Only about half of recommended preventive services offered during annual checkups


Doctors offer or suggest only about half of the screening tests and other preventive services that guidelines recommend doctors offer to patients during their routine medical checkups, a new study finds. That’s not so bad, say some experts, given how little financial support there is to promote prevention.

By Glenda Fauntleroy, Contributing Writer
Health Behavior News Service 

New research finds that patients may not always receive all of the screening tests and counseling services that are due during their medical checkups.

According to a study, appearing in the upcoming issue of American Journal of Preventive Medicine, more than 20 percent of U.S. adults visit their physicians each year for periodic health examination—an office visit intended for routine physicals and screenings and discussions about risk factors and lifestyle habits.

Of the preventive health services due during the examinations studied, just over half were either recommended or delivered to patients.

“Given how little the incentives and structure of the U.S. health care system support prevention, we considered this percentage impressive,” said author Jennifer Elston Lafata, Ph.D., professor of social and behavioral health at Virginia Commonwealth University. “What does and does not happen during a physician office visit is due to a mix of factors, including what the patient needs and wants to address. ”

The researchers captured audio recordings of 484 office visits by patients between the ages of 50 and 80 by 64 primary care physicians over a 2-year period in southeast Michigan.

Key Points

  • Doctors recommend or deliver about half of recommended preventive care services to adult patients during periodic checkups, a new study finds.
  • Doctors are most likely to recommend or deliver screening tests for colorectal cancer, hypertension and breast cancer.
  • Patients with higher BMI are more likely to receive preventive services when they are due, while older patients are less likely to receive preventive services.

The goal of the study was to see how often physicians delivered 19 national guideline-recommended preventive services, such as screening tests for cancer and hypertension, counseling on tobacco and alcohol use, and immunizations to patients who were eligible and due.

Of the 2,662 services due during those visits, 54 percent were delivered.

Those most likely to be given were screening tests for:

  • Colorectal cancer (92.9 percent),
  • Hypertension (92 percent), and
  • Breast cancer (88.9 percent).

“I believe with the widespread use of electronic health records and new delivery models of care we can increase the percentage,” said Charles Cutler, M.D., a practicing internist in Norristown, Pa. “Team-based care with each member providing services based on his or her level of education is ideally designed to have all patients receive all the preventative and screening services now recommended by national guidelines.”

Lafata and her colleagues also found patients were least likely to receive counseling about:

  • Aspirin use,
  • Diet,
  • Flu immunization and
  • Vision screening.

And the likelihood that patients were delivered recommended services decreased with the patients’ age and increased with higher body mass indexes (BMI).

“My hunch is that patients with higher BMIs probably are more likely to seek medical treatment, since they are likely to have one or more [chronic] medical conditions,” suggested Cutler. “Once being treated for these conditions, an obese patient would seemingly be more likely to be offered screening for preventive disorders.”

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.

Providence Mill Creek Medical Building - 12800 Bothell Everett Hwy, Everett.

Seattle Children’s opens urgent-care clinic in Mill Creek


Seattle Children’s Hospital will open a walk-in Urgent Care Clinic at the Seattle Children’s Mill Creek Clinic in Mill Creek, tomorrow, Wednesday, January 18th.

The new clinic will be located in the Providence Mill Creek Medical Building – 12800 Bothell Everett Hwy, Ste. 150, Everett, WA 98208.

The clinic will provide treatment for children, teens and young adults ages 0-21 needing non-emergency medical care in the evenings, over the weekends and during the holidays.

No appointments or referrals are necessary.

Providence Mill Creek Medical Building - 12800 Bothell Everett Hwy, Everett.

In general, the cost — and time waiting — are less at urgent care clinics than they are at emergency rooms.

Hours of operation for Urgent Care at Seattle Children’s Mill Creek Clinic will be the same as Children’s Urgent Care Clinics in Bellevue and Seattle:

  • Monday through Friday from 5 p.m. to 10:30 p.m. and
  • Saturday, Sunday and holidays from 11 a.m. to 8 p.m.

Children’s Urgent Care Clinics are not intended for serious or life-threatening emergencies, hospital officials cautioned, and if a child being seen at a Children’s Urgent Care Clinic has an emergent medical need, the patient will be transferred to an Emergency Room (ER).

To help parents decide whether to take a child to the ER or to urgent care, Seattle Children’s has prepared a quick guide:

Doctor in white coat writes on clipboard

Peeking in on your doctor’s notes


By Michelle Andrews

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

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

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

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

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

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

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

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

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

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

More From This Series: Insuring Your Health

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

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

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

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

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

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

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

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

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

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

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

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

Please send comments or ideas for future topics for the Insuring Your Health column to

KHN wants to hear from you: Contact 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.


Is overnight sleep testing overprescribed?


By Jenny Gold
This story was produced in collaboration with 

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

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

Annie Mokonya, a registered sleep technician, prepares Lauretta Martin for a sleep test at the National Rehabilitation Hospital in Washington, D.C. in December (Photo by Jenny Gold/KHN)

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

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

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

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

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

Critics worry that overnight tests to diagnose apnea may be overprescribed.

Critics, however, worry that overnight tests to diagnose apnea, particularly those done in sleep labs, may be overprescribed at great cost to the health care system.

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

Medicare payments for sleep testing increased from $62 million in 2001 to $235 million in 2009.

At the same time, insurer spending on the procedure has skyrocketed. Medicare payments for sleep testing, for example, increased from $62 million in 2001 to $235 million in 2009, according to the Office of the Inspector General.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This article was reprinted from 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.

Baby drinks from bottle

Weekend Reading: International baby business and Medicare whac-a-mole


Every week, reporter Jessica Marcy selects interesting reads from around the Web.

The Washington Post Magazine: A Family Learns The True Meaning Of The Vow ‘In Sickness And In Health’

Two wedding rings one on top of the other.

Seven years later Robert was still mentally impaired and his personality far different than before the accident, but he knew his family, knew he had had a brain injury that upended their lives, and asked lots of questions. He carried with him at all times a reporter’s notebook, in which he had written the information most important to him: his daughters’ ages — 9 and 11 — and that he has “known my honey” 18 years. … Robert had looked at Page with earnest eyes and the relaxed demeanor he used to have and asked if it was hard for her to pack up the house: “Does that cause you distress, darlin’? Make you sad?” Page took his hand, and her eyes filled with tears. “We had the best days of our lives and the worst days of our lives in that house,” she said quietly (Susan Baer, 1/5).

Photo courtesy of Photo by Marja Flick-Buijs

Columbia Journalism Review: The Bloodying Of PolitiFact: What Is Medicare, Anyway?

Now it’s my turn to weigh in on the “Lie of the Year,” the gimmick PolitiFact uses to highlight the most egregious misstatements of the past year. This time, though, the fact-checking service stumbled into a fusillade of criticism from such unlikely bedfellows as New York Times liberal columnist Paul Krugman and the conservative Wall Street Journal’s online opinion page. The lie, according to PolitiFact, was the Democrats’ assertion that Republicans voted to end Medicare when the House voted last spring to embrace a voucher plan pushed by Wisconsin congressman Paul Ryan. The fact is Republicans by supporting Ryan’s voucher plan did essentially vote to end Medicare. … PolitiFact and others should have left it there and devoted space to the larger issue. Medicare may be wildly popular, but it is not well understood by most people — be they beneficiaries, politicians, or journalists. Deconstructing how this complicated and misunderstood program works and the historical context for proposed changes would go a long way to helping the public evaluate the arguments from both Democrats and Republicans (Trudy Lieberman, 1/6).

