Lewis and her husband Troy “learned to question all test results,” said the 46-year-old jewelry designer.

Every time your health care team orders a test, you should ask what the test will show, why the test has been ordered, and when you should expect to see the results. And if you don’t understand the answers, don’t be afraid to ask again, says Dennis Novak, M.D., a general internist and associate dean of medical education at Drexel University College of Medicine.

Will This Be on the Test?

You’ve had the conversation with your health care team, but you’re curious to learn more about the tests that they have ordered. These Web sites can be your “answer key” to learn more about what the tests will tell, and what to expect when you have them.

“It’s always OK to ask about stuff you didn’t understand,” Novak said. If you get tests and walk out without getting your questions answered, that’s a problem.”

In the exam room, you often get a lot of information that might be hard to remember later.  You can request that your doctor take a minute to write down details like: ‘the name of that test for me, please’ or ‘Exactly what condition(s) is this test trying to uncover?’ It is also fine to ask about recommended resources to help you: ‘Do you have any written materials that describe how I can prepare or what I should expect during this test?’ or ‘Can you recommend a Web site, or someone to call for more information?’

Doctor inspects mammogram. Photo by Bill Branson/NCI

“I do my best to let my patients know when tests are routine versus more in-depth,” says Peter Osterbauer, M.D., an Alaska neurologist. “For people with a potentially serious or life-threatening diagnosis, I strongly recommend that a dedicated appointment is made with their physician to discuss which tests are recommended, the potential risks and benefits of these tests and how the test results will affect further treatment decisions.”

Haralee Weintraub, a women’s clothing entrepreneur who was diagnosed with breast cancer eight years ago, used information on how her test results compared to others to decide on a medication after chemotherapy and radiation.

Although the recommended drug “statistically would increase my lifespan [by] about 7 percent, I had horrible bone aches…and thought it was not worth it to me to be miserable,” she recalls. “The doctor explained the risks and the tests, and at the end, it was my choice.”

There is one issue doctors rarely if ever discuss: How much does the test cost? Before you agree to a test, increasingly you must put on a “health consumer” hat. Does your insurance cover the test, and even if so, what are your out-of-pocket costs? In an emerging trend, some employers now expect workers to spend more of their own money on medical services that they consider overused or less than valuable.

Once you’ve taken the test, follow-up is essential. And it’s one place where mistakes happen often, according to researchers. For instance, in a 2007 study of California primary care doctors, about 20 percent of patients didn’t get timely or appropriate notification of their abnormal test results.

The lesson? Never accept that “no news is good news,” says Davis Liu, M.D., a family physician in Sacramento, Calif. “Always request that you see your test results, good or bad.” You should also be sure that you know how you will be notified about the results, how long you should wait for the results and who you should call to follow up after receiving the results.

Be aware, Osterbauer says, that some kind of tests can take longer than others. “Accuracy can be affected if the processing or interpretation of test results is hurried,” he says. “For example, a pathologist could quickly glance at a tissue sample under a microscope and miss important findings.”

Your health care office may ask how you would like to receive your test results, since some offices now deliver routine test results through an automated phone or e-mail system. If you’re offered a choice of how to receive the results, the test is routine and the result is normal, this style of delivery might work for you. But if your tests are for a special condition, or if the results are unclear or not labeled “normal,” you should insist that your health care team discuss the results with you in person.

What’s Next?

You have your test results in hand—so what’s next?

“Tests results in and of themselves don’t describe what’s happening to a patient,” warns Lawrence Gordon, M.D., a New York ear, nose and throat doctor. “The result itself isn’t as significant as what it means to the patient, and what it means to his or her doctor.”

After the results come in, it’s time to talk about what the tests show and what they might mean for your ongoing care. Even if it’s a routine test like a cholesterol check, your health care team should go over the results with you and discuss what further measures—from medication to watchful waiting to another test—might be necessary.

One way to start the conversation, suggests cancer survivor Haralee Weintraub, is to ask what the “normal” test results would be, and ask your doctor to talk about where your results fall in comparison. After you understand how you compare, it can be easier to talk with your doctor about what steps you might take next.

If you’re someone who sees multiple physicians, including specialists, you should have these discussions with the health care worker who ordered the test, according to Dr. Gordon. “Most tests try to answer a particular question, and the doctor ordering it is in the best position to initially interpret the results,” he notes. But if you’ve had a test ordered by a specialist, he adds, you should still share those results with your primary care team.

Another critical task that often falls on patients these days: getting their test results to all the doctors who need to see them. Arranging this takes time and commitment, but it’s often the only way to make sure your results don’t fall through the cracks.

Take Charge of Your Tests

You can’t order your own tests, and you may not be able to interpret them without the help of your health care team. But your test results are vital to your health, so it’s important to do what you can to ensure that they are useful to you.

Persistence can be key, as Christy Johnson found out. The 27 year-old from Birmingham, Ala., undergoes regular testing for Graves disease, a thyroid disorder. For six months, she never saw a result, even though “every time I go for a visit, they have me address an envelope to myself so they can send me my labs,” she wrote on her treatment blog, Life With Graves.

Johnson asked everyone in her doctor’s office for results, but got no response until her doctor jotted down the results on the back of—you guessed it—a patient lab envelope. She finally received the official results by enlisting the help of a patient advocate at the testing hospital.

“The doctor asked me why I wanted to see the results,” she recalled. “‘Because I am trying to be very proactive about my health,’” she told him “‘and I can’t do that if you don’t provide me with the information I need to do that.’”

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.

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Time for your checkup

New nursing competency rules go into effect

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Under rules that went into effect January 1st, licensed nurses in Washington State are required to document that they have met new education and practice requirements adopted by the Washington State Nursing Care Quality Assurance Commission.

