By Judith Graham
Kaiser Health News

Doctors assess patients' breathing, heart rate and blood pressure routinely at office visits. Soon, they may be adding body mass index to that list too.

Tracking this measure – an indicator of whether someone is obese or overweight – as if it were a vital sign at medical checkups is among a new set of strategies recommended for battling obesity, a concern that some experts predict will affect 42 percent of adults by 2030.

Although professional medical societies have said for years that physicians should monitor patients' body mass index, most doctors fail to do so. For example, a 2006 survey of family physicians found that fewer than half checked BMIs for children over the age of 2, even though 71 percent knew this has been recommended.

Just over 40 percent of adult patients in commercial HMOs had documented BMI measurements in 2009 and 2010, according to a survey by the National Committee for Quality Assurance, an organization that evaluates health plans. That figure falls to 12 percent for patients in commercial PPOs, a more common type of plan.

The Institute of Medicine last week called for the medical profession and health insurers to become more rigorous in their approach in a report proposing an anti-obesity campaign that would involve every part of society, from individuals and families to schools, communities, workplaces, the food industry and the media.

Pointing to the more than 90 million children, teens and adults counted as obese, well-established links to medical conditions such as diabetes, hypertension, heart disease, and arthritis, and annual healthcare expenses exceeding $190 billion, the report urged comprehensive and sustained action.

For physicians, monitoring body mass index – a ratio of height to weight – is at the top of the list of priorities because it's the best way to identify people who have a weight problem. (Adults are counted as obese if they have a BMI of 30 or higher; children if their BMI is at the 95 percentile or higher for kids of the same age and sex.)

"We need to normalize the process of obesity screening and lifestyle counseling so they're usual and people expect this," said Dr. Sandra Hassink, a member of the panel that prepared the IOM report and director of the Obesity Initiative at Nemours, a pediatric health system in four states.

Medical groups call for change
Groups such as the American Medical Association and the American Academy of Pediatrics have recommended regular BMI checks for years. Several health care systems also have embraced the practice. Kaiser includes BMI as a "vital sign" in electronic medical records for nearly 9 million members, and it is planning to do the same for physical activity, another contributor to the obesity epidemic, said Ray Baxter, the plan's senior vice president for community benefit and health policy.

(Kaiser Health News is not affiliated with Kaiser Permanente.)

So why the problem? Many harried physicians are unprepared to advise people about how to change their behaviors, unconvinced they have time to do so, and therefore look skeptically at screening, said Dr. Robert Kushner, clinical director of the Comprehensive Center on Obesity at Northwestern University.

If doctors are overweight themselves, they're less likely to recognize the issue in their patients, research shows. What's more, doctors aren't trained in medical school to handle weight issues. They also often aren't convinced obesity treatments work, and many believe there aren't good community programs to which they can refer patients.

"The question is, how many programs are out there for primary care doctors to refer to in the community, and answer is – not many," said Dr. Ned Calonge, a Colorado physician who is the immediate past chairman of the U.S. Preventive Services Task Force.

Northwestern is tackling a part of that by weaving instruction in "lifestyle medicine" throughout all four years of a new medical school curriculum being introduced this August.

Another significant problem has been a historic lack of reimbursement from insurers for obesity screening and counseling. That changed last year for seniors, when Medicare said it would cover up to six months of weight loss counseling for obese beneficiaries as part of a package of new preventive services. Nearly 13 million Medicare members are thought to be obese.

Meanwhile, new preventive services guidelines from the government call for all insurance plans to cover obesity screening and counseling without charge to patients.

And insurers are expanding childhood obesity programs following a 2010 recommendation from the U.S. Preventive Services Task Force that endorsed comprehensive weight management programs for youngsters at least 6 years old. Previously, the task force supported BMI screening but not weight loss programs.

Seeking evidence-based programs
For the insurance industry, the challenge now is providing evidence-based programs that can be introduced on a broad scale.

UnitedHealth Group is promoting "Join for Me," a year-long behavioral modification program piloted with the YMCA of Greater Providence, R.I., in which youngsters 6 to 17 years old, accompanied by a parent, learn about healthy eating and exercise in a group led by a coordinator.

