Lessons Learned from Years with Dentists

Hiring an Emergency Dentist The pain that is usually caused by tooth decay can be overwhelming. To put the pain to an end, a person should consider hiring an emergency dentist. Those suffering from dental abscess are also likely to experience a lot of pain. To eliminate dental pain, hiring a dentist will be necessary. To stop tooth decay from deteriorating, an emergency dentist is required. When a person has a knocked tooth, seeing a dentist the soonest possible will go a long way. To prevent the further deterioration of the problem, a dentist should be hired the earliest possible opportunity. An emergency dentist will also help those who have a broken tooth. The kind of the technology that the emergency dentist is using has to be put into account. When the emergency dentist is using cutting edge technology, comfortable care will usually be availed to the patient. The patient should hire the emergency dentist who will offer exceptional experience to the patient. Prior to hiring an emergency dentist, a person should consider the staff working for him. The dentist should always have a team that is well learned to deal with such emergencies. The client should also consider the services offered by the emergency dentist. The patient has to ensure that the emergency dentist offers what he is looking for. Having a comprehensive examination conducted might be the aim of certain patients. To get a suitable and safe mouth guard, a person should consider looking for an emergency dentist.
The Best Advice on Dentistry I’ve found
Before taking part in any kind of sport, a person should always wear a mouth guard. The best way to protect teeth from damage when taking part in a sport is by wearing a mouth guard. The dental team should always be experienced. When the dental team has the right experience, it will be much easier for the patient to meet their objectives. The client should also ensure that the dentist takes part in ongoing training. When the patient visits the offices of the dentist, he should always feel comfortable. Accordingly, the staff of the cosmetic dentist should always be friendly to the patient. Before hiring a cosmetic dentist, a person should consider the kind of strategies that they use.
The Path To Finding Better Professionals
For the patient to achieve certain goals, the strategies of the dentist have to be effective. The patient should hire the emergency dentist who is accessible. The testimonials of other people should be taken into account before hiring an emergency dentist. The testimonials of the former patients of the emergency dentist will make it simpler for a patient to make a decision. The patient should be able to afford the services of the emergency dentist.

Will Louisiana’s Medicaid Expansion Be A Harbinger For Georgia?


Louisiana and Georgia have many political similarities. Both states face significant health challenges affecting their populations. And until recently, both states had identical approaches to Medicaid expansion.

Georgia Gov. Nathan Deal, a Republican, has rejected expansion since he took office in 2011, and GOP lawmakers have repeatedly backed him up. They point to concerns about the future cost of expansion, saying it would eventually put too much strain on the state budget.

But on Friday, Louisiana will become the 31st state — and only the third Southern state — to expand the government program, which is jointly financed by state and federal governments. Gov. John Bel Edwards, a Democrat elected last fall, on his second day in office reversed the course set by his predecessor, Republican Bobby Jindal, by signing an executive order that began the process. Already, more than 200,000 state residents have been signed up.

This KHN story also ran in Georgia Health News. It can be republished for free (details).

“This isn’t just about expanding health care coverage and saving money,’’ Edwards said earlier this month when addressing reporters at a seminar sponsored by the Kaiser Family Foundation. “We want healthier people in Louisiana.” (KHN is an editorially independent program of the foundation.)

And there are small signs of a crack in the opposition to expansion in Georgia.

Georgia state Sen. Renee Unterman (R-Buford), who chairs the Senate Health and Human Services Committee, recently made headlines calling for Georgia to “re-examine’’ the possibility of Medicaid expansion, perhaps looking at a “waiver’’ plan similar to the Arkansas expansion program.

“We have to open that box and look just a little bit and see what’s available,” Unterman told WABE, the NPR affiliate in Atlanta. “Hopefully, if you draw down federal dollars, you can free up some of those state dollars. Right now, we’re just pumping out state dollars to stay in the midst of the crisis.”

A task force created by the Georgia Chamber of Commerce is formulating proposals that would extend coverage to more of the state’s uninsured but not along the lines of a conventional Medicaid expansion.

Yet Georgia state Rep. Sharon Cooper of Marietta, the Republican chairwoman of the Georgia House’s Health and Human Services Committee, told Modern Healthcare that she and her colleagues will entertain the proposals, but added that she doesn’t believe an expansion plan will solve the problem of access to care.

“The problem with expansion is, ‘Who is going to treat these people?’ ” Cooper said. “We don’t have the physicians, nurse practitioners or physician assistants to care for them in rural areas of the state.”

Since the beginning of 2013, five rural hospitals have closed in Georgia.

A Tale Of Two Southern States

America’s Health Rankings puts Louisiana 50th among states — 10 spots behind Georgia. The state has high rates of obesity, hypertension and diabetes, and a high mortality rate from cancer. For Georgia, the rankings note its large number of low-birthweight babies.

Louisiana also has a very high share of people living in poverty, but Georgia has a larger percentage without health insurance (16 percent).

One key difference between Georgia and Louisiana is the Peach State’s much stronger fiscal situation. Louisiana, where the energy industry is very important, has been hit hard by a decline in oil prices. Edwards inherited what he calls a record state deficit.

But ironically, that deficit eased the road for expansion, officials say. “The budget crisis was a catalyst for the Legislature to come aboard,” said Dr. Rebekah Gee, secretary of the Louisiana Department of Health.


Aretha Frison, of the New Orleans area, works at an animal hospital part time and battles depression. (Andy Miller/Georgia Health News)

A study found that the expansion would produce net savings of $184 million for Louisiana, including in-state money paid to hospitals and moving some current Medicaid patients into a better federal matching rate of 95 percent.