The new rules “will assure nurses stay current on the knowledge and skills of their nursing practice”, the Commission said.

Under the new rules nurses must document:

  • That they have engaged in 531 hours of active nursing practice within the previous three years.
  • That they have completed 45 hours of continuing education.
  • And that they have conducted self-assessment of their practice to identify their strengths as well as opportunities for new learning.

To enforce compliance, the Commission will conduct random audits of all nurses starting in 2014. For nurses undergoing disciplinary action, audits will be routine.

Nurses who are audited will be required to provide verification that they have actively practiced for at least 531 hours during the previous 36 months as well as documentation of their continuing education activities.

Nurses who do not meet the 531 hour requirement can apply of an inactive license status.

To return to practice from inactive status, nurses may need to complete a refresher course or participate is some form of commission approved remedial program.

Nurses who don’t comply will be offered technical assistance to help bring them into compliance; however, those who fail to meet the new program’s requirements may be subject to disciplinary action, including fines, required remedial activities and/or denial of re-licensure.

To learn more:

  • Visit the Washington State Nursing Care Quality Assurance Commission’s website.


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Congress

How to reach a compromise on health-care reform

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Improving The Health Law In 2011: Realistic Ways To Reach Bipartisan Compromise

Robert Laszewski, President of Health Policy and Strategy Associates

The new health care law can be changed in ways that would make it acceptable to a bipartisan majority in the new Congress — and, therefore, to the American people.

But to find this elusive middle ground requires consideration of the competing philosophies at the heart of the nation’s political divisions regarding this sweeping measure.

For starters, liberals want a health insurance system in which everyone is covered in a more equitable health insurance pool, but conservatives argue the individual mandate used to accomplish this goal is an unconstitutional encroachment on individual freedom.

Liberals also want a standardized competitive marketplace for health insurance ensuring consumers get comprehensive benefits, but conservatives argue that this would destroy choice and the free market, and create hundreds of pages of rules about what people can and can’t buy.

And liberals want every citizen to be entitled to a comprehensive health insurance plan — a defined benefit. But conservatives want individuals to have incentives, including tax incentives, to purchase and use coverage responsibly — defined contribution health insurance.

However,  there are ways to modify the new health law so that it includes the key elements both sides see as central to moving toward covering everyone and doing it in a way we can better afford.

The key elements of such a compromise could include:

1. Eliminating the individual mandate and replacing it with freedom of choice with responsibility

The existing mandate gives many families the choice of paying a fine they can’t afford or paying even higher and more unaffordable insurance premiums. Because the penalty doesn’t apply when family premiums reach 8 percent of income, which will be the case for many, it isn’t even a very effective individual mandate.

Instead, a compromise could make guarantee issue health insurance entirely voluntary. If it is purchased when the consumer is first eligible — such as when the exchanges are first available or at the time of a new job — the consumer would not be subjected to underwriting or preexisting condition rules. The compromise, though, should let consumers purchase and use their health insurance at any other time.

But if they didn’t purchase coverage when they were first eligible, any preexisting condition would be subject to a two-year waiting period.

2. Eliminating the benefit mandates in the new law and creating a free market of health insurance choices, but with a standardized baseline for ease of comparison

Eliminate all of the benefit mandates in the new law requiring individual market and exchange consumers to purchase only plans that are yet to be outlined in what will be hundreds of pages of regulations.

Instead, a compromise could have only two new benefit requirements.

One could be a standard plan, which would take the law’s existing “silver plan” and use it as a baseline. Every insurer would have to offer this coverage on the exchange or in the individual market. But insurers could also offer consumers any other plan design, so long as they told consumers the relative actuarial value the other plans had to the standard plan.

The second would be a health savings account. Every insurer would have to offer an HSA-style program and state its value relative to the standard plan. Consumers who would be eligible for premium subsidies would have any premium savings deposited in a health savings account.

3. Eliminating the “Cadillac” tax on high cost health insurance plans and introducing elements of a conservative defined contribution approach to the existing liberal defined benefit legislation

With exchange premium subsidies already based upon the value of the new law’s silver plan (and they should continue to be), the compromise could limit the employer deduction for health insurance, as well as the individual income tax exemption for employer-provided health insurance, to the cost of the standard plan (currently the silver plan) in any year. Phase this limit in over a period of seven-years — to 2018, when the “Cadillac” tax was to take effect. As a result, tax policy would continue to support comprehensive coverage but also provide real incentives for consumers to buy wisely.

4Using the budget gains from limiting the existing health insurance tax preference to pay for such things as improving the now inadequate insurance subsidies for the middle-class, permanently fixing the Medicare physician payment issue, or for reducing the deficit.

In 2008, the CBO calculated a 10-year savings of $450 billion by limiting health plan tax preferences to the 75th percentile of premiums then paid by employers.

5Letting states have the flexibility to experiment with alternatives . . .

. . . by enacting the proposal by Sen. Ron Wyden, D-Ore., and Sen. Scott Brown, R-Mass., that would move up to 2014 the year in which states can submit proposals to the Secretary of the Department of Health and Human Services to implement their version of health care reform. The law already allows states to petition the federal government to use the overhaul’s money to enact their own plans so long as they cover as many people as the new law would have — but not until 2017.

The Republican House of Representatives will almost certainly vote to repeal the new health care law early this year. But everyone knows that is for show — the Democratic-controlled Senate will not go along, nor will President Barack Obama.

On the current partisan political track, we are destined to have a stand-off for two years with Democrats and Republicans blaming each other for gridlock while uncertainty over the new health law, and its 2014 deadlines, has consumers, employers, and health industry stakeholders unable to plan for the future — only providing another burden of uncertainty in an economy trying to regain its footing.