Slate: Make Me A Baby As Fast As You Can

The booming business in international surrogacy, whereby Westerners have begun hiring poor women in developing countries to carry their babies, has been the subject of plenty of media buzzing over the past few years. Much of the coverage regards the practice as a win-win for surrogates and those who hire them; couples receive the baby they have always wanted while surrogates from impoverished areas overseas earn more in one gestation than they would in many years of ordinary work. … But make no mistake: This is first and foremost a business. And the product this business sells — third-party pregnancy — is now being offered with all sorts of customizable options, guarantees, and legal protections for clients (aka would-be parents) (Douglas Pet, 1/9).

Reason: Medicare Whac-A-Mole

It is often said that you can’t put a price on health. But for decades that is exactly what the federal government has attempted. Since the birth of the entitlement, a parade of legislators and bureaucrats has been playing billion- and trillion-dollar games of Whac-A-Mole with Medicare, knocking down spending with an elaborately constructed set of technocratic payment schemes in one area only to see it rise back up in some other part of the system. Obama is merely proposing to try it one more time (Peter Suderman, January 2012).

American Medical News: 5 Simple Ways To Cut Medical Practice Costs

Photo of Vierdrie

Physicians are finding that a few simple steps can open the door to big savings in operating a medical practice. General operating costs for multispecialty practices have increased 52.6 percent since 2001, exceeding revenue gains in that period, according to the Medical Group Management Assn., which uses such groups as bellwethers for the overall practice economy.

But those expenses were cut 2.2 percent in 2010, according to MGMA. … Consultants and experts recommend looking for savings in five key areas: office supplies, office equipment, medical supplies, finance and consulting, and energy costs (Karen Caffarini, 1/9).

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.

Map by Jim Irwin (Creative Commons License)

The public option lives


Map by Jim Irwin (Creative Commons License)

By Sarah Varney, KQED

This story is part of a reporting partnership that includes KQEDNPR and Kaiser Health News.

In a cavernous room just east of San Francisco, an army of phone operators fields calls from their customers. A large computer screen blinks the number of people on hold: two, and the average wait time: one minute, 12 seconds.

These phone operators working in a non-descript office park in Alameda are employed by a large health insurance plan, and they’re willing to go the extra mile for their customers.

They’ll schedule a doctor to come to your home, a pharmacist to drop off a prescription, and they’ll even help you fill out an application for food stamps.

“We do things for them that a traditional, commercial health plan doesn’t do,” says Ingrid Lamirault, chief executive officer of the Alameda Alliance for Health, a county-run, not-for-profit insurer.

The much celebrated, and much maligned, public option may have died in Congress, but it’s alive and well in California.

Unique in the nation for having public health insurance plans that are run by counties, California has plans that stretch from San Francisco to the Mexican border and cover 2.5 million residents.

Listen to audio of the story

Listen to Sarah Varney’s report on county-run health plans in California:

Looking Ahead To 2014

The Alameda Alliance for Health has a network of doctors and hospitals just like a private health insurance company, and it covers 200,000 people in Oakland and neighboring cities.

Just like private health insurance companies, the alliance also administers a managed care plan for Medicaid beneficiaries and additional plans for county workers.

The alliance’s CEO Lamirault doesn’t plan on stopping there.

In 2014, under the federal health overhaul law, millions of Americans will be able to buy coverage through state-based insurance exchanges.

In California, government-run public plans, like the Alameda Alliance for Health, will go head-to-head with private insurance companies to compete for all those new customers, and those who run the county plans believe they can offer a robust network of doctors and hospitals to bargain shoppers looking for low-cost coverage.

“I think when some people get to make a choice,” says Lamirault, “having local offices they can walk into and get help with things and get their questions answered, and when they call customer service they get their calls answered in under two minutes. Those kinds of things are important to them.”

Throughout California, county plan members largely go to public health clinics and county hospitals. But many counties also contract with private physicians and top-notch research hospitals.

They even share the same lobbying group as the big-named insurance companies, the California Association of Health Plans.

Some of those companies don’t have a lot of love for their public brethren. “Certainly, there are some health plans that didn’t like the idea of having to compete with these public plans,” says Anthony Wright, a public plan booster and executive director of Health Access, a Sacramento-based health care consumer advocacy group. “Especially ones that, having come out of the Medicaid program, are used to providing care at cheaper rate.”

A Continuum Of Care?

In 2010, when California became the first state in the nation to pass legislation establishing an insurance exchange under the Affordable Care Act, Anthem Blue Cross tried to bar public plans from the new marketplace.

As the public plans try to attract new customers, one of their biggest advantages may simply be disgust among some consumers with well-known health insurance brands.

In a letter to state lawmakers, the company said Congress soundly rejected the notion that the government should sell coverage in the private market, and California should not follow suit.

Wright, and others, argued successfully that almost half of those expected to buy insurance through the exchange are likely to be low- and moderate-income consumers, and many of them may have, at one point, been on Medicaid or another government-sponsored health program.

“Some of these folks who are close to the poverty line may have already been in these public plans previously,” says Wright. “And so it made sense that this might actually be a good environment for them, to be an option and for people to continue their care with them even as they move up the income ladder.”

Insurance companies say they will happily compete on price so long as the public plans do not get preferential treatment.

As the public plans try to attract new customers, one of their biggest advantages may simply be disgust among some consumers with well-known health insurance brands.

“I think insurance companies have made a bad name for themselves, deservedly so,” says Kim Burke, an art school teacher in San Francisco, who was turned down for coverage by private insurers because of pre-existing medical conditions.

For the last several years, Burke has paid a low-monthly premium for coverage in San Francisco’s public health plan. She says when the exchange opens in 2014, she’ll hold on to her public plan–and her grudge.

“I applied to four different insurance companies, all of which denied me for pre-existing conditions,” says Burke. “So I’m not really too keen on purchasing their product since they already denied me care when I really wanted it.”

For many health insurance customers, though, the ultimate selling point may simply be who has the cheapest product.

Insurance companies in California say they will happily compete on price so long as the public plans do not get preferential treatment.

Today, doctors and hospitals accept low reimbursement rates from public plans, in many cases as part of their charity care. That allows the public plans to keep their premiums low, but private plans say they are charged higher prices.

The preferential treatment is not likely to last into the new world of insurance exchanges. When the exchange opens in 2014 in California to people with higher incomes, the government-run plans will have to pay providers more than they do now, says Sumi Sousa, officer of policy development at the San Francisco Health Plan.

Sousa says the utopian belief that public plans always cost less just doesn’t pencil out. “Some commercial providers, because they’re so large, they’re able to spread their cost over a much broader network,” says Sousa. That’s not the case for many county-run health plans in California, which tend to be quite small.

Still, says Sousa, the public plans do have low overhead: Executives like her earn a fraction of the salary paid to the big CEOs, and they don’t have stockholders.

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.


Small steps to big health change


By Randy Dotinga & Kelly Malcom

Health Behavior News Service 

We often give a chilly reception to the idea of going “cold turkey” when it comes to anything that has to do with changing behaviors and habits, even those that may be important for our health.

And no wonder: habits become habits because they give us something we think we need. Maybe they make us feel better (hello, chocolate!) or they bring comfort, familiarity or convenience to our lives.

Once we get used to doing things a certain way, the idea of changing a routine behavior can seem overwhelming. And we worry (with good reason) that we won’t be successful if we try to change our habits all at once.

Joan Christensen, a 57-year-old dance teacher from North Branford, Conn., understands. The recession and personal challenges sent her into a depression. She coped by eating more, ballooning her 5-foot-4 frame up to 204 pounds. “I was feeling sorry for myself and food became my solace,” she says. Yet, she wasn’t motivated to turn her life around.

Then a medical crisis hit. Suddenly, Christensen was ready to make changes, but didn’t know where to start. With the help of her physician, she began to take small but meaningful steps to reduce her weight. It worked.

“I’m a new woman,” Christensen says. Through a series of small steps over a period of six months, she lost 44 pounds.

What can I do to ensure my success in changing my behavior?