Part of Louisiana’s push to enroll new people in Medicaid has come through a unique mailing to 105,000 food stamp recipients, like Aretha Frison, of the New Orleans area, who works at an animal hospital part time and battles depression.

She said she “had been hitting a lot of brick walls” when trying to get psychiatric care but now “it seems like Medicaid is the golden ticket.”

About 180,000 other people were ‘’auto-enrolled’’ from a previous “waiver’’ program that did not provide coverage for hospital services or prescription drugs.

Help For Hospitals

Advocates for Medicaid expansion in Georgia often tout the expected benefits for the state’s hospitals, many of which are financially stressed. Though hospitals in other states have reported substantial revenue gains as a result of expansion, Louisiana’s complicated system of funding for hospitals may not yield many clear winners.

Louisiana has had an unusually heavy reliance on ‘’disproportionate share’’ funding, which the state pays out to those hospitals serving a large number of indigent or uninsured patients.

While the giant Ochsner Health System said Medicaid expansion would be slight improvement for the system financially, Baton Rouge-based Our Lady of the Lake Hospital said expansion may bring a payment cut overall with the loss of disproportionate share funds.

But low-income residents should benefit greatly.

More than half of the 4,000 medical patients at the New Orleans CrescentCare health center are expected to qualify for Medicaid under expansion, which may lead to better care options.

For example, Alicia Honomichl, a registered nurse there, said expansion will help more people obtain PrEP, a medication that can prevent a person from getting HIV from an infected individual, whether through sexual contact or sharing of drug-injection equipment.

Dr. Peter DeBlieux, chief medical officer of the brand-new University Medical Center New Orleans, said the Medicaid change is “earth-shattering’’ for his patients.

Patient access to regular medications will be “low-hanging fruit’’ that will come from expansion, and “I expect [cancer] screenings to skyrocket,” he said.

This story was done in partnership with Georgia Health News.

Old Motels Get New Life Helping Homeless Heal


Just up the freeway from Disneyland, in the Orange County city of Buena Park, Paul Leon stood outside the beat-up remnant of a seedy motel. Above him, a faded pink sign advertised the Coral Motel, whose rooms back in its prime cost 35 bucks a night.

“This particular motel was going to be taken back by the city of Buena Park, because of the drugs, alcohol, prostitution,” Leon explained.

But Leon, CEO of the Irvine-based Illumination Foundation, a homeless services nonprofit, had a different idea. He proposed turning the motel lobby into a triage center and converting the rooms into clean recovery facilities for homeless people recently discharged from the hospital. And that’s what he did.

This story also ran on KQED’s State of Health and California Report. It can be republished for free (details). KQED's California Report

It’s impossible for homeless people to recover from a health crisis when they just go back out onto the street after being discharged from the hospital. They end up returning repeatedly to emergency rooms and hospitals, which are very expensive.

Recuperative care centers are pricey to set up, but the motel model was just the opposite, Leon says.

“The beauty of this [is] it’s the poor man’s recuperative,” he said. “They’re not the Hyatt or the Hilton, but they do serve a purpose for us. The costs to run it are much less.”

The motel recovery room costs about half as much as a hospital would — about $2,000 less a day for each patient. And it’s like being at home. In fact, it may be even better than home, because it has a nurse on staff to help supervise care and handle complications.

Leon, who was trained as a public health nurse, launched the Illumination Foundation to provide precisely this type of care and links to the community.

The foundation now has expanded the motel model to six sites in four counties — Orange, Los Angeles, Riverside and San Bernardino.

Elvin Quiñones, 55, in his room at the Coral Motel in Buena Park, Calif., on Friday, February 12, 2016. After gallbladder surgery, Quiñones didn’t have anywhere to recover and ended up at the motel used by the Illumination Foundation Recuperative Care . (Heidi de Marco/KHN)

Quiñones in his room at the Coral Motel in Buena Park, Calif., in February 2016. After gallbladder surgery, Quiñones didn’t have anywhere to recover and ended up at the motel used by the Illumination Foundation Recuperative Care. (Heidi de Marco/KHN)

Elvin Quiñones, one of the patients at the Coral Motel, padded across the motel parking lot in flip-flops to show off his previous home — a small white Datsun B210 sedan.

“I’ll show you my house,” he said, “it’s not very big.”

Quiñones is a large man, and it’s hard to picture him crammed into the car along with his two dogs. In the days immediately following his gall bladder operation, he had to fit a bunch of medical gear, too.

“I’ll be honest, I was sleeping in front of the 24-hour Walmart, because they had a bathroom,” Quiñones recounted. “I still had a tube stuck inside me that was draining, so I needed someplace where I could empty out the drain.” Being homeless and helpless, he added, is something he’ll never forget.

“It’s surreal. You think you’re going to wake up and it’ll all be a nightmare. And you wake up and it’s not,” he said. “It’s just the next day.”

Elvin Quiñones, 55, visits his two chihuahuas at the Santa Fe Animal Hospital usually every other day. Quiñones put them in the kennel the day he became homeless. (Heidi de Marco/KHN)

Quiñones visits his two chihuahuas at the Santa Fe Animal Hospital usually every other day. Quiñones put them in the kennel the day he became homeless. (Heidi de Marco/KHN)

A week after his medical release, the hospital called and helped place him in the motel.

“This is a new model of care for Orange County,” said Ginny Ripslinger, vice president of network of care at St. Joseph Health System.

Hospitals and health insurers help fund the motel-based care centers, Ripslinger said, because they save money by stabilizing these patients. The dollars they contribute are in addition to any payments from Medi-Cal, the state- and federally funded health program for people with low incomes.