If the Congress waits until after the 2012 elections before seriously considering changes to the law, it will be 2013 and less than a year before key elements of the legislation are due to take effect.

Or, we can recognize that both sides can get a lot of what they really want by agreeing to a few key and carefully placed changes to the existing law.

Liberals can improve even further the promise that consumers will have access to comprehensive health insurance while still bringing down the cost and underwriting barriers.

Conservatives can significantly move toward their goal of a free market for health care by expanding choices and crafting new incentives for people to make more efficient health care purchasing decisions.

And, these objectives can coexist, giving the American people the confidence we really have accomplished something.

Or, both sides can play a cynical game in the run up to 2012 and the people can be the losers.

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

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baby sucking bottle

One in three U.S. babies has a weight problem

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Close up of a baby sucking a bottleInfants not Exempt From Obesity Epidemic

By Glenda Fauntleroy, Contributing Writer
Health Behavior News Service

Most people understand that children are part of the obesity epidemic. However, a revealing new study finds that obesity might begin in babies as young as nine months old.

In this study, researchers looked at where the children ranked on standard growth charts. Their weight was considered normal if their weight in relation to their length and stature placed them in the lower 85th percentile. If their weight placed them between the 85th and 95th percentile, they were considered “at risk” for obesity. If they ranked above the 95th percentile, they were considered obese. — Editor

“With the consistent evidence that the percent of overweight children has steadily increased over the past decade, we weren’t surprised by the prevalence rates we found in our study, but we were surprised the trend began at such a young age,” said lead study author Brian Moss, at the social work school at Wayne State University in Detroit.

31.9 percent of babies at nine months and 34.3 percent at two years of age were either at risk or obese.

The new study used data from the Early Childhood Longitudinal Study-Birth Cohort to analyze the early weight of 16,400 U.S. children born in 2001. Of these, 8,900 were nine months old and 7,500 were two years old.

The researchers found that 31.9 percent of babies at nine months and 34.3 percent at two years of age were either at risk or obese.

The study also found that children who were Hispanic and from lower-income families were at greater risk of being obese than white children, while Asian Americans and Pacific Islanders had lower risk. Female children were at lower risk for obesity than males.

“Being in an undesirable weight category at nine months subsequently predisposed children to remain in a less desirable weight category,” said Moss, whose study appears in the January-February 2011 issue of the American Journal of Health Promotion.

Childhood obesity expert Joyce Lee, MD, an assistant professor in pediatric endocrinology and health services research at the University of Michigan at Ann Arbor, confirmed that obesity is indeed becoming a problem in increasingly younger children.

“At younger ages, it is critical for parents to watch their child’s nutritional intake as this will be the main determinant of their weight status,” Lee said. “There is no approved ‘diet’ for children that young, so parents should communicate with their child’s health care provider about healthy ways to feed their child.”

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.

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Chubby

Many on Medicare missing out on discounted drug coverage

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By Phil Galewitz
KHN Staff Writer

More than 2 million Medicare beneficiaries have failed to sign up for a program that could save them thousands of dollars a year in drug costs despite government mailings, ads and even pitches from rock and roll legend Chubby Checker.

The subsidy program, called Extra Help, can provide significant savings on the cost of Part D prescription drug coverage for low-income Medicare beneficiaries. The government estimates Medicare recipients can save an average of $3,900 a year.

The subsidy, which began in 2006, helps reduce prescription drug premiums, co-pays and deductibles and plugs the “doughnut hole” or gap in coverage that starts when beneficiaries exceed $2,840 in total drug costs.

The Department of Health and Human Services and the Social Security Administration jointly oversee the subsidy program.

Nearly 10 million of the nearly 25 million people enrolled in Part D prescription plans received the low-income subsidy this year. Of those, more than 8 million people were automatically enrolled in the subsidy program, mostly because they are on both Medicaid and Medicare or receiving other federal government support.

study released in September by researchers at Georgetown University and the University of Chicago estimated that 2.3 million people were eligible for the program but didn’t apply.

Seniors and the disabled are eligible for the subsidy if their income is less than $16,245 a year for individuals and $21,855 for married couples living together.

The percentage of those not automatically enrolled who do seek the discounts – about 40 percent – has changed little since 2006, the researchers found.

The study was commissioned by the Kaiser Family Foundation. (KHN is a program of the foundation.)

“This is a really hard population to reach,” said Vicki Gottlich, an attorney with the Center for Medicare Advocacy.  She said many low-income beneficiaries may not speak English or have stable housing that makes it difficult to get them to enroll.

Seniors and the disabled are eligible for the subsidy if their income is less than $16,245 a year for individuals and $21,855 for married couples living together. The value of their stocks, bonds and bank accounts can’t exceed $12,510 for individuals and $25,010 for married couples. The income definition doesn’t include the value of homes or automobiles.

Over the past five years, both Social Security and the Centers for Medicare and Medicaid Services have run publicity campaigns about the subsidy, including using direct mail and working with faith-based organizations and seniors’ groups.

In June 2009, CMS gave states $25 million in grants to help get the word out about the program. This initiative includes special efforts targeting seniors in rural areas and Native Americans. The grant program continues until June 2011.

In addition, in January 2010 Social Security launched a new television, radio and Internet campaign with Chubby Checker.  The theme of the marketing blitz was that Social Security says there is a “new twist” that makes it easier for senior citizens to qualify for extra help with Medicare prescription drug costs.

Seniors can apply for Extra Help throughout the year.

Mark Hinkle, a spokesman for Social Security, said the agency is doing everything it can to get those eligible to enroll.