  • Get help from your primary care doctor (or another professional, like a nutritionist)—they may have access to resources you don’t know about.
  • Make changes you’re about 70 to 80 percent sure you can accomplish.
  • Set up your environment to trigger the behavior you want to engage in (i.e. if you want to floss your teeth more frequently, put the dental floss next to your toothbrush).
  • Focus on the positive impact of what you are doing, rather than how far you have to go.
  • Think about finding or creating a support group.

It’s not just common sense that backs up her go-slow approach. Research supports it too, suggesting we’re more likely to improve our health if we don’t pressure ourselves into developing new routines overnight but instead take time to learn new habits.

“We talk as if willpower were the whole show,” says Christensen’s physician, David Katz, M.D., director of Yale University’s Prevention Research Center. “But that’s like thinking you can climb Mount Everest if you just want to badly enough. Nonsense. You need mountaineering skills.”

Tipping Points

“Rationally, you’d think motivation would be strong enough to get you to adopt a health behavior, but it’s not,” says BJ Fogg, Ph.D., director of the Persuasive Technology Lab at Stanford University.

“Motivation and habits actually live in different worlds.”

Fogg works on creating systems to change human behavior and adapting those systems for use with mobile devices. “Motivation and habits actually live in different worlds,” Fogg says.

Motivation, he explains, is important for developing the initial surge in energy to make a change, what he calls a motivational wave.

For Christensen, her motivational wave wasn’t voluntary. She became ill one particularly busy day after eating an unhealthy breakfast and skipping lunch.

Nausea, stomach pains and shortness of breath hit her all at once. “I sat down and cried,” she recalls. “I was spiraling out of control and had hit bottom. I then knew that it was now or never.”

It’s quite common for a medical crisis to serve as a tipping point, Katz notes.

“Unfortunately, tipping points do tend to come in the aftermath of calamity, such as after a heart attack or stroke. Sometimes they occur when a medical crisis strikes a family member or friend,” he says. “Sometimes they are due to other kinds of events that change our perspective-such as pregnancy. What is most powerful varies with the individual.”

If you can’t quite bring yourself to begin changing your health for the better, there are things you can do to help move in that direction. Talk to your doctor, Katz suggests, and ask about the perils of the status quo and the possible benefits of changing your habits.

Simply having motivation, wherever it originates, is not enough to develop new habits. “One of the problems is when people fail at changing their behavior they blame themselves and their lack of motivation. They are blaming the wrong thing,” says Fogg.

Online Support for Health Change

You might start out with an online health assessment like this tool from Dartmouth:

Looking for ideas about small steps that could make a big difference to your health? Check these online resources:

  • General health information and guidance about healthy living is available from the U.S Department of Health and Human Services at
  • The U.S. Department of Health & Human Services offers 119 ideas about small steps you can take to improve your diet and get more exercise. Examples: Grill, steam or bake instead of frying. Choose a checkout line without a candy display. Walk to a co-worker’s desk instead of emailing or calling.
  • The American Dietetic Association offers a variety of small ways to shave calories off your daily diet. Examples: Don’t eat out of a box or bag because you’ll feel like you need to finish everything. Satisfy your ice cream urge by buying brands that are slow-churned and have reduced calories.


  • is available from the Tobacco Control Research Branch of the National Cancer Institute to offer help with quitting smoking.

Mental health and substance abuse:

  • This resource guide from a California non-profit lead by Robert and Jeanne Segal with support from Rotary International could be helpful for a wide range of health concerns including mental health and substance use information:

Skill-Building over Time

Katz says some people actually prefer to make a big change in one fell swoop. They might suddenly quit smoking or start following their insulin injection routine to the letter. “It’s constitutionally who they are,” he says.

But researchers have found that most people do better with a slower, step-by-step approach, Katz says. To use this approach effectively, however, you may need an education in exactly what your options can be.

People often fail at making important changes because they lack information, adds Judith H. Hibbard, Ph.D., a professor of health policy at the University of Oregon who studies the choices people make about their health. “They don’t know what their role is in the care process, and they’re overwhelmed with the task of managing their health. It’s more like being defeated and discouraged rather than being lazy.”

With her doctor’s help, Christensen learned new weight-loss techniques. She started keeping a food diary, for instance, to give her insight into her daily diet. “You don’t realize what you are putting in [your body] until you see it on paper,” she says.

She began eating six times a day instead of going from breakfast to dinner without food. She cut down on sugar by changing brands, learned to savor her food instead of wolfing it down and tried new recipes.

“It isn’t easy…in the beginning it was very hard to give up sugar,” she says. “But you soon learn that it’s not a necessity. I can now go out and watch people have dessert around me, and it doesn’t faze me. It is empowering to know that you are in control. And I have found that gaining control over my weight and eating habits has taught me to take control in the areas of my life that were causing the overeating.”

If you’re overweight, you may think Christensen’s success is unrealistic. But a landmark 2002 study published in the New England Journal of Medicine finds that a moderate amount of weight loss, the kind you can achieve through fairly minor changes in exercise and eating habits, had a bigger positive effect on overweight people at risk for diabetes than preventive medication had.

Those who exercised a half-hour a day and lost just 5 to 10 percent of their weight-10 to 20 pounds for a 200-pound person-were almost 60 percent less likely to develop diabetes.

If 30 minutes seems like too much, Fogg suggests starting shorter. “Tiny habits grow into full behaviors over time. If you get in the tiny habit of exercising for three minutes and that becomes a true habit, you will eventually just naturally end up doing 30 minutes,” he says. “Over time, you develop the physical capabilities and arrange the world around you to make it easier.”

Building Confidence

Needles don’t bother Joan Reder, a medical transcriptionist with the Scripps Health System in San Diego. That’s a good thing: She has had type 1 diabetes for 35 years and daily insulin injections have long been part of her daily routine.

But something does make the 59-year-old Reder nervous: technology.

Recently, she was intrigued by the idea of converting to using an insulin pump that would allow greater control of her insulin levels. But it worried her, too.

For one thing, the idea of using new technology didn’t thrill her. “I’m not a techie person. I know what I need to know to use my computer, and the rest…well, I don’t want to know,” she says.

She had also heard a secondhand horror story about the pump and didn’t want to shell out money for a pump that she might not want to keep using. “So having a pump was really scary to me,” she recalls.

Then she discovered that she could enroll in a study that allowed her to get extra support from medical staff and try the pump without making a major financial commitment. It also helped that she was able to turn to other diabetics in a support group and learn tips about how to use the pump.

“They know things that your doctor can’t tell you unless your doctor has diabetes, like how to eat pizza or M&Ms with the pump,” she says.

Christensen tried the pump and loved it. Instead of giving herself insulin injections throughout the day, she programs the pump’s computer to deliver the amount she needs based on what she eats.

That’s much easier than going through the multiple injections that she used to endure to be able to safely eat certain foods.

She now regularly wears the pump, which weighs about half a pound and delivers the insulin through a tube that goes under the skin in her stomach. “There’s a lab test that I take every time before I see my endocrinologist. The ideal measurement is 7 or below. The day I started on the pump, it was 8.4. Three months later, it was a 6.7.”

That improvement wouldn’t have happened without the support that helped her gain the confidence to take the small step of simply trying the pump, she says.

Taking It Home

Confidence, it turns out, is crucial to improving health through small steps. To take advantage of the powers of confidence, it’s a good idea to make changes that you’re about 70 to 80 percent sure you can accomplish, says David Sobel, M.D., medical director of patient education and health promotion for Kaiser Permanente’s Northern California system.

Judith Hibbard said she’s heard of dieters whose first step was to eat nine donuts a day instead of 12.

Katz and Hibbard say there are many other small steps you can take if your goal is to lose weight. Don’t shop while you’re hungry, for instance, and prepare a shopping list to guide healthier choices. At work, take the stairs a few days a week instead of the elevator.