"Doctors are in short supply" and it makes sense to conduct intensive behavioral change programs in the community, not in their offices, said Dr. Deneen Vojta, senior vice president of UnitedHealth's Center for Health Reform & Modernization. For overweight and obese adults, the company is looking at offering a version of the Diabetes Prevention Program, a well-studied intensive intervention that has been shown to help people lose weight.

WellPoint has taken a different approach, choosing to work through doctors and with the Alliance for a Healthier Generation, an organization that's trying to convince health plans to offer more comprehensive coverage for obesity counseling and treatment. The alliance asks participating plans to offer four visits with a child's primary care doctor and four visits with a dietitian if the youngster is found to be overweight or obese. So far several plans, including WellPoint, Aetna, Humana and Highmark, Inc., have signed up, and 2.4 million children are covered.

WellPoint recently launched a limited pilot study of this type of benefit in California and is learning what physicians need and members want before deciding whether to roll it out more broadly, said Harvinder Sareen, clinical program director for the insurance company.

Insurance companies and some self-insured employers are also exploring the use of financial incentives -- cash payments or reduced premiums or deductibles – to motivate members to keep their weight in check and to adopt other lifestyle changes. One program at UnitedHealthcare offers members up to $250 for reaching a BMI of 25 or less, and similar incentives for not smoking and lowering cholesterol and blood pressure.

"Is there coverage [for obesity] is yesterday's conversation. Today's conversation is how to design coverage to encourage people to use it and continue using it," said Karen Ignagni, president of America’s Health Insurance Plans, an industry trade group.

Others disagree that coverage for obesity counseling is adequate.

"The problem is there's no real incentive for the insurance industry to pay for better prevention and treatment, because the costs are immediate while the benefits are long-term," said Dr. David Ludwig, director of the new Balance Foundation Obesity Prevention Center at Children's Hospital, Boston. "Although reducing the prevalence of obesity is one of the most profitable investments the healthcare system could make, it doesn't make a lot of sense for individual plans when families change policies every three to five years."

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By Lena Groeger
ProPublica

Each prescription drug you take has a unique code that the government can use to track problems. But artificial hips and pacemakers? They are implanted without identification, along with many other medical devices. In fact, the FDA doesn’t know how many devices are implanted into patients each year – it simply doesn't track that data.

The past decade has seen numerous high profile cases of malfunctioning medical devices, which have lead to injury or even death. Critics say the FDA's minimal monitoring of devices contributes to these problems.

“If you’re lucky, you might find a sticker on the operating room note that was left over from the product,” said Richard Platt, who runs the Harvard Pilgrim Health Care Institute. Otherwise, there is little way of knowing what device was used.

Right now, the FDA depends mostly on voluntary reports from doctors, patients, manufacturers and hospitals to notify them of problems with devices already on the market. The agency does have some power to require manufacturers to conduct further studies or track a particular device once it is sold. But many devices don’t get that level of surveillance.

“It’s much like a patchwork of streams of information getting to the FDA,” said cardiologist Frederic Resnic of Brigham and Women’s Hospital, who has worked with the FDA on medical device safety monitoring. “The FDA is relying on anecdotal and very variable information about the safety of medical devices.”

If manufacturers get word from a doctor or hospital about a death or injury that occurred as a result of their product, they are legally obligated to investigate the event and report it to the FDA. But the process isn’t straightforward, as has become clear in the recent controversy over the malfunctioning St. Jude’s Riata defibrillator leads (wires that connect a defibrillator to the heart). The FDA said an individual doctor’s report helped alert them to the problem, but it was months before the device was recalled.

According to attorney William Vodra, a regulatory law expert and member of the Institute of Medicine panel that published a report on medical device safety last year, the number of doctors who actually contact manufacturers is small.

And after being notified of patient harm, manufacturers can minimize their own responsibility if they point the blame elsewhere, said health policy expert Diana Zuckerman, president of the National Research Center for Women & Families.

For example, if someone dies from complications in a surgery to remove an implant, the manufacturer may argue that it was the surgery – not the implant – that killed the patient.

“You have a system that is not rigorous, the standards are not always understood, and they are interpreted differently by different people,” Zuckerman said.

The FDA responds to the criticism by pointing out that while every medical device carries a potential risk, the vast majority of devices perform well and improve patient health. An FDA spokeswoman emphasized that the agency must evaluate thousands of medical devices each year, and is constantly looking for ways to better and more quickly identify problems.