Helen Boesch of Perry, Mich., said the subsidy helped her parents, Richard, 76, and Daisy Yenson, 68. Both live with her and have cancer. She estimates the subsidy will save each of them at least a few thousand dollars every year. “It’s really nice to get some help,” she said.

The number of people eligible for the subsidy is expected to rise this year because of two recent changes to the rules. The cash value of life insurance policies is no longer counted toward the asset limit, and assistance received from friends and relatives to pay for household expenses such as food or utilities is also no longer counted as income.

Unlike standard Medicare Part D enrollment – which occurs annually between Nov. 15 and Dec. 31 – seniors can apply for Extra Help throughout the year.

As a result of the HHS campaign about 120,000 people have applied for the Medicare drug subsidy, according to federal reports. Through the same marketing campaign, about 100,000 people have signed up for the Medicare Savings Plans, which lowers the cost of doctor visits and the Medicare Part B premium.

Results of the $25 million campaign that provided grants to states varied widely, according to data collected by the National Council on Aging.

For instance, Pennsylvania, which received $1.1 million grant, has signed up 5,742 people for the two subsidy programs from June 2009 through September 2010. But Texas, which got a $1.2 million grant, has signed up 2,430 people. Nevada has found the fewest people –  584 – through the grant program while Illinois has signed up the most — more than 30,000.

States used the grants in different ways to find eligible Medicare beneficiaries. They’ve given grants to nonprofits to go into homeless shelters, work with religious groups and set up enrollment kiosks in public libraries.

In Wisconsin, the grant money has gone to advocacy groups that have visited senior centers, food pantries and even distributed flyers at trailer parks, said Peg Nugent a Medicare training counselor at the Greater Wisconsin Area Agency on Aging Resources.

Using its $800,000 grant, the state has helped find 7,600 people for the subsidy programs. “There’s still a lot more people out there,” Nugent said.

But officials have much to overcome in the recruiting effort. They say that in addition to not knowing about the program, some people don’t sign up because they think they won’t meet the eligibility or are afraid of taking the help.

As Elaine Wong Ekin, executive director of California Health Advocates, explained,  “It can be a pride issue or the stigma about asking for assistance,” she said.

To apply for Extra Help, go online to the Social Security website or the Extra Help website or call Social Security at 1-800-772-1213.

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

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rotator-cuff-con_ill-1

Picking a treatment for a rotator cuff tear

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Your Options for Treating Rotator Cuff Tears

By Carolyn M. Clancy, M.D.

It’s a fact of life: as we get older, we’re more likely to get hurt when we exercise or take on certain everyday tasks. Routine activities like playing tennis or placing items on shelves can result in a common problem—the rotator cuff injury.

Tears in the rotator cuff are not a huge health setback. But they can limit movement and cause serious pain. There are several ways to treat rotator cuff tears, including surgery and non-surgical treatments. You’ll want to understand your options before you make a decision.

To help you, my agency, the Agency for Healthcare Research and Quality (AHRQ), offers a guide called Treatment Options for Rotator Cuff Tears. It explains in plain language how this common, age-related injury is treated and the pros and cons of ways to treat it.

Illustrations: Agency for Healthcare Research and Quality

The good news is that most treatments work. But some options may be better for certain patients. For example, older or sicker patients often do better without surgery.

Knowing how your rotator cuff works helps you understand how it can be injured. The rotator cuff is a group of four muscles and tendons that hold the “ball” of your upper arm bone firmly in your shoulder socket. Your rotator cuff allows you to lift and rotate your arms. The tendons can tear much like a piece of leather. Sometimes, the tendon is only slightly damaged. Other times, the tendon suffers a complete tear, meaning that it has torn away from the bone.

Rotator cuff injuries are more common as we age. More than half of adults older than 60 have a partial or complete rotator cuff tear compared to only 4 percent of adults under 40. Natural wear and tear can cause this injury. An accident, such as falling, can also cause your rotator cuff to tear. So can overuse from repeated actions, such as lifting, painting, or throwing.

To choose a treatment, it’s important to know how non-surgical and surgical Illustration of arthroscopic rotator cuff repairtreatments compare for their ability to relieve pain and restore movement and function. There are three common ways to treat such tears without surgery: physical or occupational therapy; oral medicines, such as acetaminophen or “nonsteroidal anti-inflammatory drugs;” or steroids taken as a pill or an injection.

Your doctor will make a recommendation based on the damage to the tendon of your rotator cuff. Physical therapy may be enough to improve the pain and weakness, or surgery may be a better choice. In some cases when physical therapy does not improve symptoms, surgery is needed.

In most rotator cuff repair surgeries, a surgeon stitches the torn edges of the muscle or tendon back together or connects the tendon back to the ball of your upper arm bone. The three types of surgery to treat a rotator cuff tear are:

  • Arthroscopic surgery: The surgeon makes very small cuts into the muscles of your shoulder and uses an arthroscope (a small tube attached to a camera and tiny surgical instruments) to repair the tear.
  • Open surgery: The surgeon makes a larger opening into the muscles of your shoulder and repairs the tear with regular surgical instruments.
  • Mini-open surgery: The surgeon uses an arthroscope for the first part of the surgery and then makes an opening large enough to use other surgical instruments for the repair.

Our guide, Treatment Options for Rotator Cuff Tears, summarizes scientific evidence. It shows that patients get better with both non-surgical and surgical treatments. Three types of surgery all produce the same level of improvement of shoulder function. However, arthroscopic surgery usually offers a shorter recovery time. A few studies found that some patients who had mini-open surgery returned to work or sports about 1 month sooner than those who had open surgery.