You further your chance at success if you set up your environment to help trigger the behavior you want, according to Fogg. “If you want to floss more, put the floss next to your toothbrush.

When developing habits, you should try to make something you already do become the trigger for the next thing.”

Success, if you reach it, will build your sense of confidence, but don’t stop early in the process. “The thing about small steps is that you need to keep moving forward and take the next step after that,” Hibbard says.

Luckily, Fogg points out, “In general, the more you do a behavior, the easier it is to do.”

As you move forward, remember the lessons of Christensen and Reder: it’s easier to change your life when supportive people are behind you. Friends and family can make a big difference, as can the staff at your medical office. Some people also seek out support groups.

“Social support can be helpful if the people around you already have the habit you want,” says Fogg.

If you can’t find the help you need, consider creating support systems yourself, as Reder did. She co-founded a group at Scripps Health’s Behavioral Diabetes Institute that matches diabetic patients with other similar patients who serve as mentors. The program is called Diabetes TLC, with the initials standing for “talk, listen, connect.

The idea is to give the kind of insight and support that doctors can’t provide because they don’t suffer from the condition themselves, Reder says.

“The small steps our clients have taken with support from one of our teammates have assisted many of them in making huge changes, including better lab results, weight loss, testing their glucose more often and more balanced lives,” she says. “If you give people a list of 22 things they have to do, they’ll say forget it. If you do things one or two steps at a time, you’ll experience success and get ready to do more.”

It’s a small steps-big change success story. And there’s not a cold turkey in sight.

Randy Dotinga is a Contributing Writer, and Kelly Malcom is an Editor for Health Behavior News Service.

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.

Petri Dish

New bill would put taxpayer-funded science behind pay walls


By Lena Groeger

Right now, if you want to read the published results of the biomedical research that your own tax dollars paid for, all you have to do is visit the digital archive of the National Institutes of Health.

There you’ll find thousands of articles on the latest discoveries in medicine and disease, all free of charge.

A new bill in Congress wants to make you pay for that, thank you very much.

The Research Works Act would prohibit the NIH from requiring scientists to submit their articles to the online database. Taxpayers would have to shell out $15 to $35 to get behind a publisher’s paid site to read the full research results. A Scientific American blog said it amounts to paying twice.

Two members of Congress — Reps. Darrell Issa, R-Calif., and Carolyn Maloney, D-N.Y. — introduced the bill. Rebecca Rosen ofThe Atlantic finds it curious that Issa, a well-known champion of the open Internet whose own website displays the words “keep the web #OPEN,” would back a bill that appears to be the polar opposite of open access.

As Michael Eisen, a University of California, Berkeley, biologist and open access supporter, notes, Maloney’s support seems no less mystifying since she represents “a liberal Democratic district in New York City that is home to many research institutions.”

Both Issa and Maloney have received campaign contributions from the Dutch companyElsevier, which calls itself the world’s leading publisher of scientific and medical information. According to MapLight, a website that tracks political cash, Elsevier and its senior executives last year made 31 contributions to House members totaling $29,500. Twelve contributions totaling $8,500 went to Maloney; Issa received two for a total of $2,000.

This isn’t the first effort by publishers to push Congress to roll back the NIH’s public access policy, which was enacted in 2008 and applauded by doctors, patients, librarians, teachers and students.

Under the policy, all research funded by the NIH was required to be made freely available to the public one year after publication on PubMed Central. (The NIH also runs PubMed, a biomedical research database that includes articles that aren’t federally funded and cost money to access.)

In 2009, as Eisen notes, the Association of American Publishers backed the Fair Copyright in Research Works Act. That bill never left committee, but this new bill is essentially a shorter version of the same thing (and was similarly praised by the AAP for forbidding “federal agencies from unauthorized free public dissemination of journal articles”).

Two arguments in favor of the bill crop up regularly:

  1. Publishers like Elsevier add value to every scientific journal article by overseeing the peer-review, editing and publishing process. Because of this contribution, they deserve exclusive rights to each article permanently, not merely one year after it has been published.Tom Reller, vice president for global corporate relations at Elsevier, comments here that Elsevier and other commercial and nonprofit publishers invest hundreds of millions of dollars each year in managing the publication of journal articles.”
  1. Publishing companies need this money to keep the industry going. As the AAP states: “At a time when job retention, U.S. exports, scholarly excellence, scientific integrity and digital copyright protection are all priorities, the Research Works Act ensures the sustainability of this industry.”

In the recent commotion over the bill (here’s a roundup of recent posts), the academic community has replied to both of these claims.

In response to the added value argument, Kevin Smith, scholarly communications officer at Duke University, argues that publishers don’t actually produce or add much themselves.

The work comes from academics and from the peer reviewers who volunteer their time to read and critique the work of their fellow academicsAccording to Eisen, although publishers might contribute a little something to the peer-review process (organization, supervision, etc.), this pales in comparison to the work done for free.

In response to the jobs and industry argument, Heather Morrison, a doctoral candidate at the Simon Fraser University School of Communication in Vancouver, B.C., points out that the top scientific, technical and medical publishers (Elsevier, Springer, Wiley, Informa) have seen profit margins of 30 percent to 35 percent in the last year.

Elsevier, part of a global multibillion-dollar information conglomerate with offices in New York City, publishes about 1,800 journals and last year made a profit of $1.1 billion.

The Economist makes the same point: The industry seems to be doing just fine. Furthermore, there is evidence that more jobs would come from open policies than from closed ones, says Peter Suber, an open access advocate at Harvard University.

In his response to a recent White House request for information on public access in research, Harvard Provost Alan Garber calls the current situation an “access crisis.”

He argues that public access is crucial to growing businesses, which need access to cutting-edge research to stimulate innovation, develop new products, improve existing ones, and create jobs.

“If the NIH policy is flawed,” writes Garber, “it is for allowing needlessly long delays before the public gains access to this body of publicly funded research, and for allowing needless restrictions on the public use and reuse of this research.”

Want to know more? Follow ProPublica on Facebook and Twitter, and get ProPublica headlines delivered by e-mail every day.

Photo: Sanja Gjenero

Burn ban issued for King, Kitsap, Pierce and Snohomish counties


Photo: Sanja Gjenero

The  Puget Sound Clean Air Agency has issued a Stage 1 burn ban for King, Kitsap, Pierce and Snohomish counties, as a high-pressure system brings cold temperatures and calm winds to the region and creates conditions that can trap smoke from wood fires and other air pollutants.

Under the ban the use of fireplaces and uncertified wood stoves is prohibited until further notice.

Air quality is expected to worsen at least through Friday, especially in communities where residential wood burning is common, Clean Air Agency forecasters said.

Air pollution can trigger asthma attacks, cause difficulty breathing, and make lung and heart problems worse.

Air pollution is especially harmful to people with lung and heart problems, people with diabetes, children, and older adults (over age 65), the agency warned.

The Washington State Department of Health recommends that people who are sensitive to air pollution limit time spent outdoors, especially when exercising.

Photo by Sanja Gjenero

During a Stage 1 burn ban:

  • No burning is allowed in fireplaces or uncertified wood stoves. Residents should rely instead on their home’s other, cleaner source of heat (such as their furnace or electric baseboard heaters) for a few days until air quality improves, the public health risk diminishes and the ban is cancelled.The only exception is if a wood stove is a home’s only adequate source of heat.
  • No outdoor fires are allowed. This includes recreational fires such as bonfires, campfires and the use of fire pits and chimineas.
  • Burn ban violations are subject to a $1,000 penalty.

It is OK to use natural gas, propane, pellet and EPA certified wood stoves or inserts during a Stage 1 burn ban.

(Note: The Seattle Parks Department prohibits beach fires at Alki and Golden Gardens during air quality burn bans.)

How to tell if a wood stove is certified, and OK to use during a Stage 1 burn ban?