Beyond the financial interest of hospitals, providing funding for this motel-based care is “just the right thing to do,” Ripslinger said. “We don’t want to discharge them to the street, and there’s an obligation on the hospitals to provide continuity of care and safe discharges.”

    The men’s dorm at the Illumination Foundation Recuperative Care in Santa Fe Springs, Calif. The organization offers housing assistance, medical care and mental health services to the homeless population in the area. (Heidi de Marco/KHN)

    Victor Ramirez, 61, uses his ventilator at the men’s dorm at the Illumination Foundation Recuperative Care in Santa Fe Springs, Calif., in February 2016. The Guatemalan native became homeless after he lost his job at a car wash in Los Angeles. (Heidi de Marco/KHN)

    Lloyd Brooks, 57, sleeps in the men’s dorm at the Illumination Foundation Recuperative Care in Santa Fe Springs, Calif., in February 2016. Brooks is recovering after getting his left leg amputated due to an infection. “I’d be withering away somewhere in the streets if I wasn’t here,” said Brooks. (Heidi de Marco/KHN)

    Roberto Arce, 47, at the men’s dorm at the Illumination Foundation Recuperative Care iin Santa Fe Springs, Calif., in February 2016. Arce, a Mexican native, will be at the dorm for 2 weeks after suffering from heart failure. (Heidi de Marco/KHN)

    There’s also an added benefit to accommodating these homeless patients in motel rooms for two or three weeks.

    “You might say they’re a [captive] audience,” Riplinger said. “We can then provide the social services and the linkages to the community for stable housing and get them in a protected environment.”

    Leon said he has been working with dozens of cities across the country to establish similar models elsewhere.

    “If you’re just starting and you don’t have a recuperative care program,” he said, “one easy quick method is to use motels. They could basically start within days to house some of the patients that are the most vulnerable.”

    Every city has a homeless problem, Leon added, and every city has its own version of the beat-up Coral Motel. It’s a rare opportunity, he said, to turn two big problems into one solution.

    This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

    This story is part of a partnership that includes KQED, NPR and Kaiser Health News.

    HHS Proposes To Streamline Medicare Appeals Process

    The Department of Health and Human Services Tuesday proposed key changes in the Medicare appeals process to help reduce the backlog of more than 700,000 cases.

    The measures “will help us get a leg up on this problem,” said Nancy Griswold, chief law judge of the Office of Medicare Hearings and Appeals.

    If there was not a single additional appeal filed and no changes in the system, it would take 11 years to eliminate the backlog, Griswold said in an interview.

    Her office has faced increased criticism from health care providers and beneficiary advocates lately for its inability to speed up appeals and reduce the backlog. The latest critique came earlier this month in an investigation from the Government Accountability Office.

    Use Our Content

    This KHN story can be republished for free (details).

    This latest effort still falls short of what is needed, said Tom Nickels, executive vice president at the American Hospital Association. “We are deeply disappointed that HHS has not made more progress in addressing the delays despite the more than two years since the delays began,” he said.

    The new proposals, as well as increased funding requests, are expected to eliminate the backlog by 2021 by streamlining the decision-making process and reducing the number of cases that go to the third level of appeals, where many cases linger waiting for a hearing and then a decision from an administrative law judge. From the day of the hearing, it currently takes an average of slightly more than two years for a decision in appeals from hospitals, nursing homes, medical device suppliers and other health care providers.

    Among the proposed changes:

    • Designate some decisions from the Medicare Appeals Council, the last of four stages of appeals, as precedents that decision-makers at lower levels would have to follow. That could eliminate redundant appeals and resolve inconsistencies in interpretation of Medicare policies.
    • Allow senior attorneys to handle some of the procedural matters that come before the administrative law judges, such as dismissing a request for a hearing after the appellant has withdrawn the request, Griswold said.
    • Revise how the minimum amount necessary to lodge an appeal is determined. Under current rules, an appeal must involve payment of at least $150, based on the amount the provider charged. HHS is proposing to use Medicare’s allowed amount instead, which tends to be lower, and that could reduce the number of claims that could be appealed.
    • Eliminate some steps in the appeals process to simplify the system.

    Although advocates have sought changes to speed up the appeal process, Alice Bers, an attorney at the Center for Medicare Advocacy, was skeptical about some of the proposals. The effort to set up a system of precedents, she said, “could restrict coverage for needed items and benefits for seniors that they are entitled to by law.”

    And the change in calculating the minimal amounts “could make it harder for beneficiaries to reach that threshold,” said Bers. It might not sound like a lot of money, Bers said, “but for an elderly woman living on Social Security that’s several meals or co-pays for medicine.”

    The proposals do not address what hospital representatives say is a key cause of increasing appeals, independent audit contractors who can reject payments to hospitals. The American Hospital Association contends that those contractors unnecessarily cut off many payments and that hospitals frequently win the appeals.

    According to the GAO study, audit-related appeals decided at the administrative law judge stage — the third level of appeals — increased 37-fold from 2010 through 2014, compared to only 1.5 times for appeals of other kinds of claims.

    But Griswold said that currently only about a third of the pending cases at this stage involved recovery audit contractors, after settlements were reached with appellants who agreed to accept partial payment. As a result of these agreements, 4,245 cases from just 16 appellants were withdrawn from the system as of May 12, according to government statistics.

    Griswold also said Medicare will continue to process beneficiary appeals before those from hospitals, doctors and other health care providers. The practice began in 2014.

    The proposed changes will be posted on the Federal Register website and open to comments through Aug. 29.

    KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

    ‘Digital Health’ Not Just For Well-Heeled Fitness Fiends


    When we hear the phrase “digital health,” we might think about our Fitbit, the healthy eating app on our smartphone, or maybe a new way to email our doctor.

    But Fitbits aren’t particularly useful if you’re homeless, and the nutrition app won’t mean much to someone who struggles to pay for groceries. Same for emailing your doctor if you don’t have a doctor or reliable internet access.

    “There is a disconnect between the problems of those who need the most help and the tech solutions they are being offered,” said Veenu Aulakh, executive director of the Center for Care Innovations, an Oakland-based nonprofit that works to improve health care for underserved patients.

    At most digital health “pitchfests,” it’s pretty much white millennials hawking their technology to potential investors.

    “It’s about the shiny new object that really is targeted at solving problems for wealthy individuals, the ‘quantified-self’ people who already track their health,” Aulakh said. “Yet … What if we could harness the energy of the larger innovation sector for some of these really critical issues facing vulnerable populations in this country?”

    A small but growing effort is underway to do just that. It’s aimed at using digital technologies — particularly cellphones — to improve the health of Americans who live on the margins. They may be poor, homeless or have trouble getting or paying for medical care even when they have insurance.

    The initiatives are gaining traction partly because of the growing use of mobile phones, particularly by lower-income people who may have little other access to the internet.

    This story also ran on NPR. It can be republished for free (details).

    The Affordable Care Act and the expansion of Medicaid have added millions of previously uninsured people to the nation’s health care system, including community health clinics that serve poor and largely minority populations, according to a California Health Care Foundation report. (California Healthline is an editorially independent publication of the California Health Care Foundation).

    In California alone, the number of people on Medi-Cal, the state’s version of the Medicaid program for the poor, rose from 7.5 million in 2010 to 12.4 million by early 2015. Many Americans remain uninsured, however, because they live in states that have declined to expand Medicaid eligibility.

    Health advocates say it’s important to tailor digital health technologies to lower-income people not only to be fair, but because they’re more likely to have chronic illnesses, like diabetes, that are expensive to treat.

    Health-care providers have incentives as well. They are being rewarded financially under the Affordable Care Act, Medicare and Medicaid for keeping patients healthy, and this goes beyond simply performing medical procedures and prescribing drugs.

    For now, experiments targeting low-income people are a tiny part of the digital health industry, which racked up an estimated $4.5 billion in venture funding in 2015 alone. Entrepreneurs are still trying to figure out how they’re going to get paid by serving this population, and government health programs like Medicaid and Medicare are taking a while to figure out how they’re going to pay providers for approaches that don’t involve a doctors’ visit.

    But Jane Sarasohn-Kahn, author of the California Health Care Foundation report, says investors are getting more interested in digital health initiatives for low-income patients simply because there are so many of them.

    Investors are eyeing the “fortune at the bottom of the pyramid,” she said, much as Walmart profits from selling low-priced items to millions.

    “It’s now sexy to scale,” she says. “If you can have impact [on many people], inexpensively, you can make a lot of money. If we get it right, we can do well and do good.”

    Some initiatives are simple and cheap, like Text4Baby. The free text-messaging service for pregnant women and new moms offers English- and Spanish-language information about prenatal care, labor and delivery, breastfeeding, developmental milestones, and immunizations — all timed to the baby’s due date.

    Operated by the nonprofit ZERO TO THREE and the mobile health company Voxiva, Inc., Text4Baby has reached nearly 1 million women since starting in 2010. In one survey, more than half of them reported yearly incomes of less than $16,000.

    Other experiments are far more elaborate. In California and Washington state, San Francisco-based Omada Health is testing a version of Prevent, a diabetes and heart disease prevention program that’s been modified for “underserved” populations — basically people on Medicaid or who are uninsured. The free program offers patients a digital scale as well as behavior counseling and education, access to a personal health coach and an online peer network.

    To adapt the program, the company made it available in Spanish and English and lowered its reading level from 9th grade to 5th grade. Bilingual health coaches were hired, and the educational materials now acknowledge potential food access, neighborhood safety and economic issues that participants may face, said Eliza Gibson, Omada’s director of Medicaid and safety-net commercial development.

    The scale doesn’t require a wireless connection, and the patient just needs to be able to access the internet for one hour each week, Gibson said.

    Omada is enrolling 300 community clinic patients in Southern California and rural Washington in a year-long clinical trial of Prevent, in hopes that the program can demonstrably slow the progress of diabetes.

    There is a disconnect between the problems of those who need the most help and the tech solutions they are being offered.

    Patients at other community clinics in California will try out the program but won’t be included in the clinical trial, Gibson said. Omada Health is also offering a version called Prevent for Underserved Populations that specifically targets low-income community clinic patients.

    Among the people trying out the program is Susy Navarro, an elementary school substitute teacher who lives in the Spring Valley community east of San Diego. After being diagnosed with prediabetes, Navarro, 28, set an ambitious goal to lose 100 pounds. In the meantime, she is taking medication to stave off Type 2 diabetes.

    “You name it, I’ve probably tried it — Weight Watchers, low-fat, low carb, pills, injections, acupuncture,” Navarro said. “The first time I try things it goes very well, I feel like I’m very successful, then I wean off and I’m not successful. This program focuses more on life choices that are going to help us out long-term, not just for a little bit.”

    Navarro described the scale she was given as “sophisticated looking — all black, flat, digital.” It has been programmed to her weight profile — she is considered obese — and transmits her weight every morning to the program’s counselors.

