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Indiana’s Claims About Its Medicaid Experiment Don’t All Check Out

Indiana expanded Medicaid under the Affordable Care Act in 2015, adding conditions designed to appeal to the state’s conservative leadership. The federal government approved the experiment, called the Healthy Indiana Plan, or HIP 2.0, which is now up for a three-year renewal.

But a close reading of the state’s renewal application shows that misleading and inaccurate information is being used to justify extending HIP 2.0.

This is important because the initial application and expansion happened on the watch of then-governor and now Vice President Mike Pence. And Seema Verma, who is President Donald Trump’s pick to lead the Centers for Medicare & Medicaid Services, helped design it. (Among other functions, CMS oversees all Medicaid programs.) So, states are watching to see if the approval of Indiana’s application is a bellwether for Medicaid’s future.

To get the program extended again, the Indiana Family and Social Services Administration has to prove to CMS that the experiment is working and that low-income people in the state are indeed getting access to care and using health care efficiently.

The key part of Indiana’s experiment requires low-income participants to make monthly payments. Advocates say this promotes recipients’ taking personal responsibility for their health care. But some health policy experts say the information provided by the state shows that the provision isn’t working as well as it should. Some examples:

The Claim: Most members are making regular payments to maintain coverage. The Fact: A lot of people are missing the first payment.

The state’s application says that “over 92 percent of members continue to contribute [to their POWER accounts] throughout their enrollment.”

This claim is missing context. Here’s a primer on how HIP 2.0 works: Members can get HIP 2.0’s more complete coverage, the HIP Plus plan, by making monthly payments into a “Personal Wellness and Responsibility Account,” or POWER account.

If they don’t make the payments, there are penalties. If a recipient makes less than the federal poverty level — about $12,000 a year — they’re bumped to HIP Basic, a lower-value plan that requires copays and doesn’t include vision or dental insurance.

If a recipient is above the poverty line and misses a payment, they become locked out of coverage completely for six months.

The state’s claim that 92 percent of members make consistent payments is based on data in a report by the Lewin Group, a health policy research firm in Virginia that evaluated HIP 2.0’s first year.

But the Lewin report also says that when people sign up for HIP 2.0 they can be declared “conditionally enrolled,” which means they’re eligible but have not yet made their first payment.

According to the Lewin report, in HIP 2.0’s first year, about a third of people who were conditionally enrolled never fully joined.

“I don’t see those numbers being captured,” said Dr. David Machledt, senior policy analyst with the National Health Law Program, which advocates for low-income individuals. Machledt said the state should recalculate the figure to include those people, because it’s potentially an indicator that people are confused about how the program works or that they can’t afford the payments.

He added that the figure cited is based on the first year of HIP 2.0, and that the rate of losing coverage for missing payments has increased substantially since then.

The Claim: HIP 2.0 users check their POWER account. The Fact: More than half of people don’t even know they have one.

The state says the POWER account is promoting personal responsibility in health care; meaning, if someone is aware of how much they are spending, they’ll choose their medical care wisely. As evidence, the state writes in its application that 40 percent of HIP Plus members “check their [POWER Account] balance at least once a month.”

Again, the state leaves out important context. According to the Lewin report, most people in HIP Plus didn’t know they had a POWER account. Of those who did, 40 percent checked their account once a month, but that’s much smaller than 40 percent of all HIP Plus members. In fact, an analysis of the numbers shows only about 19 percent of HIP Plus members reported checking the balance of their POWER account monthly.

Rather than evidence of personal responsibility, Judy Solomon, vice president for Health Policy at Center on Budget and Policy Priorities, sees evidence of confusion.

“I think that’s another really significant finding [in the Lewin report] that so far I have never seen the state come to terms with,” said Solomon.

A spokesperson for the state wrote in an e-mail that the phrase “of the members surveyed” was unintentionally omitted from the application.

The message did not address the overall concern that the statement was misleading.

The Claim: People on HIP Plus are more responsible. The Fact: Experts say HIP Plus is just better insurance.

The application also says “HIP members who contribute [to their POWER accounts] are twice as likely to obtain primary care (31 percent to 16 percent), have better prescription drug adherence (84 percent to 67 percent), and rely less on the emergency room for routine treatment.”

Machledt said simply showing that HIP Plus members use the emergency room less frequently than HIP Basic members doesn’t tell the whole story.

“They don’t talk about the risk profile of those different groups,” Machledt said. He said people who are above the poverty line are generally less likely to frequent the ER in the first place. “There’s no evidence to me that they’ve risk-adjusted … to show that they’re comparing apples to apples,” he said.