To decide what is right for you, consider asking your doctor questions such as:

  1. What are the pros and cons of non-surgical or surgical treatments for me?
  1. If I need surgery, which type (open, mini-open, or arthroscopic) do you think would be best for me?
  1. What type of care will I need after surgery?
  1. When can I return to my usual activities?
  1. Will these treatments help my rotator cuff for many years?
  1. When should I expect to feel better?

Getting information about the risks and benefits of different treatments helps you make an informed decision. And we know that informed patients often have a shorter path to better health.

I’m Dr. Carolyn Clancy, and that’s my advice on how to navigate the health care system.

More Information

Agency for Healthcare Research and Quality
Treatment Options for Rotator Cuff Tears: A Guide for Adults
http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=545

Current as of January 2011


Internet Citation:

Your Options for Treating Rotator Cuff Tears. Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy, January 4, 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/cc/cc010411.htm

Illustrations courtesy of AHRQ’s Effective Health Care Program from the publication: Treatment Options for Rotator Cuff Tears: A Guide for Adults. Rockville, MD: Agency for Healthcare Research and Quality; October 2010. AHRQ Publication No. 10(11)-EHC050-A.

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Newborn preemie baby hand NICU

Your hospital may be “in network”, but is its NICU staff?

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Insurers Sometimes Reject Neonatal Intensive Care Costs

By Consumer Columnist Michelle Andrews

Many expectant parents are pretty savvy these days about making sure that their obstetrician and the hospital where they plan to have their baby are in their health insurance network.

Using an out-of-network provider would almost certainly mean higher out-of-pocket costs: The plan might pay just 60 percent of charges, for example, instead of 80 percent or more.

However, fewer parents-to-be realize that they may be in for a nasty surprise if their baby is premature or for some other reason needs special care immediately after birth: The neonatal intensive care unit (NICU) personnel at their in-network hospital may be out of network.

“Some hospitals do contract with other clinical provider groups to run their NICUs,” says Marie Watteau, director of media relations at the American Hospital Association.

The companies that staff the NICUs may accept the same insurance carriers as the hospital, or they may not. “When selecting a hospital, pregnant women should … verify that all hospital care, including NICU care and physician services, are in network,” says Watteau.

Nathan and Sonji Wilkes thought they had covered all the insurance bases before the birth of their son, Thomas, seven years ago. Their obstetrician and the hospital near their Englewood, Colo., home were all in network.
They checked with the health insurer that provided their coverage to estimate their out-of-pocket costs. The expected total: $400.

Thomas’s birth was uneventful. But when hospital personnel circumcised him, he wouldn’t stop bleeding. He was given a diagnosis of hemophilia, treated and placed in the hospital’s NICU, where he received treatment to stop the bleeding and remained under observation for a day.

More From This Series: Insuring Your Health

A few weeks later, the Wilkeses got a $50,000 bill for Thomas’s NICU stay. They learned that the unit, located on the same floor as the regular nursery and delivery rooms, was staffed by a company under contract to the hospital, and the company didn’t accept the family’s insurance plan.

“We just thought it was part of the hospital,” says Nathan Wilkes. “We had no idea that it was even an option that the NICU could be in a different network.”

About 75 percent of the infants who wind up in neonatal intensive care come in because they’re premature; the remaining 25 percent have other medical problems. In 2009, one U.S. baby in eight was born prematurely, defined as birth before 37 weeks’ gestation, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.

Costs related to prematurity totaled at least $26.2 billion in 2005, or $51,600 per premature infant.

Although the rate of premature birth has declined slightly in recent years, it’s still more than 30 percent higher than in 1981.

There are many factors associated with preterm birth, including chronic health conditions such as diabetes and high blood pressure and fertility treatments that result in multiple births.

An Institute of Medicine report found that medical bills and other costs related to prematurity totaled at least $26.2 billion in 2005, or $51,600 per premature infant.

Heather Ablondi’s water broke at 25 weeks, and she delivered her daughter, Abigail, about 2 1/2 weeks later. The doctors at Inova Fairfax Hospital, near the family’s home in Sterling, told her that it was unlikely her daughter would survive. Abigail weighed just 2 pounds, 9 ounces, her lungs were immature and she had sepsis.

Abigail pulled through and is now 4 years old. But she spent the first three months of her life in the NICU and accumulated $750,000 in bills.

Shortly after her birth, the hospital billing department gave Ablondi the bad news that their insurance plan might not cover all the NICU expenses because the staff was out of network. “All of this stuff you’re trying to juggle while you have a sick child,” she says.

Kimberly Gibbs, a spokeswoman for the Inova Health System, declined to comment on the Ablondi case, saying she couldn’t discuss specific patients because of privacy laws.

In general, she said, most health plans in the Washington area that contract with Inova also cover the neonatology staffs. But she advised patients to consult with their health plans ahead of time to confirm if the charges would be covered.

(This was the Ablondis’ first experience with insurance problems related to childbirth, but not their last: A previous Insuring Your Health column examined coverage difficulties during Heather Ablondi’s pregnancy with her second daughter, Bethany.)

An astute social worker alerted the family to one possible way to address the billing problem: Abigail might qualify for Medicaid, the federal-state program for low-income or disabled patients.

Under federal rules, if Abigail met certain weight and other medical criteria, she could be deemed disabled under the Supplemental Security Insurance program and thus be eligible for Medicaid. Babies weighing less than 1,200 grams (about 2 pounds, 10 ounces) are considered disabled; Abigail weighed 1,162 grams.

People generally must meet income guidelines to qualify for Medicaid. But “while the child is in the institution, the child’s income alone is what’s looked at for Medicaid purposes,” says Mary Kahn, a spokeswoman for the federal Centers for Medicare and Medicaid Services.

Don’t take no for an answer.