Age matters – if the stove is over 20 years old, it is likely uncertified and prohibited for use during a burn ban.  Uncertified wood stoves are no longer legal to sell or purchase in the State of Washington due to the significant pollution they generate.  A certified stove will have an EPA label on the back.

For more information:

Purple Heart_Thumbnail

Washington state program helps vets on Medicaid get their VA benefits


It is commonly accepted that many poor veterans and their families find themselves on Medicaid, even though, in many cases, they would qualify for more generous benefits from the Department of Veterans Affairs.

The VA’s Aid and Attendance program, for instance, helps wartime veterans receive the care they need to stay in their homes or assist with long-term care expenses.

But many who are entitled to this benefit end up on Medicaid — which has significant implications for the veteran’s family members.

In 2003, the state of Washington began a pilot program to identify veterans who were falling through the cracks. In the years since, the program has served thousands of people who qualified for this assistance.

At the same time, it has helped relieve some of the fiscal pressure placed on the state’s Medicaid program by shifting these costs to the federal VA. Viewed as a win-win, the program has become a model for other states.

KHN asked two state officials invovled in the program’s operations to explain the basics of the Veterans Benefit Enhancement Project — how it came to be and why it is making a difference for both the state’s veterans and its budget.

Bill Allman, who developed and now manages the Washington State Health Care Authority’s program.Alex Deluao of the Washington State Department of Veterans Affairs

Bill Allman: How PARIS is helping veterans in need

About 10 years ago, I first heard about a federal databank called PARIS — the Public Assistance Reporting Information System. I

t was set up to allow both state and federal programs the opportunity to compare public assistance files, primarily to look for cheaters who were double-dipping by drawing the same kind of benefits from different government programs.

Astonishingly, a broader use of such a databank had gone unrealized until I started asking questions, particularly about the military and veteran program information available to the states.

With my background in medical assistance for the state of Washington, I was well aware of the fact that many poor veterans and their families were winding up on the rolls of Medicaid, never realizing that they might also be eligible for richer federal benefits.

For example, the VA will pay elderly/disabled veterans up to $23,396 per year and surviving spouses of veterans up to $12,691 per year.

And, the National Care Planning Council estimates that approximately 11.5 million seniors – about 33 percent of all people older than 65 – could qualify for pension or death pension benefits.

For my part, I am still stunned to realize how many veterans did not realize they qualified for the federal benefits.

It occurred to me that PARIS may offer a way to reverse this reality by pinpointing the many veterans who were seemingly falling through the cracks.

Here’s why: the PARIS data is keyed to an individual’s social security number, and includes information about state welfare and medical assistance billings, as well as that person’s eligibility for civil service benefits; Defense Department programs like CHAMPUS, a health plan for military dependents and surviving spouses; and the TRICARE managed care plan that serves many active duty military and retirees.

Therefore, armed with this databank, I had a way to uncover who was eligible but not receiving these veteran’s health care benefits.

In short, it was exactly what I had been looking for, because I was well aware that being on Medicaid was a disadvantage in another way.

If you know a veteran or family member in Washington State who needs our help, please let the VA know how we can reach them. 

When veterans died on Medicaid, their families usually lost their small estates because long-term-care-related Medicaid clients typically pay for a small portion of the health care they receive, but the programs do require the recovery of those costs if a client dies and leaves any kind of an estate behind.

Thus, the state, in this case Washington, has first claim or lien, through the “estate recovery process,” on a deceased veteran’s home, as well as other property and assets that went untouched while the individual was still alive.

But that’s not true for federal veteran benefits because those are provided in gratitude for the veterans’ service to country. As a Vietnam veteran myself, I was very conscious of what that difference might mean, and I had already begun to seek out ways to counter it.

PARIS was the answer. With a little effort, I found ways to use the federal databank to locate veterans on Medicaid and then help them transition to federal benefits. It had a good payoff for the state, too, which was dealing with budget crunches throughout the decade.

I took what I found to the head of my agency — Dennis Braddock, himself a helicopter pilot in the Vietnam War — and got the go-ahead to set up a pilot program in Clark County, which is located in southwestern corner of the state.

The initiative also has gotten the strong backing of Mike Gregoire, the husband of our current governor and a strong advocate for Washington state veterans.

We began our pilot in 2003, focusing at first on long-term care beneficiaries, most of them in nursing homes. From the very beginning, we worked in partnership with the Washington State Department of Veterans Affairs and other state social action programs.

Since then, we have become a model for many more states, with more than two dozen now beginning to evaluate the PARIS system and set up similar programs.

“Connecting veterans and their families to benefits they earned through their military service is simply the right thing to do,” John Lee, director of the Washington State Department of Veterans Affairs, told me. “This partnership allows us to reach out to veterans and families and let them know we’re here to help.”

For my part, I am still stunned to realize how many veterans did not realize they qualified for the federal benefits. In addition, they didn’t know that Medicaid benefits often aren’t free.

We’ve helped thousands of veterans in the eight years since we got our pilot up and going, and I think it’s fair to say we’ve saved millions of dollars for those veterans. Taxpayers, too, have benefited by some $30 million in cost avoidance as of the end of Fiscal Year 2011.

The program’s successes include not only moving vets onto federal VA health care  programs, but also enhancing some vets’ current benefits and lining up monthly cash payments and dependent benefits.

It’s amazing to me in retrospect that these loopholes exist in our health care system, letting people fall through the cracks when a little bit of forethought can prevent that.

I’m proud of our state for leading the way on this effort. The system we’ve pioneered is now in place to help future vets like those returning from Iraq and Afghanistan. I’m just one person and we’re just one state, but we made a big difference. That thought just knocks me down.

Bill Allman is the manager of the Washington State Health Care Authority Veterans Benefit Enhancement/PARIS Projects. Readers with questions about PARIS or related projects can contact him at

Alex Deluao: Helping low-income veterans maintain the best possible quality of life

As Americans, we feel a sense of gratitude to those who raise their hands and defend our freedoms.

But sometimes, veterans miss out on the benefits they earned, something we often see when it comes to health care and long-term care.

You might be surprised that many people who served in the military either don’t consider themselves to be veterans or are too proud to ask for these benefits. This is especially true for older veterans whose military service is a distant memory, often decades old and sometimes purposefully forgotten.

For the most part, they probably got along just fine without anything from the government. But circumstances can change and sometimes extra help is necessary.

Take, for example, an older couple that recently received the assistance they needed from a veterans’ program.

The husband, a Korean War veteran, served his country, came home, and built a family and a career. He always had enough money saved away for the emergencies that life presented. But after suffering an injury, he knew he needed extra help.

His wife had been caring for him but she too was becoming frail, and he was worried that taking care of him was putting too big a burden on her.

So far, we have helped connect more than 3,300 veterans or their widows to these programs and their benefits.

That’s when the Veterans’ Affairs Aid and Attendance program proved crucial to this couple’s well-being.

This federal program can help wartime veterans remain at home or assist them in paying for long-term care. It’s available to lower-income veterans and their widows, who also qualify for VA pension benefits.

A large number of veterans across the country who qualify for this aid, however, somehow are slipping through the cracks. It leads to this very serious question: How do we connect veterans who are in need and who are eligible to this benefit?

Thanks to the creative thinking of employees at the Washington State Department of Social and Health Services and the Washington State Department of Veterans Affairs, we have found an answer.

In 2003, our agencies joined forces and started a pilot project to match federal VA data with the Public Assistance Reporting Information System.

PARIS, as it’s known, shows us who has applied for Medicaid benefits. When we match that information against the Federal VA’s data, we can identify eligible veterans or their widows, and help them apply for VA Pension and Aid and Attendance.

So far, we have helped connect more than 3,300 veterans or their widows to these programs and their benefits.

It’s one of those rare situations where everyone wins. Veterans receive monthly payments that can be used for in-home care or long-term care, and our state saves millions of dollars with fewer people using the Medicaid program.