While the FDA makes the adverse event reports publically available in a searchable database, it doesn't have a standardized system for reviewing reports once they are sent in, said Vodra, the attorney. A disclaimer on the site specifically states that the data is "not intended to be used either to evaluate rates of adverse events or to compare adverse event occurrence rates across devices."

“What you would normally consider the simplest kind of data analysis is not done,” said Zuckerman. Often, doctors catch a malfunctioning device before the FDA ever notices.

In one case, a group of Pennsylvania doctors noticed that several patients were showing severe complications a few years after getting an IVC filter – a device designed to capture blood clots. Bits of the filter were breaking off, causing chest pain and a dangerous build-up of fluid and pressure around the heart. In 2010 the doctors conducted their own study and found that the filter broke in a quarter of all patients who used it.

On the day that study was published, the FDA issued a warning saying it had received over 900 reports of problems with IVC filters since 2006, and that the device was meant to be removed after a few months, not left in permanently.

There have been numerous attempts at reform. Five years ago Congress ordered the FDA to set up a post-market surveillance system to track the safety of all medical projects, but a system hasn’t yet been set up for medical devices.

A year later the FDA announced the Sentinel Initiative, which would combine existing data from electronic health records and medical claims to track drugs, vaccines, and devices. Some groups of hospitals or other organizations have voluntarily set up registries to collect information about the make and model of devices.

While the FDA has made significant progress on tracking drugs, it’s not yet in a position to do the same thing for devices, according to Harvard’s Platt, who is the principal investigator of Mini-Sentinel, the FDA's pilot program for the national system. The data isn't there.

The FDA has long acknowledged the need for a unique device identifier system, and got permission from Congress to set one up five years ago. No such system of ID-tags exists yet, but after several recent high profile medical device failures, the issue getting some attention from Congress. A proposed Senate bill, which cleared the Health, Education, Labor and Pensions Committee last week, sets a timeframe for implementing a unique identification system, among other reforms.

“If UDI’s were used in a consistent way, we could use the same kinds of techniques we've developed for drugs for devices,” said Platt. “It would be a huge breakthrough.”

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Lots of Americans buy the argument that we should ration health care according to lifestyle. So do many employers who are trying to charge their obese employees more for health insurance.  But if we are going to penalizing the health care sinners amongst us, shouldn’t we target all of those who raise our collective health care bill through poor lifestyle choices? This means you, cat owners.

The costs of a cat-loving America ought to be looked at in the same vein as recent calls to tax fat people. According to a Forbes magazine poll, one in three Americans believe that obese people should pay more in taxes than those who maintain a healthy weight. The same sentiments prevail among doctors in the UK. 

Overweight people cost the system a ton. People seem to think it's fair to ask them to pay more if they choose to munch chips while reclining on the Lazyboy watching Paula Deen on TV. Let's apply the same logic to all lifestyle choices. Cats are costing each one of us a lot of money to treat the allergies, asthma, skin problems and hospitalizations that they cause.

According to the Humane Society of the United States, there are over 86 million owned cats in the USA.  Nearly a third of you own these furry disease vectors. More than half of you cat owners have the gall to own more than one! 

At a recent meeting on immune diseases in Chicago, doctors and scientists who are studying allergies made it clear that cats are a menace. I learned that 17 percent of Americans, or 60 million of us, have allergies to cats.  So that means the odds are high that either you are allergic or someone you have over to your house could be.

Once a cat is in a home it is nearly impossible to get the cat allergens out of the bedding, carpets and furniture. The cost to all of us of treating cat-induced asthma, rhinitis, skin reactions and allergies is big. While there are no specific numbers for paying for the shots and drugs to treat the health problems due to cats, the overall medical cost for treating all allergies in the USA exceeds $7 billion.  And that does not include time lost from work or days out of school due to allergies.

One drug that is now frequently prescribed for kids and adults with chronic asthma due to exposure to cats, omalizumab, costs anywhere from $6,000 to $24,000 a year depending on dose. One in 2,000 of those with cat allergies require a trip to the hospital in any given year due to an acute adverse reaction to shots or drugs!