Indiana argues that the higher levels of primary care use and drug adherence for those making POWER account payments “confirms the principle of personal responsibility.”

But Solomon said the differences in behaviors simply confirm something else: Those who pay their POWER account have better insurance. HIP Plus makes it easier for people to access primary care and to adhere to their prescription drug regimens, Solomon said.

“The policy for people in HIP Plus is that they get a three-month supply of drugs, and can even use mail order, without any copays,” she said. Meanwhile, people in HIP Basic have to pay copays and are limited to a one-month supply of drugs.

Solomon said getting less primary care and relying on the ER for health crises is worse for patients and could also mean higher costs. “You have large numbers of people that are not getting care in the right place at the right time, and not maintaining adherence to prescription drug regimens.”

The Claim: HIP 2.0 is meeting its enrollment projections. The Fact: No, it isn’t. [caption id="attachment_704066" align="alignright" width="370"] Enrollment projections for HIP 2.0 submitted to CMS in 2014. (Healthy Indiana Plan Expansion Proposal/FSSA)[/caption]

The state’s application reads “HIP has continued to meet its enrollment goals with over 394,000 individuals fully enrolled in HIP as of December 1, 2016.”

But the state isn’t meeting its enrollment goals. According to a chart published in 2014 in Indiana’s original proposal for HIP 2.0, its enrollment goal for December of 2016 was higher: 424,339. (The chart is off by a month, because the state started HIP 2.0 a month later than planned, so the actual projection for December 2016 appears on the line for November 2016.)

The most recent enrollment report shows 403,142 HIP members in January 2017, short of the state’s projection of 427,702.

The Claim: Surveys show people like HIP 2.0 The Fact: This survey’s results are unreliable.

There’s reason to doubt the survey results that underlie much of the Lewin report, according to Dr. Leighton Ku, director of the Center for Health Policy Research at the Milken Institute School of Public Health at George Washington University.

“They were not using what would generally be considered best practices in their survey methodology,” Ku said.

Ku said the methodology available to the public is vague. From the information provided, he said, there are multiple ways that bias could have been introduced into the survey results used in the Lewin report. For one thing, the sample sizes of the survey were too small to draw accurate conclusions, Ku said, and the data was analyzed using “not an optimal method.”

Ku said that the results are not displayed in a scientific manner and that it appears the survey and analysis were done in a hurry. “You would not, as a survey researcher, have great confidence in the results that they show,” he said.

Conclusion

As Indiana looks to extend HIP 2.0, health policy experts say it’s important to get an accurate picture of how well the program is working. Requiring POWER account payments was key to making the program a reality in Indiana, but they say a more traditional Medicaid expansion — one that does not require monthly payments and six-month lockouts — is a better option.

Dr. Jennifer Walthall heads the Indiana Family and Social Services Administration, the government agency that runs HIP 2.0. She said that in order to comment on discrepancies between the state’s extension application and the Lewin report, “I would have to go back and look at the way that these data were reported.” She continued, “I’m happy to look into that and get that for you.”

In a separate prepared statement, the agency noted that the state “has made significant achievements” on HIP 2.0’s stated goals and that it looks forward “to continuing to build on these successes with future versions of HIP. … The analysis of this program is constant and ongoing and includes continuous conversation with our federal partners to discuss all aspects of the proposed waiver as well as program outcomes.”

If the application does not go forward, the state could choose to expand Medicaid under the Affordable Care Act without any special provisions, or not accept the expansion at all. The federal government welcomes public comment on Indiana’s application until March 17.

This story is part of a partnership that includes WFYI, Side Effects Public Media, NPR and Kaiser Health News.

Hospitals, Both Rural And Urban, Dread Losing Ground With Health Law Repeal

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PRINCETON, Ill. — Commuting past the barren winter fields in northern Illinois, Cathie Chapman worries about the future.

More than a year ago, she lost her job at a nearby rural hospital after it closed and, as Republicans work to dismantle the Affordable Care Act, wonders whether she’ll soon be out of work again.

“Many of my friends did not find jobs they love,” she said. “They’re working for less money or only part time. Some haven’t found any jobs yet, even after a year.”

Now she runs the pharmacy at Perry Memorial Hospital here, warily watching the Republicans’ repeal efforts.

“I think everybody who works in health care now feels a little uneasy,” said Chapman. “We don’t know what’s coming around the corner, and how it will affect us. But we know that change is happening so fast, it is exhausting and difficult to keep up with.”