Veterans also are able to utilize a benefit they earned through their military service, which, unlike Medicaid benefits, do not have to be re-paid.

There is nothing more satisfying than pioneering ways to help deserving people and we continue to be amazed at how much this partnership has done to help Washington’s veterans.

At WDVA, our goal is to help veterans and their families get connected with everything they earned, and we’re always looking for innovative ways to reach them.

If you know a veteran or family member in Washington State who needs our help, please let us know how we can reach them. Call us at 1-800-562-2308 or visit us online at To find another State’s Department of Veterans Affairs visit

Alex Deluao is the manager of the Washington State Department of Veterans Affairs Olympia Service Center.

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.

Gruber Thumb

The health law goes graphic


By Michelle Andrews

Nearly two years after the passage of the federal health law, more than 40 percent of people say they know little or nothing about how the law will affect them, according to the Kaiser Family Foundation’s latest monthly health tracking poll, published in December.

That figure hasn’t budged since April 2010, just after the law was signed.

Jonathan Gruber, an economist at the Massachusetts Institute of Technology, aims to change that with a book, “Health Care Reform: What It Is, Why It’s Necessary, How It Works,” that explains the ins and outs of the law in an innovative way: an adult comic-strip form similar to graphic novels.

Gruber was one of the architects of the Massachusetts’ health care overhaul, which included many features that appear in the federal law, and he advised the Obama administration and Congress on the Affordable Care Act.

I spoke with him about his new book, which he co-authored with HP Newquist. The book is illustrated by Nathan Schreiber.

Q. What made you decide to write a book for consumers about health reform?

A. I think what really inspired me was hearing that when you polled consumers about the Affordable Care Act they were split in their support. But when you polled them about individual pieces of the law, they liked it.

As an educator, you didn’t have to do any more than explain what the law did [to gain support]. It needed to be explained in a way that people understood.

Q. Why did you choose a graphic novel format?

A. The publisher approached me about doing it that way. At first I wasn’t that enthusiastic. I didn’t think it would be that effective. But the publisher said they had done a graphic novel about the 9/11 Report.

My son likes graphic novels, he’s 17. He said it’s a great opportunity, it’s a great medium. When you’re on a plane and they want to teach you what to do in case of accident, they hand you a graphic. I think it was the right call.

Q. Who’s the primary audience for this book?

A. I wrote it for the person who is confused and open-minded about this bill. The person who doesn’t understand it. The two groups I really hope will read it and benefit from it are the independent voter who was inclined to like Obama and knows it’s a big, transformative bill and wants to learn more, and the disaffected Democratic voter. I’m stunned that many don’t support it.

Q. Do you think it will change any minds? Turn opponents into supporters?

A. I don’t think it’s going to change the minds of anyone who’s convinced it’s a bad piece of legislation. But it could change the minds of those who are wary and concerned.

Q. You showcase Massachusetts as an example of how health reform can work, noting that it employs some of the same elements that appear in the federal law, like the individual mandate that requires people to have insurance. What should readers be aware of about Massachusetts’ experience with health reform? Has anything surprised you?

A. I would say the point the book tries to make is that Massachusetts was successful in what it tried to do. It reduced the number of uninsured and lowered non-group insurance premiums.

Premiums for individual market plans fell by 50 percent relative to national trends. The biggest surprise to me is that employer-sponsored health insurance actually went up after reform when it was falling everywhere else in the country.

It speaks to the power of the [individual] mandate. People said, “Give me health insurance,” and they did.

Q. You talk about how health care reform will help Anthony, Betty, Carlos and Dinah, all of whom have different health insurance situations. But you don’t discuss what will happen to Emilio the undocumented worker, who won’t get coverage under the new law. Did you consider talking about who loses out under health reform, including the roughly 11 million illegal immigrants?

A. You hit on a great issue: Who loses out under the law. People don’t lose out. Emilio doesn’t lose out, he just doesn’t gain. A lot of people don’t gain. By design, the bill leaves a lot of people alone, including those with employer-sponsored insurance.

They don’t lose but they don’t gain either. As for undocumented immigrants, there was no support to help them. Unfortunately, the law leaves them out in the cold. That was just a political reality.

Q. I know it’s a big piece of legislation and you were trying to cover a lot of ground, but I couldn’t help thinking as I read the book that in some places you oversimplified in such a way that it made the law look better than it is. Can you talk a bit about concerns some may have that you may confuse readers by making sweeping statements about the benefits of this law?

A. Certainly I wrestled a lot with where to simplify and where not to. I think I tried my best to never be misleading. At the end of the book there’s a set of references where people can go to learn more about the law.

I think the truth is that most people don’t want that level of detail. It’s for people who just want to know what the heck is this bill.

Q. In the book you discuss the long-term care program created under the law, the CLASS Act, which the administration has decided not to implement, at least not at this time. Obviously, this law is changing and evolving. Depending on what happens in the next election, it could change a lot. What do you think is going to happen? Do you have any plans to update the book?

A. I am fairly confident, I think there’s a better than 50 percent chance, for the Supreme Court not to turn down the mandate, and voters not to kick Obama out of office.

If both those things go that way, I think it will be an incredibly positive thing for the Democrats in 2016. It will be good for them because the law will be doing good things by then.

States need to move more quickly if we’re going to implement the law smoothly. I can see it starting out roughly and being in great shape in a year or two.

My guess is I wouldn’t want to update [the book]. I haven’t really thought about that.

Please send comments or ideas for future topics for the Insuring Your Health column to

KHN wants to hear from you: Contact 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.

Photo by Brainloc

Health spending slowed in 2010


Photo by Brainloc

By Marilyn Werber Serafini
KHN Staff Writer

National health care spending grew slowly for the second consecutive year in 2010, bringing it in line with growth in the U.S. economy, the Department of Health and Human Services reported Monday.

Spending grew by 3.9 percent in 2010, to $2.6 trillion, while the gross domestic product increased 4.2 percent, according to the agency, which published its findings in the journal Health Affairs.

In 2009 spending increased 3.8 percent. By contrast, in 2007, it grew by 7.6 percent. Spending increases sometimes reached double digits in the 1980s and 1990s.

While spending growth overall remained slow, for the first time in seven years premiums for people in private insurance plans grew faster than what was spent on their care, according to the Centers for Medicare and Medicaid Services.

Premiums in 2010 rose 2.4 percent, slightly lower than the 2.6 percent increase in 2009. But private health insurers’ spending on actual benefits rose only 1.6 percent in 2010. That’s down from 3.7 percent in 2009.

Spending grew by 3.9 percent in 2010, while the gross domestic product increased 4.2 percent.

The recession had a lot to do with the trend, CMS officials said. With fewer people insured, and private insurers generally picking up less of the cost, patients went to the doctor and hospital less.

Karen Ignagni, president of America’s Health Insurance Plans, said that the portion of premiums “allocated to health plans administrative costs was among the lowest in recent years, despite the fact that health plans have been incurring new compliance and regulatory costs related to the health care reform law.”

Spending on prescription drugs also declined in 2010. Not only did individuals buy fewer drugs, but there were also more switches from brand to lower-cost generic medications. Moreover, CMS noted that fewer new drugs came onto the market.

Economy only part of the explanation

Two health care analysts, however, said that the explanation may go beyond the recession. “The utilization slowdown is at least in part structural, and not just cyclically driven by the economy, and the adoption of higher cost sharing plan designs will result in some level of permanent slowdown in trend,” said Ana Gupte, a senior analyst at Sanford Bernstein, which conducts research for investors.

Tom Miller, resident fellow at the American Enterprise Institute, said that the trend is worth watching since it has continued more than a couple of years.

“We may have broken the old dynamic, where there’s an ingrained force that says we will spend more on health care than we do on other things,” he said.