Once she went home, Abigail was no longer eligible for Medicaid because her parents’ income was taken into consideration.

The family’s insurance policy covered the baby’s NICU stay at the out-of-network rate of 60 percent, and Medicaid took care of nearly all the rest. Including their deductible and other out-of-pocket charges, Ablondi estimates the family paid $24,000 for Abigail’s birth.

Her advice: Don’t take no for an answer. Initially, the insurer refused to pay any of the NICU bills. Eventually it paid its share.

Things weren’t much different at the local Medicaid office, says Ablondi. The first person said Abigail couldn’t qualify because of the family’s income.

Eventually, Ablondi talked to a supervisor who, she says, was also clueless. “But she did her research and called me back.” Abigail got the coverage she needed.

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

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How will we implement health reform in Washington state?

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Health-care reform has passed, but how will we implement all the changes the new law will require?

To try to come up with some answers, more than 300 experts will come together in Seattle on Wednesday, Jan. 6th for the 2011 State of Reform conference.

The sessions will look at:

  • Implementing Federal Reforms. What will the federal healthcare reforms look like in Washington State?  How will they be unique?
  • Next Steps for Washington State. What are the next steps to extend system reform here in the state?  Where can our state go from here?
  • Policy Meets Politics. Meet the political figures, thought leaders, and key opinion makers behind the politics of health care policy.
  • Implementing Federal Reforms. What will the federal healthcare reforms look like in Washington State?  How will they be unique?

Keynote speakers include Susan Johnson, regional director, US Dept. of Health and Human Services, Region X and Mike Kreidler, insurance commissioner, State of Washington

The conference will be held at the Hilton Seattle Airport and Conference Center.

To learn more and to register:

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Sprouts from Kent firm linked to Salmonella outbreak

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The Kent firm Sprouters Northwest is recalling its clover sprouts after they have been linked to an outbreak of Salmonella infections that has sickened four people in Washington State and two in Oregon.

Consumers should not any products from Sprouters Northwest that contain clover sprouts but instead should discard them immediately or return them to the store, Washington State health officials said.

The sprouts are sold in a variety of package sizes labeled “Clover Sprouts,” or as mixed varieties that contain clover sprouts as an ingredient with “best by” dates of 01/16/2011 or earlier (see list, below).

The recalled sprouts were distributed to grocery stores and restaurants in Washington, Oregon, Idaho, and Alaska.

The outbreak began in mid-December among consumers living in Benton, King, Kitsap, and Grays Harbor counties, officials said. None has required hospitalization.

Washington State Department of Health advises:

Salmonellosis is a common infection; about 650 to 850 cases are usually reported each year in our state. It can cause diarrhea, fever, and vomiting. Symptoms usually develop within one to five days after eating contaminated food. Most people usually get better on their own.

People who have eaten sprouts and developed symptoms should contact their health care provider. Salmonellosis can cause serious illness that can lead to hospitalization and even death. The risk is particularly high for the elderly, people with low immune systems, and the very young.

Specific products subject to the recall included:

The 4oz. (UPC 8 15098 00201 6) and 5oz. (UPC 0 33383 70235 3) containers of Clover sprouts

The 1lb. bags of Clover (UPC 0 79566 12351 5) and 2 lb trays of Clover (UPC 0 79566 12362 1)

Clover Onion sprouts in 4oz. (UPC 0 79566 12361 4) and 5oz. (UPC 0 79566 12361 4) containers

Deli sprouts in 4oz. (UPC 8 79566 12305 4) and 5oz. (UPC 0 33383 70267 4) containers

Spicy sprouts in 4oz. (UPC 8 15098 00202 3) containers

Brocco sandwich sprouts in 4oz. (UPC 8 15098 00028 9) containers

Consumers who have purchased these clover based products are urged to return them to the place of purchase for a full refund. Consumers with questions may contact the company at 253-872-0577 Mon-Fri 7AM -11AM.

To learn more:

  • For more information on salmonellosis read the Washington State Department of Health’s fact sheet on salmonellosis.
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Nine ways the new health law may affect you in 2011

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Opponents of the new health care overhaul law are threatening to repeal, defund and kill it in court, but that isn’t stopping Washington from implementing a number of important provisions in 2011.

While many people will welcome the new benefits, some will face higher costs as a result of the law.

Seniors are affected by several of the provisions. They will get big discounts on prescription drugs and free preventive care, but some in Medicare Advantage plans may lose coveted extra benefits such as vision and dental coverage.

Everyone will be able to count calories when dining at chain restaurants or sidling up to vending machines.

But forget about using pre-tax income in popular flexible spending accounts to pay for over-the-counter medications, unless you get a prescription.

These changes follow a handful of early benefits that debuted in 2010. Already, adult children are allowed to remain on their parents’ policies until the age of 26, for example, and insurers can no longer cancel coverage when people get sick (except in cases of fraud).

The following are nine health law changes to take note of this year.

Will you get an insurance rebate?

An umbrella sheltering medicines - credit MicrosoftStarting this year, health insurers must spend at least 80 percent of their premiums on medical care, or face the possibility of giving rebates to consumers. The rule applies to policies purchased by individuals who don’t get coverage through work, and for many policies offered by employers.

For policies sold to large employers, insurers must hit an 85 percent spending target. Self-insured employers are exempt from the rule. The goal is to pressure insurers to restrain profits and administrative costs, such as overhead, marketing and executive salaries.

But insurers probably won’t be issuing too many rebates, which would go out in 2012. Of the 75 million people who have insurance that is covered under the rule, the government estimates that 9 million will be eligible for a rebate in 2012.

That’s because many insurers reach those target levels now, and the ones that don’t may adjust so they meet the spending limits. Other insurers may drop out of the market.