    The program, with its daily weigh-ins, helps her pay attention to what she eats, and her blood sugar levels are declining, Navarro said. She also appreciates the ability to connect online with fellow patients on her “team.” “It’s very awesome — you get to know the other members and feel like it’s a team effort.”

    As they continue to explore digital health possibilities for underserved patients, developers are learning more about what works and what doesn’t, says Sarasohn-Kahn. For example, apps chew up a lot of cellphone data, so many community clinic patients prefer lower-cost text messaging.

    At the Petaluma Health Center, a network of community clinics in Sonoma County, Calif., staffers offered free, simplified “loaner” digital devices to patients after a hospital stay to help them avoid complications that could land them back in the hospital.

    They first offered an Android tablet to allow for a video visit with a health professional, but patients were reluctant to take it, saying it was hard to hide and could be stolen, said Dr. Danielle Oryn, the network’s chief medical informatics officer.

    Then they tried iPhones, in which everything was locked down except the ability to call 911 and a single button triggering the video visit. Those were more acceptable. Still, there were challenges. Would patients, some recuperating at homeless shelters, have access to electricity to charge their phones? Oryn said they had to learn by trial and error. She was surprised and pleased to see seniors accepting the technology. Every loaner iPhone was returned to the clinic.

    Oryn’s advice to the captains of the digital health industry?

    They should “not necessarily come in with too many assumptions. They should come with an open mind and a willingness to listen,” Oryn said. “Safety-net people are very excited to have these companies interested in them and to share their experiences.”

    This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

    Case Study: My Experience With Removals

    Top Creams that Help Remove Scars If one has a scar on the skin; it can become a source of displeasure to him/her. As such, it is vital to look for a solution to solve the problem. However many people continue to suffer discomfort since they don’t understand various treatment options they can give to their scars. After people have been given information on available options, they will be able to apply one of them. Among the treatments for the scar available include surgical removal of the scar, laser therapy, and use of cosmetic products. Although surgical operations and laser therapy are some of the optional solutions available, they are expensive, more technical and have more side effects. This makes use of cosmetic product the solution for each self-conscious person. The skin care products used from scar treatment include powders, creams and gels. the difference is based on their viscosity. However they act on the scar by reducing its visibility. This is achieved by making use of their high moisturizing power and nourishing the skin to improve its looks. The fact that creams are compatible with each makes them the perfect choice treatment for the mark. Silicon is the ingredient that helps the scar treatment procedure to be effective. The more silicon there is a cream, the higher is its ability to remove the scar. The content of the silicon in cream is indicated in percentage on the package. Online product review forums are such a wonderful place where one can find out the best brands that are reputed. This platform allows you to get the latest information on various brands and how they have been viewed by experts and consumers experiences. Look for the best-rated cream in terms of effectiveness. One of the critical concerns that should be analyzed is the duration of wait before the product shows up the results. Consumers are craving for products that will act on the scar instantaneously. The products have no known side effects and therefore one buys the product with confidence. The scar will diminish as soon as the cream has been applied giving the consumer the confidence to raise his/her head high.
    Getting To The Point – Products
    The good thing is that some companies are delivering their scar removal creams at very pocket-friendly prices. This has opened the door to the application of the creams to every person irrespective of his /her financial status. These companies also offer after sale services and deliver the cream to the doorstep of the client. This eliminates the need to go shopping for the scar treatment creams, ordering them from any place at any time of the day. The creams are clearly labeled to ensure that buyers can easily spot them to avoid confusing them in the local retail outlets. The need for persevering a scar on the skin is no more.Getting To The Point – Products

    States Offer Privacy Protections To Young Adults On Their Parents’ Health Plan


    The health law opened the door for millions of young adults to stay on their parents’ health insurance until they turn 26. But there’s a downside to remaining on the family plan. Chances are that mom or dad, as policyholder, will get a notice from the insurer every time the grown-up kid gets medical care, a breach of privacy that many young people may find unwelcome.

    With this in mind, in recent years a handful of states have adopted laws or regulations that make it easier for dependents to keep medical communications confidential.

    The privacy issue has long been recognized as important, particularly in the case of a woman who might fear reprisal if, for example, her husband learned she was using birth control against his wishes. But now the needs of adult children are also getting attention.

    “There’s a longstanding awareness that disclosures by insurers could create dangers for individuals,” said Abigail English, director of the advocacy group Center for Adolescent Health and the Law, who has examined these laws. “But there was an added impetus to concerns about the confidentiality of insurance information with the dramatic increase in the number of young adults staying on their parents’ plan until age 26” under the health law.

    More from this series

    Federal law does offer some protections, but they are incomplete, privacy advocates say. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a key federal privacy law that established rules for when insurers, doctors, hospitals and others may disclose individuals’ personal health information. It contains a privacy rule that allows people to request that their providers or health plan restrict the disclosure of information about their health or treatment. They can ask that their insurer not send the ubiquitous “explanation of benefits” form describing care received or denied to their parents, for example. But an insurer isn’t obligated to honor that request.

    In addition, HIPAA’s privacy rule says that people can ask that their health plan communicate with them at an alternate location or using a method other than the one it usually employs. Someone might ask that EOBs be sent by email rather than by mail, for example, or to a different address than that of the policyholder. The insurer has to accommodate those requests if the person says that disclosing the information would endanger them.

    A number of states, including California, Colorado, Washington, Oregon and Maryland, have taken steps to clarify and strengthen the health insurance confidentiality protections in HIPAA or ensure their implementation.

    In California, for example, all insurers have to honor a request by members that their information not be shared with a policyholder if they are receiving sensitive services such as reproductive health or drug treatment or if the patient believes that sharing the health information could lead to harm or harassment.