As in other areas of the economy, he said, people are checking their spending on health care because they are faced with paying a greater share of the cost. “This is more in balance with how we’ve pulled back on consumption spending in other areas. Even this last remaining holdout has begun to buckle, and it’s been enough years to say the basic forces are changing.”

Federal share of spending rises

At the same time, there has been a shift in health care spending from the private sector and the states to the federal government. The federal government’s share of total national health care spending increased from 23 to 29 percent between 2007 and 2010.

Over the same time, business’ share of health care spending decreased from 23 percent to 21 percent, and spending by state and local governments declined from 18 percent to 16 percent.

Again, CMS officials cite the recession; the federal government gave states extra help to get Medicaid coverage to more uninsured people. The federal government matches state spending on Medicaid, and, during the recession, it stepped up its contributions. Still, total spending on Medicaid increased 7.2 percent in 2010, which is down from 8.9 percent growth in 2009.

Medicare spending grew 5 percent, which is slower than the 7 percent growth the year before. The main reason, according to CMS, was that the health law required the federal government to decrease payments to Medicare Advantage plans.

About a quarter of Medicare beneficiaries are enrolled in these private insurance plans, and Medicare had been paying about 14 percent more for people in these plans than in the traditional fee-for-service program.

The health law aims to equalize what the federal government pays for beneficiaries in both programs.

As a result of the change, says Anne Martin, a CMS economist, enrollment in Medicare Advantage plans increased more slowly in 2010, as beneficiaries instead chose traditional Medicare, reversing a long-time trend. Following several years of declines, enrollment in fee-for-service increased 1.5 percent, marking the highest growth rate since 2004.

Enrollment in Medicare Advantage, meanwhile, increased 5.6 percent in 2010, much less than the 10.5 percent growth in 2009.

Gupte, though, says that Medicare Advantage enrollment growth has increased since then.

PHOTO: Brainloc

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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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Recall includes Excedrin, NoDoz, Bufferin and Gas-X products


The pharmaceutical company Novartis Consumer Health is recalling all lots of select bottle sizes of Bufferin, Excedrin, NoDoz, and Gas-X Prevention products distributed in the U.S., because the products may contain stray tablets, capsules, or caplets from other drugs, or contain broken or chipped tablets.

Novartis Consumer Health advises consumers who have purchased these recalled products to discontinue use and return them to Novartis Consumer Health for a full refund.

The recall includes:

  • Excedrin and NoDoz products with expiry dates of December 20, 2014 or earlier as well.
  • Bufferin and Gas-X Prevention products with expiry dates of December 20, 2013 or earlier.
Consumers should contact their physician or healthcare provider if they have experienced any problems that may be related to taking or using these drug products, company officials said.

Consumers that have the product(s) being recalled should contact the Novartis Consumer Relationship Center at 1-888-477-2403 (available Monday-Friday 9 a.m. to 8 p.m. Eastern Time) for information on how to return the affected products and receive reimbursement.

  • For more detailed information, consumers should visit the Novartis website at
  • Additional information may also be found on the FDA website at

Adverse events that may be related to the use of these products may be reported to FDA’s MedWatch Adverse Event Reporting Program either online, by regular mail or by fax:

  • Regular Mail: use postage-paid FDA form 3500 available at: — and the completed form mail to MedWatch, FDA, 5600 Fishers Lane, Rockville, MD  20852-9787
  • Fax: 1-800-FDA-0178
Embryonic stem cells (Photo: Nissim Benvenisty)

Beware of stem-cell scams, says FDA


Embryonic stem cells (Photo: Nissim Benvenisty)

Consumer Update from the FDA

Stem cell therapies offer the potential to treat diseases or conditions for which few treatments exist.

Stem cells, sometimes called the body’s “master cells,” are the precursor cells that develop into blood, brain, bones and all of your organs.

Their promise in medical treatments is that they have the potential to repair, restore, replace and regenerate cells that could then be used to treat many medical conditions and diseases.

But the Food and Drug Administration (FDA) is concerned that the hope that patients have for cures not yet available may leave them vulnerable to unscrupulous providers of stem cell treatments that are illegal and potentially harmful.

FDA cautions consumers to make sure that any stem cell treatment they are considering has been approved by FDA or is being studied under a clinical investigation that has been submitted to and allowed to proceed by FDA.

FDA has approved only one stem cell product, Hemacord, a cord blood-derived product manufactured by the New York Blood Center and used for specified indications in patients with disorders affecting the body’s blood-forming system.

Regulation of Stem Cells

FDA regulates stem cells in the U.S. to ensure that they are safe and effective for their intended use.

“Stem cells can come from many different sources and under the right conditions can give rise to many different cell types,” says Stephanie Simek, Ph.D., deputy director of FDA’s Office of Cellular, Tissue and Gene Therapies.

Stem cells that come from bone marrow or blood are routinely used in transplant procedures to treat patients with cancer and other disorders of the blood and immune system.

Umbilical cord blood is collected from a placenta with the birth mother’s consent. Cord blood cells are then isolated, processed, and frozen and stored in a cord blood bank for future use. Cord blood is regulated by FDA and cord blood banks must follow regulatory requirements.

But there are many other stem cell products, including other cord blood-derived products, that have been reviewed by FDA for use in investigational studies, says Simek.  Investigational products undergo a thorough review process as the sponsor prepares to study the safety and effectiveness of the product in adequate and well-controlled human studies (clinical trials).

As part of this review, the sponsor must show how the product will be manufactured so that FDA can make certain that appropriate steps are being taken to help assure the product’s safety, purity and potency. FDA also requires that there be sufficient data generated from animal studies to aid in evaluating any potential risks associated with the use of these products.

Consumers need to be aware that at present–other than cord blood for certain specified indications–there are no approved stem cell products.

Advice for Consumers

  • If you are considering stem cell treatment in the U.S., ask your physician if the necessary FDA approval has been obtained or if you will be part of an FDA-regulated clinical study.

    This also applies if the stem cells are your own. Even if the cells are yours, there are safety risks, including risks introduced when the cells are manipulated after removal.

  • There is a potential safety risk when you put cells in an area where they are not performing the same biological function as they were when in their original location in the body,” says Simek.

    Cells in a different environment may multiply, form tumors, or may leave the site you put them in and migrate somewhere else.

  • If you are considering having stem cell treatment in another country, learn all you can about regulations covering the products in that country.Exercise caution before undergoing treatment with a stem cell-based product in a country that—unlike the U.S.—may not require clinical studies designed to demonstrate that the product is safe and effective.

    FDA does not regulate stem cell treatments used in solely in countries other than the United States and typically has little information about foreign establishments or their stem cell products.

Thwarting a Stem Cell Scheme

In December, 2011, three men were arrested in the United States and charged with 15 counts of criminal activity related to manufacturing, selling and using stem cells without FDA sanction or approval.

According to the criminal indictment, one of the accused, a licensed midwife who operated a maternity care clinic in Texas, obtained umbilical cord blood from birth mothers, telling them it was for “research” purposes.

Instead, the midwife sold the cord blood to a laboratory in Arizona which, in turn, sent the blood to a paid consultant at a university in South Carolina.

The owner of the laboratory in Arizona was convicted in August 2011 of unlawfully introducing stem cells into interstate commerce.  She faces up to 3 years in prison and a fine of up to $10,000.

The consultant, an assistant professor, used university facilities to manufacture stem cell products. He then sent the products back to the lab, which sold them to a man representing himself as a physician licensed in the U.S.

The man then traveled to Mexico to perform unapproved stem cell procedures on people suffering from cancer, multiple sclerosis and other autoimmune diseases.

The three defendants allegedly received more than $1.5 million from patients seeking treatment for incurable diseases.