If we apply the "fat tax" logic, the obvious ethical question is why the heck are we cat-free citizens paying for the health problems associated with tolerating cat ownership? If you choose to own a cat or refuse to get rid of one even after being told to do so by your doctor, then why should I pay for this gross irresponsibility? 

So bring on the fat tax -- but tax all those who choose to make themselves, their kids and visitors sick by lifestyle choices, whether it's eating too much junk food or housing felines. And hey, employers, don’t hire cat owners, or at least make them go to classes where they can learn about the true cost that kittens impose on us all.  

While we are at it, let's impose a fine on those who fail to wear a hat while at the beach, risking melanomas, and a skiing tax for those nutty enough to speed downhill knowing that the orthopedic clinic awaits at the bottom.

Of course, none of this applies to dogs or dog owners such as me. Those who own them should receive a tax break. Pet ownership has a lot of benefits for your health, particularly if the pet is a dog. But cats are a very different matter. Those who insist that personal responsibility ought to drive what everyone pays for health insurance had better let cat owners know what is best for them.

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Kaiser Health News

Up to half of the people who are treated at hospital emergency departments and trauma centers are under the influence of alcohol, experts say. That may be a sobering statistic, yet a recent study found that emergency departments can capitalize on this “teachable moment” to discourage problem drinking in the future.

But laws in more than half the states permit insurers to deny payment for medical services related to alcohol or drug use and that can derail hospitals’ best intentions, experts say. Faced with the prospect of not getting paid for care, some emergency department personnel may sidestep the problem by simply not testing patients’ blood or urine for alcohol. 

In the study, published online in the Annals of Emergency Medicine in March, nearly 600 emergency department patients who were identified as hazardous or harmful drinkers (defined for men as drinking more than 14 drinks per week or more than four on any single occasion, and for women as more than seven weekly drinks or three on any one occasion) took part in a seven-minute interview. During the interview, an emergency department staff member discussed the link between a patient’s injuries and alcohol, as well as guidelines for low-risk drinking, and encouraged the patient to discuss what was stopping him from drinking less and to set a drinking goal.

Compared with those who received standard care, patients who took part in the sessions reduced their average number of weekly drinks significantly as well as their episodes of binge drinking and drinking and driving over the next 12 months.

“In the emergency department on a weekend, all the cases may be drug or alcohol related, and yet we don’t do” screening and intervention, says Gail D’Onofrio, the study’s lead author who is chair of emergency medicine at Yale University School of Medicine. “Our goal is to normalize this in the emergency department.”

Although some of the nearly 4,000 emergency departments screen patients for drug or alcohol use, it’s not required. Level 1 and 2 trauma centers, however, which are typically equipped to handle emergency patients suffering from serious injuries sustained, for example, in major car accidents, must screen for problem drinkers. Level 1 trauma centers must also be able to provide counseling. 

Such screening and counseling can be effective, says Larry Gentilello, a trauma surgeon who has published studies on injury prevention and substance abuse. 

“Most of the people who are injured don’t need to go into treatment,” he says. “They aren’t alcoholics or alcohol dependent. That’s why one counseling session can help them by talking about the risks of drinking.”

The extent to which so-called alcohol-exclusion laws deter emergency medical personnel from screening and counseling patients for alcohol or drugs is unknown.  

The laws have a long history. Since 1947, more than 40 states have passed measures allowing health plans to refuse to pay for care if the patient’s injuries occurred while he was under the influence of alcohol or, in some states, drugs, say experts. As people came to understand alcohol addiction and the possibility of treatment, however, it became clear that the laws were counterproductive. In 2001, the National Association of Insurance Commissioners recommended against them.

Since then, at least 15 states have repealed or amended their laws and now prohibit exclusions of coverage for drinking or drugs, according to data from the National Institute on Alcohol Abuse and Alcoholism. Maryland and the District of Columbia are among them; Virginia’s law remains in place. 

Regardless of state law, self-insured companies that pay their employees’ health care costs directly can refuse to cover employees for alcohol-related claims.

The laws have ensnared both problem and occasional drinkers.

Gentilello describes the case of a Seattle woman who was celebrating her 25th wedding anniversary and had a few glasses of champagne at dinner with her family. It was a rainy night and she was dressed up and wearing high heels. As she and her husband tried to hail a cab, she tripped on a curb, fell and broke her ankle. In the emergency department, her chart noted that she had a few drinks. Her insurer refused to pay. Washington subsequently adopted a prohibition on alcohol-related claims exclusions in 2004.