Under another part of the law, regulators have proposed that beginning July 1 premium increases of 10 percent or more be subject to additional review by states and the federal government. Insurers would have to publicly disclose some of the data supporting their requests – such as how much they’re paying for medical services.

The review would determine if the increase is considered unreasonable. Some state regulators have authority to deny an increase, but the law does not grant that power to the federal government. The proposed rule would affect policies sold to individuals and small businesses.

Lower Rx costs for seniors

Prescription drug costs could shrink $700 for a typical Medicare beneficiary in 2011, as the law begins to close the notorious doughnut hole – the gap in prescription coverage when millions of seniors must pay full price at the pharmacy – according to the seniors group AARP.

The National Council on Aging estimates the savings could reach $1,800 for some. Starting in January, drug companies will give seniors 50 percent off brand drugs while in the gap, excluding those low-income people who already get subsidies. Generics will also be cheaper.

“It’s quite significant,” said AARP’s John Rother. “People stop filling prescriptions when they hit the doughnut hole.” The National Council on Aging estimates that about 4 million Medicare beneficiaries will face the gap this year.

It has how many calories?

How many calories are in that Outback Steakhouse’s blooming onion? (1,551) Or Pizzeria Uno’s individual-size Chicago style deep-dish pizza? (2,310).

Beginning soon after the Food and Drug Administration finalizes rules in 2011, chain restaurants with 20 or more locations, and owners of 20 or more vending machines, will have to display calorie information on menus, menu boards and drive-thru signs.

Restaurants must also provide diners with a brochure that includes detailed nutritional information, like the fat content of their dishes.

Consumer advocate Jeff Cronin of the nonprofit Center for Science in the Public Interest says it will put “eating into context.”

Higher Medicare Premiums

Medicare premiums in 2011 will take a bigger bite from wealthier beneficiaries. Since 2007, this group has paid more than the standard premium for Part B, which covers physician and outpatient services.

But the income threshold was indexed to prevent inflation from moving more people into the affected group. The health law freezes the threshold at the current level: incomes of $85,000 or above for individuals and $170,000 for couples.

With that step, beneficiaries paying higher premiums will rise from 2.4 million in 2011 to 7.8 million in 2019, according to an analysis by the Kaiser Family Foundation. (KHN is part of the foundation.) Their monthly premiums this year will be between $161.50 and $369.10, while the standard premium will be $115.40.

Also, premiums for Medicare Part D, which covers prescription drugs, for the first time will be linked to income. The thresholds will be the same as those for Part B and will not be linked to inflation. About 1.2 million beneficiaries will pay the income-related Part D premium this year, rising to 4.2 million beneficiaries in 2019.

Restrictions on medical savings accounts

Consumers with flexible spending accounts (FSAs), in which pre-tax income can be used for medical purchases, can no longer spend the money on over-the-counter drugs, including ones that treat fevers or allergies and acne, unless they have a doctor’s prescription.

The new restrictions, which lawmakers included in the health overhaul to raise more revenue, also apply to health reimbursement arrangements (HRAs), health savings accounts (HSAs) and Archer medical savings accounts (MSAs). Starting this year, those with HSA or MSA accounts who spend money inappropriately will not only owe taxes on it, but also face a tax penalty of 20 percent, double what it was.

For all pre-tax accounts, medical devices such as eyeglasses and crutches, and co-pays and deductibles still qualify for the accounts. Insulin obtained without a prescription is also eligible.

Bolstering seniors’ access to primary care

Medicare is bumping up payments for primary care by 10 percent from Jan. 1 through the end of 2015. It’s an incentive for doctors and others who specialize in primary care – including nurses, nurse practitioners and physician assistants – to see the swelling numbers of seniors and disabled people covered by the program.

Health practitioners will qualify for the bonus only if 60 percent or more of the services they provide are for primary care. General surgeons also will receive an increase if they’re practicing in areas where there are doctor shortages.

Experts agree there’s a growing shortage of primary care providers, a big problem considering that the health law is expected to expand coverage to 32 million more Americans by 2019.

The bonus won’t cure the problem, but many see it as a start. “It’s significant, but it’s not the end all,” said Dr. Roland Goertz, president of the American Academy of Family Physicians, emphasizing that the bonus will end in 2015.

Staying healthy

Several provisions of the law promote health prevention, especially for seniors. Medicare enrollees will be able to get many preventive health services – such as vaccinations and cancer screenings – for free starting in January.

Specifically, the law eliminates any cost-sharing such as copayments or deductibles for Medicare-covered preventive services that are recommended (rated A or B by the U.S. Preventive Services Task Force).

Also starting in January, Medicare beneficiaries can get a free annual “wellness exam” from their doctors who will set up a “personalized prevention plan” for them. The plan includes a review of the individuals’ medical history and a screening schedule for the next decade.

The law also eliminates any cost sharing for the “Welcome to Medicare” physical exam, which previously included a 20 percent co-pay. And people working for small employers will get some help.

The law authorizes the federal government to issue grants totaling $200 million for companies with fewer than 100 workers that start wellness programs focused on nutrition, smoking cessation, physical fitness and stress management.

Trimming Medicare Advantage

The health law puts the squeeze on private health plans that provide Medicare coverage to about a quarter of beneficiaries. Payment for these Medicare Advantage plans is being restructured. Rates this year will be frozen at 2010 levels and lower rates will be phased in beginning in 2012.

Medicare says the reductions are fair because the plans are paid $1,000 more per person on average than the traditional fee-for-service program spends on a typical senior.

Dan Mendelson, president and CEO of Avalere Health, a consulting firm based in Washington, says some plans will respond by cutting ancillary benefits, such as vision and dental care.