“Scammers like these offer false hope to people with incurable diseases in order to line their own pockets with money,” says Special Agent in Charge Patrick J. Holland of FDA’s Office of Criminal Investigations (OCI), Kansas City Field Office. “FDA will continue to aggressively pursue perpetrators who expose the American public to the dangers of unapproved stem cells and ensure that they are punished to the full extent of the law.”

FDA’s OCI worked the case with the Federal Bureau of Investigations and the Internal Revenue Service’s Criminal Investigations Division.

This article appears on FDA’s Consumer Updates page, which features the latest on all FDA-regulated products.

Jan. 6, 2012

Washington Map

Washington state disciplinary actions – update


Periodically Washington State Department of Health issues an update on disciplinary actions taken against health care providers, including suspensions and revocations of  licenses, certifications, or registrations of providers in the state.

The department has also suspends the credentials of people who have been prohibited from practicing in other states.

Information about health care providers is also on the agency’s website.

To find this information click on “Provider Credential Search” on the left hand side of the Department of Health home page (

The site includes information about a health care provider’s license status, the expiration and renewal date of their credential, disciplinary actions and copies of legal documents issued after July 1998.

This information is also available by calling 360-236-4700.

Consumers who think a health care provider acted unprofessionally are also encouraged to call and report their complaint.

Here is the December 29th update issued by the Washington State Department of Health:

Note: Health care providers charged with unprofessional conduct have 20 days to respond to the Department of Health in writing. The case then enters the settlement process. If no disciplinary agreement can be reached, the case will go to a hearing.

State disciplines health care providers

OLYMPIA – The Washington State Department of Health has taken disciplinary actions or withdrawn charges against health care providers in our state.

The department’s Health Systems Quality Assurance Division works with boards, commissions, and advisory committees to set licensing standards for more than 70 health care professions (e.g., medical doctors, nurses, counselors).

Information about health care providers is on the agency website. Click on “Provider Credential Search” on the left hand side of the Department of Health home page ( The site includes information about a health care provider’s license status, the expiration and renewal date of their credential, disciplinary actions and copies of legal documents issued after July 1998. This information is also available by calling 360-236-4700. Consumers who think a health care provider acted unprofessionally are also encouraged to call and report their complaint.

Asotin County

In December 2011 the Unlicensed Practice Program issued a notice of intent to issue cease and desist order to Dezirae Houser. She allegedly provided laser hair removal treatments to clients without a license to provide the treatment.

Benton County

In December 2011 the Health Care Assistant Program ended the probation order against Patricia G. Mendez (HC00155215).Chelan County

In December 2011 the Chemical Dependency Professional Program ended the probation order against chemical dependency professional trainee Mindy L. Heinz (CO60108523).

Douglas County

In December 2011 the Health Care Assistant Program placed the license of Jennifer Dawn Paiva (HC00142564) on probation. She used a physician’s signature stamp to write a prescription for massages for herself, and used her employment status to access and modify her own health care data. She must comply with terms and conditions set against her license.

Garfield County

In December 2011 the Nursing Assistant Program ended the probation order against registered and certified nursing assistant Philip A. Northamer (NA60125638, NC60133100).

Grant County

In December 2011 the Medical Commission amended the statement of charges against physician Mohammad H. Said (MD00018311). He allegedly provided substandard care to patients with chronic pain, and failed to comply with prior conditions set against his license.

King County

In December 2011 the Nursing Assistant Program charged certified nursing assistant Devon L. Duff (NC10059114), also known as Devon L. Burlingame, with unprofessional conduct. She was convicted of assault.

In December 2011 the Board of Pharmacy charged pharmacist Craig M. Goodmanson (PH00013643) with unprofessional conduct. He allegedly failed to ensure proper supervision of the ancillary pharmacy personnel when he was a pharmacy manager.

In December 2011 the Medical Commission charged physician William H. Levy (MD00021325) with unprofessional conduct. He allegedly provided substandard care when evaluating, diagnosing and treating a patient, putting the patient at unreasonable risk for harm.

In December 2011 the Board of Pharmacy charged pharmacy technician Eugene B. Povzner (VA00050624) with unprofessional conduct. He allegedly allowed the pharmacy staff, where he oversaw the scheduling, to work beyond the required one pharmacist to three technicians ratio. He also allowed a pharmacist who was on probation with the board to work without supervision, and worked beyond the scope of a pharmacy technician. 

Okanogan County

In December 2011 the Board of Pharmacy charged pharmacy technician Kelly Anderson (VA00066204) with unprofessional conduct. She allegedly diverted oxycodone from her place of employment.

In December 2011 the Board of Hearing and Speech charged audiologist Douglas E. Moomaw (LD00001173) with unprofessional conduct. He allegedly failed to comply with terms and conditions set against his license.

Pierce County 

In December 2011 the Veterinary Board of Governors granted the application of veterinary technician Chiara Olga Colella (AT60219680) and placed her license on probation for two years. She was convicted of driving under the influence on two occasions, possession of a controlled substance — marijuana on two occasions, possession of marijuana 40 grams or less, and possession of cultivated marijuana. She must comply with terms and conditions set against her license.

In December 2011 the Nursing Commission charged licensed practical nurse Tina M. Ponton (LP00054570) with unprofessional conduct. She allegedly withdrew controlled substances, and failed to administer, waste, or document administration, and wastage. She was charged with driving under the influence.

In December 2011 the Medical Commission ended the probation order against physician Catherine A. Richardson (MD00025799). Dr. Richardson’s license is unrestricted.

Skagit County

In December 2011 the Nursing Commission charged registered nurse Laura C. Edwards (RN00134145) with unprofessional conduct. She allegedly withdrew medication, documented wastage but didn’t document administration to a patient, and took the medication for personal use.

Snohomish County

In December 2011 the Nursing Assistant Program ended the probation order against registered nursing assistant Julie Ann Davis (NA60123726).

In December 2011 the Nursing Assistant and Health Care Assistant Programs charged registered nursing assistant and health care assistant Lacey R. Standley (NA60079452, HC60111183) with unprofessional conduct. She allegedly submitted a prescription under a physician’s name for a family member without the physician’s knowledge or authorization. She also entered into a diversion program for the charge of obtaining a controlled substance by fraud or forged prescription.

Spokane County

In December 2011 the Nursing Assistant, X-Ray Technician, and Health Care Assistant Programs charged Abbey C. Aune (NC10098509, XT6022138, HC60088462, HC60024035) with unprofessional conduct. She allegedly obtained prescriptions using the name of her provider and colleague without knowledge or consent of the provider.

In November 2011 the Board of Pharmacy ended the probation order against pharmacy Northwest Health Systems (CF00058494).

Whatcom County

In December 2011 the Chemical Dependency Professional Program ended the probation order against chemical dependency professional trainee Kevin P. Maier (CO60138358).

In December 2011 the Nursing Assistant Program charged registered nursing assistant Jacob Elijah Talamante (NA60098163) with unprofessional conduct. He allegedly entered into a business transaction with patients, used a utility trailer of the patients without their permission, and used the patients’ debit card without their authorization.

Out of State

Oregon: In December 2011 the Nursing Assistant Program charged certified nursing assistant Jamie L. Armstrong (NC10057618) with unprofessional conduct. She allegedly failed to comply with terms and conditions set against her certification.

Oregon: In December 2011 the Nursing Commission charged registered nurse Cindy Susan Zapf (RN00114615) with unprofessional conduct. Her license to practice as a registered nurse in Oregon was placed on probation for two years. She was arrested for and convicted of shoplifting.

Tennessee: In December 2011 the Nursing Commission charged licensed practical nurse David L. Kinnaman (LP00053326) with unprofessional conduct. He allegedly sexually assaulted family members and patients.

Note to Editors: Health care providers charged with unprofessional conduct have 20 days to respond to the Department of Health in writing. The case then enters the settlement process. If no disciplinary agreement can be reached, the case will go to a hearing.