    “There was concern that the lack of detail in HIPAA inhibited its use,” said Rebecca Gudeman, senior attorney at the National Center for Youth Law, a California nonprofit group that helps provide resources to attorneys and groups representing the legal interests of poor children. She noted that HIPAA doesn’t define endangerment, for example, and doesn’t include details about how to implement confidentiality requests.

    Concerns by young people that their parents may find out about their medical care leads some to forgo the care altogether, while others go to free or low-cost clinics for reproductive and sexual health services, for example, and skip using their insurance. In 2014, 14 percent of people who received family planning services funded under the federal government’s Title X program for low-income individuals had private health insurance coverage, according to the National Family Planning and Reproductive Health Association.

    Even though most states don’t require it, some insurers may accommodate confidentiality requests, said Dania Palanker, senior counsel for health and reproductive rights at the National Women’s Law Center, a research and advocacy group.

    “Inquire whether there will be information sent and whether there’s a way to have it sent elsewhere,” Palanker said. “It may be possible that the insurer has a process even if state doesn’t have a law.”

    Insurers’ perspective on these types of rules vary. In California, after some initial concerns about how the law would be administered, insurers in the state worked with advocates on the bill, Gudeman said. “I give them a lot of credit,” she said.

    Restricting access to EOBs can be challenging to administer, said Clare Krusing, a spokesperson for America’s Health Insurance Plans, a trade group. A health plan may mask or filter out a diagnosis or service code on the EOB, but provider credentials or pharmacy information may still hint at the services provided.

    There’s also good reason in many instances for insurers and policyholders to know the details about when a policy is used, experts say. Policyholders also may have difficulty tracking cost-sharing details such as how much remains on the deductible for their plan.

    In addition, “if a consumer receives a filtered or masked EOB, he or she has no way of knowing whether their account has been compromised or used as part of fraudulent activity,” Krusing said.

    Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

    California Drug Price Measure Fiercely Opposed By Pharmaceutical Industry


    Drugmakers are waging a fierce campaign against a proposed California law that would require them to justify the costs of their treatments and disclose major price hikes.

    The bill has widespread support of health care providers, insurers, patients, labor and business groups. But the pharmaceutical industry is behind scathing social media messaging, warning that passage of the bill could lead to shortages of crucial drugs in some parts of the state. The industry is also applying other pressure to change the language of the bill.

    A state Assembly committee hearing on the bill is scheduled for next Tuesday.

    The legislation would require drug manufacturers to notify state agencies and health insurers within days of federal approval of a new drug that costs $10,000 or more per year or for one course of treatment. They would also be required to provide notice before they increased the price of a drug above certain thresholds, and they would have to justify the prices in both scenarios. The law would also require health insurers to disclose how much they spend on prescription drugs.

    “It’s probably amongst one of the more heavily lobbied bills — similar to tobacco and the most controversial bills,” said the measure’s author, Senator Ed Hernandez (D-West Covina).

    California is among about a dozen states considering proposals this year to impose greater price transparency on drug companies. The measures in many states have gone farther than Hernandez’s bill, requiring manufacturers to report their research and development costs, not just the prices and the reasons for them. Vermont, for example, just passed a law requiring justification of price increases for drugs that have a significant impact on the state budget.

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    Lawmakers in Sacramento will vote on the Hernandez bill before California residents decide the fate of a separate proposal, expected to be on the November ballot, that would limit the amount state-funded health programs pay on prescription drugs to no more than what the U.S. Department of Veterans Affairs pays.

    Pharmaceutical lobbyists say they and proponents of the price transparency bill will discuss potential changes so that the legislation will “work for the health care system as a whole.”

    “We’re optimistic that … there will be fruitful negotiations,” said Brett Johnson, director of state and local government policy for the California Life Sciences Association, a trade group for biotechnology and pharmaceutical companies.

    The association says it’s concerned about the bill’s requirement that drugmakers give 60-days advance notice of drug price hikes. With that foreknowledge, CLSA says, large pharmacies or other drug purchasers could hoard big quantities of drugs to avoid the higher price.

    That could leave smaller, independent pharmacies unable to acquire the drug. In such a scenario, the trade association says, communities with few hospitals or pharmacies could encounter problems obtaining certain drugs.

    Until recently, the pharmaceutical industry was the lone opponent to California’s drug price transparency measure. Now, the California NAACP, and groups representing seniors and chronic disease patients have joined their ranks.

    California Life Sciences Association is taking its message straight to consumers with a paid campaign on Facebook and Twitter.

    The legislation “allows profiteers to exploit urban & rural communities by hoarding meds,” one Twitter ad from CLSA warns. An ad on Facebook claims the law would encourage the “stockpiling of medications that could lead to shortages for patients with diabetes, cancer and other chronic conditions.”

    The CLSA says drugmakers object to the way the bill “tries to paint drug costs.” For example, it notes that the legislation would require manufacturers to report price increases, not decreases. The association says prescription drugs can help reduce the cost of disease, but that a transparency law would make it harder for the industry to develop cures.

    Proponents say the measure, if passed, would provide only a small glimpse of drug industry pricing practices.

    “Drug company opposition to this modest transparency bill has been over the top,” said Anthony Wright, executive director of the advocacy group Health Access, which co-sponsored the bill. “The idea that the prescription drug companies are being so vitriolic … in their rhetoric, really does raise the question of what pharma is hiding.”

    California Healthline reached out to five members of the Assembly Health Committee, representing both political parties, to gauge their sentiment toward the legislation. Only one of them offered a comment.