But he calls this “a transition year” and says more significant changes will come in 2012, when in addition to the rate reductions, the government begins offering bonuses to top-performing Advantage plans based on quality measurements.

Fighting hospital infections

MRSA - Photo Janice Haney Carr CDCAbout 1.7 million patients pick up life-threatening, but preventable, infections at hospitals, according to a study earlier this year in the Archives of Internal Medicine.

In July, Medicaid will say “enough.” The federal government – which shares the cost of this program for the poor with states – will stop paying for treatment of some hospital-acquired infections.

The Medicare program for the elderly and disabled and many private insurers already ban payments for treating many of these infections.

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

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Local health news of the week

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Using a team approach to improve care

In an article appearing in last week’s issue of The New England Journal of Medicine, researchers at Group Health Cooperative and the University of Washington report on the results of a program that used a team approach to improve care of patients with depression who had poorly controlled diabetes, heart conditions or both. Such patients often do poorly.

In the study, a team of nurses and physicians worked closely with one group of patients, teaching them to better manage their diseases, including their depression, and setting targets for bringing down their blood sugars, blood pressure and other factors that increase their risk of serious complications, such as stroke, heart disease and kidney failure.

For comparison, the researchers followed a second group of patients who continued to receive their usual care.

At the end of the year, the researchers found that compared to the patients who received usual care the patients in the team-care group were more likely to have greater decreases in their LDL cholesterol, blood pressure and glycated hemoglobin (a measure of blood sugar control), and greater improvement in their depression. They also were reported a better quality of life and more satisfaction with their care.

The results, the researchers concluded, suggest that such a team approach may improve care of people with multiple chronic diseases complicate with depression.

The cost of the extra care averaged $1,224 per patient.

Psychiatrist Wayne J. Katon, M.D., of UW’s Department of Psychiatry & Behavioral Sciences, was the paper’s lead author. Group Health diabetes expert David McCullough, M.D. was the paper’s senior author.

To learn more:

  • Watch Group Health video about the project.

Vally Medical to challenge ruling on bed expansion

Valley Medical Center plans to appeal the state Health Department’s decision to prevent the Renton hospital from adding beds while allowing the MultiCare Health System to build a new hospital 10 miles away in Covington, Puget Sound Business Journal’s Peter Neurath reported last week.

Auburn Regional Medical Center also sought to add beds to its facility, but its application was turned down by the state as well, and it, too, is reviewing its options to appeal, Neurath writes.

To learn more:

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Good news on global health

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Many, if not most, news stories on global health are grim, focusing on disease and poverty, misery and suffering

But are we getting the real story?

In this video, Hans Rosling professor of International Health at Karolinska Institute in Uppsala, Sweden and Director of the Gapminder Foundation, uses brilliant animated slides and humor to show that great–in fact, astounding–progress is being made in improving the health in even the poorest nations of Africa, Asia and South America.

Here he focuses on strides being made in reducing child deaths world-wide.

Intrigued? Learn more about statistics–painlessly–in this hour-long BBC documentary hosted by Professor Rosling.

To learn more:

  • Learn how to use the Gapminder software to animate your own statistics.
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Washington state bans synthetic marijuana

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Synthetic marijuana products known as “K2″, “Spice”, “Black Mamba” and other street names will be banned in Washington State under emergency rules issued by the state Board of Pharmacy.

The new rules will go into effect January 7, 2011.

The products are typically made from a mixture of herbal products that have been sprayed with chemical compounds similar to the active ingredient in marijuana, which smoked can give the smoker a marijuana “high”.

The products are available in a variety of retail shops, including smoke and “head” shops, as well as over the Internet.

Packet of the synthetic marijuana product Spice

Photo by Schorle under GNU Free Documentation License

Over the last year Washington State Poison Control Center has seen an eight-fold increase number of calls related to synthetic marijuana products, the Board of Pharmacy said.

Under the new rules, the products will be classified as Schedule I controlled substances in the state, which will make them illegal to make, possess, and sell.

K2, Spice and other synthetic marijuana products has already been banned by the Federal Drug Enforcement Agency last week, but state bans are easier for law enforcement agencies to implement than federal prohibitions, the Board of Pharmacy said.

To learn more:

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King County homicides, traffic deaths lowest in ten years

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The number of deaths in King County due to homicide and traffic accidents last year were the lowest in ten years, according to a report released this week by King County Medical Examiner’s office.

Of an estimated 12,967 deaths in the county in 2009, the Medical Examiner’s office conducted autopsies on 2,190.

Of those, 989 were determined to be natural deaths, 632 accidental deaths, 253 suicides, 141 traffic deaths and 63 homicides.

In 59 cases the cause of death was not determined.

Compared with 2008, deaths due to homicide, traffic accidents and other accidents were down, but deaths due to natural causes and suicide were up, the Medical Examiner’s office said.

From 2008 to 2009:

  • Homicides dropped from 85 to 63.
  • Deaths due to traffic accidents fell from 163 to 141.
  • Suicides rose from 210 to 254.

The most frequent instrument of death in homicides and suicides were guns, which were used in 41 of the county’s 63 homicides and 100 of the county’s 253 suicides.

Falls were the most common cause of accidental death, most of which occurred among elderly age 70 and over.

To learn more:

  • The full report will be posted on the Medical Examiner’s webpage this week.
  • Visit the King County Fall Prevention and Resources webpage.
  • Suicide prevention services can be found at webpages of the Crisis Clinic and the Youth Suicide Prevention Program or calling the Crisis Clinic’s hotline: 1-866-427-4747
  • For information about safe firearm storage visit the website of LOK-IT-UP.
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