It’s unclear how frequently insurers continue to apply such laws to avoid paying claims. Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade organization, says the group doesn’t know what member practice is. Cynthia Michener, a spokeswoman for Aetna, says that “to our knowledge” the company doesn’t apply such exclusions. Other insurers, including UnitedHealthcare and Humana, didn’t provide information about their practices.

But a professor who has written about such laws says there are indications that health plans continue to use them to deny payment.

“There are tons of these cases,” says Sara Rosenbaum, a professor of health law and policy at George Washington University’s School of Public Health and Health Services.  “The only evidence we have suggests that these cases go on.”

“There’s no reason to think that insurers, eager to hold down costs, wouldn’t continue” to deny payment based on such exclusions, she adds.

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By Judith Graham
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Large numbers of seniors aren’t receiving recommended interventions that could help forestall medical problems and improve their health, according to a new survey from the John A. Hartford Foundation.

Notably, one-third of older adults said doctors didn’t review all their medications, even though problems with prescription and over-the-counter drugs are common among the elderly, leading to over 177,000 emergency room visits every year.

Falls cause over 2 million injuries in people age 65 and older annually, but more than two-thirds of the time doctors and nurses didn’t ask older patients whether they’d taken a tumble or provide advice about how to avoid tripping on carpets or slipping on the stairs, the Hartford poll found.

Similarly, depression can cause people to become socially isolated, suicidal, or stop taking care of themselves, but 62 percent of seniors said doctors and nurses hadn’t inquired about whether they were sad, depressed or anxious.

The results, which cover a period of 12 months, speak to doctors’ and nurses’ lack of training in geriatric medicine.  Providers need to recognize that “care of an 80 year old differs from that of a 50 year old,” said Dr. Rosanne Leipzig, professor of geriatrics at the Mount Sinai School of Medicine in New York. But too often, this doesn’t happen.

Seven interventions examined in the Hartford study are part of Medicare’s annual wellness visit, which became a no-cost benefit available to all seniors in the government health program in January 2011.  Yet 54 percent of older people surveyed by the foundation had never heard of the Medicare wellness visit while another 14 percent weren’t sure if they had.

Only 2.3 million seniors out of a total 35 million with traditional Medicare coverage took advantage of wellness visits last year, according to government data.  Medicare pays doctors about three times their ordinary office visit rate for asking about older adults’ ability to function, evaluating their mood, recommending preventive services, and connecting them with community resources during wellness visits.

“These are low tech, low cost interventions that are easy to do and that can have a huge impact on an older person’s medical care and their quality of life and function.  But too many providers and older adults don’t realize they’re important,” said Dr. Sharon Brangman, chairwoman of the board of directors of the American Geriatrics Society and professor of medicine at SUNY Upstate Medical University.

Christopher Langston, program director at the Hartford Foundation, said older adults should schedule a Medicare wellness visit and talk to their doctors about recommended preventive care.  The Rand Corp. has found that only 30 percent of older adults get care supported by medical evidence, compared to 55 percent of the general population, he noted.

Still, despite gaps in care uncovered, 97 percent of respondents reported being satisfied with their primary care providers.

The mission of the Hartford Foundation is to improve the health of older adults.  Its survey, released Tuesday, asked 1,028 people age 65 and older between February 29 and March 3 about their experiences with care. The study was conducted online by Lake Research Partners and had a margin of error of +/- 3.1 percentage points.

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By Sarah Barr
Kaiser Health News

Few doctors think of themselves as rich, and only about half think they’re fairly compensated, according to survey results released this week by Medscape.

The annual survey isn’t scientific – and perhaps, not surprising, either — but it offers insights into what nearly 25,000 physicians earn, and how they view that number. In 2011, compensation self-reported by surveyed physicians ranged from an average of $156,000 for pediatricians to $315,000 for radiologists and orthopedic surgeons.

The survey showed that 51 percent of all physicians — and 46 percent of primary care physicians – think they’re compensated fairly.

Only about 11 percent of doctors consider themselves rich, mostly because of their debts and expenses, according to Medscape.

The survey also offers a glimpse at how physicians view coming changes to the health care system, such as efforts to improve quality or offer care through accountable care organizations, which are integrated systems included in the federal health law.