    Assemblymember Freddie Rodriguez (D-Pomona) said he supports prescription drug affordability and price transparency, but “wants to make sure we go about [it] in a way that does not end up harming consumers.” He didn’t comment on whether he would vote for the legislation.

    Families USA, a national health consumer advocacy group, said this bill, along with measures in other states, are part of a larger movement to increase transparency across the health care system.

    “There is a lot of opportunity for states to push the envelope, and California is definitely doing that,” said Caitlin Morris, program director for health system transformation at Families USA. “Hopefully, [California] will create a path, along with Vermont, for other states to take up this issue.”

    This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

    Doctors Wrestle With Mixed Messages When Deciding Whether To Prescribe Painkillers


    Steve Diaz, an emergency medicine doctor at Augusta’s MaineGeneral Health, says he knows what patients want when they come to him in pain. Drugs. And preferably strong ones.

    “The only thing they think of is, ‘Do I get a pill?’” he said.

    And with abuse of prescription painkillers like OxyContin, methadone and Percocet soaring, the instinct, public health experts say, should be to say no. Or at least, not necessarily. The Centers for Disease Control and Prevention put out a new guideline this spring, advising doctors to prescribe the highly addictive drugs, known as opioids, in smaller doses and only when truly needed.

    But another federal policy — a provision of the 2010 federal health law linking hospital payments to patient satisfaction surveys — may be complicating efforts to curb opioid prescribing as part of the nation’s effort to address the painkiller abuse epidemic.

    This KHN story also ran in USA Today. It can be republished for free (details).

    As part of these surveys, amidst questions about night-time noise levels and hospital staff proficiency, patients can evaluate how doctors managed their pain, and if clinicians did all they could to treat it. That’s setting up a system, doctors say, where physicians’ ratings can get caught between patient demands and sound medical judgment.

    It’s something Diaz says he sees play out in his own hospital, where he’s also a senior vice president and chief medical officer.

    “The patient says, ‘I’m in pain, and you’re not meeting my needs.’ And [doctors] might say, ‘I’m being graded on this. I’ll give this patient something, to get them over the hump,’” he said. “No one will overtly say, ‘I’m doing this to not get a bad score. But in the back of their mind … and knowing they’ll be publicly rated, I think it leads to making that subconscious decision.”

    Now, as advocates seek an all-hands-on-deck response to the nation’s opioid crisis, many physicians are calling on federal authorities to change these satisfaction surveys.

    Doctors “feel like they’re getting mixed signals,” said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. On one hand, “they’re getting this signal [from the CDC] to not prescribe opioids. And on the other, they’re getting this signal to manage patient pain so it’s zero.”

    Blue prescription bottle with white pills and prescription.

    And that second signal can create expectations that ultimately feed into the problem. When patients get painkillers in the emergency department or hospital, they often expect that treatment to continue. The drugs are highly addictive. Researchers believe unnecessary prescribing may be a key factor in fueling abuse.

    In 2014, the most recent year for which data is available, about 2 million Americans abused prescription painkillers, according to the Centers for Disease Control and Prevention. More than 14,000 died from overdosing on them.

    With that concern, more stakeholders are pushing for action. This spring, organizations such as the American Hospital Association and the advocacy group Physicians for Responsible Opioid Prescribing called on the Centers for Medicare & Medicaid Services, the responsible federal agency, to eliminate the questions, rephrase them or disconnect them from hospital payments. But the evidence on how meaningful that change might be remains scant.

    CMS is now testing different phrasing, said Jonathan Gold, a spokesman at the Department of Health and Human Services. Changes in the questions would look at how clinicians discuss pain with patients, rather than how they treat it.

    That builds on a statement agency officials published in a May JAMA opinion piece. Officials said they were “exploring how best to measure” experiences including how patients’ pain is treated.

    Meanwhile, on a separate track, a group of Senators has introduced legislation to eliminate the pain questions from the official hospital survey.

    Without a fix, doctors face pressure on two fronts, said Joan Papp, an emergency physician in Cleveland, who has advocated removing pain management as a factor in assessing patient experience. She compared the concern about painkiller prescribing to antibiotics — a third of antibiotics given aren’t necessary, she said, and can in fact cause negative public health consequences. But doctors give them because they think patients expect more than just advice like bed rest, hot tea and time.

    With painkillers, that same pressure to do something is compounded by financial stakes, she said.

    “Not only are we seeing patients, but the federal government, pushing to prescribe, sometimes inappropriately,” she said.

    Technically, patient surveys shouldn’t affect an individual doctors’ pay. The surveys are meant, according to CMS, to measure the hospital’s culture as a whole.

    No one will overtly say, ‘I’m doing this to not get a bad score.’

    But in practice, it’s hardly unusual for hospitals to pay physicians at least in part based on patient ratings, Diaz said. So those doctors can perceive a direct connection between making money and convincing patients they’ve thoroughly treated their pain.

    CMS officials say, though, that there is no evidence that prescribing painkillers improves a hospital’s scores. Though a June study suggested a possible relationship between opioid prescribing and higher scores, the authors cautioned that the difference was small and could have had other causes. In addition, research from 2014 found that, in emergency departments, prescribing opioid painkillers didn’t help scores. Still others argue the pain questions are just a small part of a large survey.

    But that all misses the point, said Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing. Even if giving painkillers doesn’t actually boost hospital ratings, many doctors think it does. That adds pressure to give patients unnecessary drugs that could hook them.

    For example, another 2014 study, which surveyed about 150 doctors, found that almost half said pressure to get better scores encouraged them to give unnecessary or inappropriate treatment, including prescribing heavy-duty painkillers.