More than half said they expect their incomes to decline because of ACOs (although very few were participating in such a system), and only 25 percent said quality measures and treatment guidelines will improve patient care.

Overall, 54 percent of physicians said they would choose medicine as a career again. Only 41 percent said they would choose the same specialty and 23 percent would choose the same practice setting.

Others groups that survey physicians about their income include the Medical Group Management Association and Merritt Hawkins. A 2011 MGMA report, for instance, which looked at data from 2010, found the median compensation for radiologists was $471,253 and $192,148 for physicians in pediatric/adolescent medicine.

Medscape surveyed 24,216 physicians across 25 specialty areas from Feb. 1-17, 2012 using a third-party online survey collection website.

Physician compensation in 2011:

Pediatrics -- $156,000
Psychiatry -- $170,000
Obstetrics/Gynecology -- $220,000
General surgery -- $265,000
Plastic surgery -- $270,000
Cardiology -- $314,000
Orthopedics -- $315,000
Radiology -- $315,000

For complete chart: http://capsules.kaiserhealthnews.org/wp-content/uploads/2012/04/doc-salaries-500.png

This story was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation, a nonpartisan health care policy research organization which is unaffiliated with Kaiser Permanente

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By Michelle Andrews
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Two years after its passage, the sweeping health care overhaul remains deeply controversial, with both political parties trying to use it to their advantage in the upcoming elections. As GOP lawmakers constantly deride "Obamacare" and threaten to repeal it, it’s easy to forget that implementation marches on, and a number of notable changes will take effect for consumers this year. 

They will, that is, unless the Supreme Court strikes down some or all of the law, including the requirement that nearly everyone have health insurance beginning in 2014. If that happens, all bets are off. Provisions that have already taken effect -- such as allowing adult children to remain on their parents’ health plans until age 26 and the 50 percent discount on brand-name drugs for seniors who reach the so-called donut hole in their prescription drug plans -- could be rolled back, and provisions for 2012 cancelled. The court will hear arguments in the case later this month and a decision is expected this summer.

If the law stands, here are the major new provisions that will affect consumers this year:

Free contraception coverage
Starting in August, the Obama administration's new rules on contraceptive coverage that have generated such controversy take effect. That means that women in a new health plan or in an existing one that has changed its benefits enough to not be considered grandfathered under the law will be able to receive contraceptives without an out-of-pocket charge. In addition, these plans will have to provide a variety of basic women’s health services, including well-woman visits (breast exams, pap smears, etc); screening for gestational diabetes; HPV testing; counseling for sexually transmitted infections; counseling and screening for HIV; and screening and counseling for interpersonal and domestic violence.

Religious employers such as churches are exempt from the new requirement. Colleges, hospitals and other employers that are affiliated with religious institutions are not exempt, but employees at those institutions will receive free contraceptive services from their employer's insurer.

Religiously-affiliated employers have a one-year grace period to implement this change, so some employees may not receive the free benefit until August 2013.

Rebates for consumers
Under the health-care overhaul, insurers have to spend at least 80 to 85 percent of premium revenues on medical claims and quality improvement or else rebate the difference to policyholders. In most group plans, that would mean the employer.

How much consumers can expect to receive remains an open question. An analysis by the National Association of Insurance Commissioners, based on 2010 data, estimated that insurers would have returned $2 billion to consumers had the provision been in force then. The analysis said rebates would have gone to 53 percent of people in individual plans, 23 percent in small-group plans and 15 percent of large-group plan members.

In December, the Obama administration estimated that 9 million Americans might receive rebates totaling up to $1.4 billion, also based on 2010 data. The administration says some reports show insurers have been moderating their premium increases to avoid having to pay rebates. But other policy experts aren't so sure.

"My guess is that rebates will be higher [than the NAIC estimate] in 2011," says Timothy Jost, a law professor at Washington and Lee University who helped prepare the NAIC report. "Insurers seem to have raised their premiums based on projected increases in utilization that never occurred."

Clearer descriptions
Beginning in September, at the start of the open enrollment season, all health plans will have to provide concise, consistent plan information aimed at allowing consumers to easily understand their benefits and compare plans.

Every plan will be required to give people a short summary of coverage and a uniform glossary of terms. It will also have to provide examples of how much the plan would cover if someone had a baby or was managing Type 2 diabetes -- two common situations that should make it easier for people to compare plans.

"This is a big deal," says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation. "Some of the materials people get explaining their health plan benefits are extraordinarily confusing, and this should make it clearer." (Kaiser Health News is an editorially-independent project of the Foundation.)

Shrinking doughnut hole
The health care overhaul is slowly eliminating the ‘doughnut hole.’ This is the break in Medicare prescription drug benefits that, in a standard plan, begins after total drug spending by the beneficiary and the health plan exceeds $2,930 and continues until the beneficiary has hit the $4,700 out-of-pocket limit.

Last year, Medicare beneficiaries with high drug costs got a 50 percent discount on brand-name drugs once they reached the doughnut hole. This year, they'll see a 14 percent discount on generic drugs as well.

Drug costs will continue to diminish in coming years, until in 2020 the doughnut hole no longer exists and Medicare beneficiaries with drug plans will simply be responsible for 25 percent of their drug costs.

'Accountable Care'
Last December, the administration announced that 32 health-care organizations would participate in a three-year Pioneer Accountable Care Organization programaimed at providing better, coordinated care for 860,000 Medicare beneficiaries. Providers -- including hospitals, clinics and physician groups -- that work together to improve beneficiaries' health and to bring costs down will share in the savings that they achieve.

Although Medicare beneficiaries may not realize that their health-care provider is participating in the program, they may start to notice changes in their care this year, says Debra Ness, president of the National Partnership for Women and Families. She leads the Campaign for Better Care, a coalition of organizations focusing on improving health-care delivery.

"For some of these folks, it may start to feel like they have a team working with them, or like their primary-care provider is developing an individualized care plan," she says. "Compared to what happens now, it could feel like a pretty big change."the

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By Rachael Rettner
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The idea of putting maggots into open flesh may sound repulsive, but such a therapy might be a quick way to clean wounds, a new study from France suggests.

Men in the study, all of whom had wounds that wouldn't heal, were randomly assigned to have dead and unhealthy tissue removed from their lacerations by either standard surgical therapy or maggots (that eat dead tissue).

After about a week, men who received the maggot therapy had less dead tissue in their wounds than men who underwent surgery, the researchers said.

However, after two weeks, the immature insects had lost their advantage: Both groups had about an equal amount of dead tissue in their wounds. And in the end, the maggots did not help the wounds heal faster.

Although the effects of maggot therapy were not dramatic, it may be useful in certain cases, such as in patients with diabetes, whose wounds need rapid control, the researchers said. But continuing the maggot therapy beyond one week is not of benefit, they said.

Medical use of maggots was approved in 2004 by the U.S. Food and Drug Administration. However, only a small minority of patients with unhealing wounds receive the treatment, said Dr. Robert Kirsner, a dermatologist at the University of Miami School of Medicine, who was not involved in the new study.

The study included about 100 men with wounds on their lower limbs. About half received maggot therapy and half received surgical treatment. For the maggot therapy, sterile maggots were placed in a small pouch that was placed on top of the wound. The therapy was applied twice a week for two weeks.

Neither the patients nor the doctor evaluating the wounds knew which therapy a patient received (patients wore a blindfold when their bandages were changed.)

After eight days, the percentage of dead tissue in the wounds of patients who received the maggot therapy was 54.5 percent, compared with 66.5 percent in patients who received surgery. But after 15 days and 30 days, the amount of dead tissue in the wounds was about the same for both groups.

The number of patients who reported feeling a crawling sensation in their wound, and the number reporting pain, was also about the same in both groups, according to the study, which was conducted by researchers at the University Hospital Center of Caen , in France.

Maggots secrete an enzyme that dissolves dead tissue but leaves healthy tissue alone, Kirsner said.

Although there are few risks to the treatment, "there is a gross factor to it," Kirsner said. "Patients have to be very psychologically strong," he said.

Another group of patients that may benefit from the therapy are those who cannot undergo surgery, for instance, if they cannot receive anesthesia, Kirsner said.

Future research should determine whether the effects of maggot therapy can be improved using more maggots, and whether an increase in the number of critters would be painful, the researchers said.

The study is published online in the journal Archives of Dermatology.

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