    “Our epidemic of opioid addiction has been caused by over-exposure to prescription opioids,” he said. Creating incentives for hospitals “to make sure nobody ever walks out the door feeling they should have gotten a pain medication and they didn’t — that isn’t a cause of the opioid epidemic, but it’s a contributing factor.”

    Doctors are feeling the pressure less now than they did even five years ago, said Wanda Filer, president of the American Academy of Family Physicians and a practicing doctor, as a result of rising concerns regarding painkiller abuse. But the tension still exists.

    “I have many members who tell me they’ve been threatened [by patients] when they won’t give a prescription,” she said.

    Meanwhile, no one’s been able to measure how much overprescribing by physicians contributes to the problem. Researchers are still identifying all the factors that have pushed more opioids into the public sphere. And that complexity, advocates said, makes it difficult to quantify the impact of removing the survey questions.

    “There are many, many, many fronts which need action,” Filer said. But making sure doctors don’t have extra reason to push painkillers should be part of that, she said.

    Given the scope of painkiller addiction, that’s an essential part of policy makers’ approach, Kolodny argued.

    “The problem we’re dealing with is an epidemic of addiction. Some people develop addiction because they took drugs to feel effects. But many people develop addiction by taking drugs prescribed by doctors,” he said. “Once people are addicted, they’re not using the drugs because it’s fun. They’re taking them because they’re addicted, and feel that they have to. And it’s awful.”

    End-Of-Life Care Better For Patients With Cancer, Dementia: Study Finds


    A new study offers surprising findings about end-of-life care — specifically, physicians tend to be more likely to accommodate the advanced-care wishes of patients with cancer or dementia than renal disease, congestive heart failure, pulmonary disease or frailty.

    “There’s been a lot of focus on end-of-life care for cancer,” said Melissa Wachterman, the study’s principal author and a physician at the VA Boston Healthcare System and the Boston-based Brigham and Women’s Hospital. “But most people don’t die of cancer. And the quality of end-of-life care for those dying of other conditions … is not as good.”

    The research was published online Sunday in JAMA Internal Medicine.

    Researchers examined survey data from the families of about 34,000 people who died in the Veterans Affairs health system between Oct. 1, 2009 and Sept. 30, 2012. They looked at how those families rated the quality of medical care and whether patients had access to things like a palliative care consultation, whether they died in hospice or the intensive care unit — a majority prefer the former — and whether they had a do-not-resuscitate order in place, since those usually stem from end-of-life planning conversations.

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    About 60 percent of people with a relative dying of cancer or dementia said their relative got excellent end-of-life treatment, with about 80 percent saying the relative always got the care he or she wanted.

    Those figures drop off for other conditions: About 55 percent of people reported excellent end-of-life care for relatives who died of renal, cardiovascular or pulmonary conditions, and about 54 percent indicated that for family members dying of “frailty.” Those same groups ranged between 73 and 77 percent in saying doctors always gave desired care.

    Patients with these conditions were also markedly less likely to have a palliative-care consultation — meetings designed to focus care on alleviating pain and improving quality of life — and tended in greater numbers to die in the intensive care unit and not in hospice care. That’s out of line with many Americans’ stated preferences. Studies show most people want to die comfortably at home, opting for fewer rather than more treatments.

    “There’s clearly room for improvement,” said Wachterman.

    Though the study focused on the VA, she said, she would expect the trend to bear out in other health care settings.

    The federal government has tried to make it easier for health professionals to accommodate patients’ dying wishes. Doctors can now bill Medicare, the health insurance program for senior citizens, for talking to them about end-of-life preferences. Federal estimates suggest that by 2040, people older than 65 will make up a fifth of the population.

    But many physicians say they feel uncomfortable or don’t know how to have these talks.

    Taking steps to better incorporate palliative doctors into the continuum of care could help, said Amos Bailey, a professor of palliative medicine at the University of Colorado Anschutz Medical Campus.

    In the short term, though, there probably won’t be enough of those specialists to meet the growing need, he said, adding that primary care physicians must be prepared. Bailey, who also directs the school’s masters’ program in palliative care, was not involved with the study but wrote an accompanying opinion piece.

    Culturally, Wachterman noted, doctors and patients alike don’t often think to talk about death preferences until it seems unavoidable. For cancer and dementia, she suggested, there may be a broader understanding that the diseases are terminal. And there’s a clearer timeline for when to start planning for death.

    “Everybody gets that if you have advanced cancer, it’s very serious,” she said. But, she added, “There isn’t always the recognition that these other conditions are also very serious.”

    But health professionals need to know what their patients would want, even if dying seems like an abstract idea, said Harriet Warshaw, executive director of the Conversation Project, a Boston-based group that promotes end-of-life planning.

    “It’s always too early and too late,” she said. “We don’t know when we’re going to die, so it’s important to get those [plans] right and have those discussions with our clinicians and our loved ones.”

    Medicare payments help, she added. But advance-planning talks need to be integrated into routine care. For instance, electronic health records could prompt doctors to float the subject with patients.

    Wachterman noted, however, that less care isn’t what everyone wants. For some patients who want to do everything possible to fight disease death in an intensive care unit could be the right outcome, even if it’s uncomfortable.

    “The right amount of the ICU is not zero, even for people at the end of life. We want to match the use of invasive interventions with patient preferences,” she said.

    But to unearth those preferences, it’s crucial to have systems and protocols that help foster open dialogue, Warshaw said.

    “We know from the research people want to have [these conversations],” she said. “It’s about getting physicians over the fear of raising this. They’re not abandoning their patients. They’re continuing to help their patients on the life journey.”