Rural hospitals have long struggled to stay open. They have far fewer patients and thin profit margins. Dozens have closed across the country in recent years, mostly in states that didn’t expand Medicaid.

But in Illinois, which did extend Medicaid to nearly all poor adults, patients at Perry Memorial have gained coverage under the Affordable Care Act and many hospitals have found firmer footing.

If large numbers of people lose their insurance under the Republicans’ replacement, the hospital’s finances — and those of its patients — would be at risk, especially after the hospital invested so much money and time in complying with the health law, said chief executive Annette Schnabel.

“We have spent the last six years gearing up towards everything that we were responsible for doing in the ACA,” said Schnabel. If the hospital has to “totally go a different direction, how will we do that? It’s going to take a lot of work.”

And for some hospitals to survive or break even, it would require Congress to restore billions of dollars in funding that kept hospitals afloat before the 2010 law took effect.

Hospitals across the country made a high-stakes trade when they signed on to the Affordable Care Act. They agreed to massive cuts in federal aid that defrayed the cost of caring for the uninsured. In exchange, they would gain tens of millions of newly insured customers. Now that deal is in jeopardy, and many hospital executives anxiously await whatever comes next.

[caption id="attachment_704108" align="alignright" width="370"] In states that have seen growth in the number of insured patients, hospitals have invested in new equipment and hired more employees. (Screenshot/PBS)[/caption]

In Chicago, John H. Stroger Jr. Hospital of Cook County is among the nation’s busiest hospitals, handling most of the city’s gunshot victims. The vast majority of its patients used to be uninsured, and the county-run hospital struggled to take care of their medical and mental health needs.

Those patients now have Medicaid coverage because of the Affordable Care Act, and the Cook County hospital system gained $200 million in new revenue to cover their services, breaking even for the first time.

“We have no interest in slipping back in what we’ve been able to do,” said Dr. John Jay Shannon, chief executive of the Cook County Health and Hospitals System. “We’re not able to do the kind of work that we do today with good will alone. Our staff are not a volunteer staff. We can’t get IV fluids and medical equipment on credit and a wink and a nod.”

Two hospital trade groups — the American Hospital Association and the Federation of American Hospitals — have warned of “an unprecedented public health crisis” if the law gets hastily scuttled.

They say if Congress repeals the law entirely and 20 million people are kicked off their insurance, hospitals will lose $166 billion in Medicaid payments alone in the next decade.

And hospitals face much steeper losses if certain Medicare cuts that were part of the law aren’t restored.

In Chicago, limo driver Jerold Exson is one patient who could lose coverage and have his hospital bills — once again — go unpaid. These days, the hospital helps enroll low-income adults such as Exson into Medicaid. In 2014, he was shot nearly a dozen times in a case of mistaken identity.

His medical care is now covered, and the hospital can provide follow-up surgeries, physical therapy and mental health treatment that were often off-limits to the uninsured.

Clinical psychologist Natalia Ruiz helps Exson manage the after-effects of gun violence. “I used to be real antsy,” said Exson who suffers from post-traumatic stress disorder. He recalled a recent moment when he was driving and a “rock hit the window, and it kind of sent me into a tailspin.”

The health law also shifted the business model for U.S. hospitals. It offered them financial incentives to move away from expensive ER visits to primary care and managing chronic conditions.

Earl Williams Sr. finally has brought his diabetes under control. He’s diligent about exercising, taking his medication and seeing his doctor.

“I had high sugar levels, I had high blood pressure, there was quite a few things that was going on with me that now I know how to control,” said Williams.

Before the Affordable Care Act, hospitals had little incentive to reduce emergency department visits, especially from Medicare patients who generate a lot of revenue.

At University of Chicago Medicine, an academic medical center, Dr. Kenneth Polonsky said if those incentives are rescinded and patients forgo preventive care, they’ll clog up already strained emergency rooms.

“We’ll go back to a very frustrating time, where people had limited options for health care, because of inability to get health insurance,” said Polonsky, dean of the Division of the Biological Sciences.

The uncertainty is also roiling county governments, which often fund medical care for the poor.

The burden on local taxpayers to fund the Cook County health system has dropped by $300 million since the health law went into effect, and repealing the law could force local governments to raise taxes.

[caption id="attachment_704106" align="alignleft" width="370"] The political uncertainty surrounding health care is roiling county governments, which often fund care for the poor. (Screenshot/PBS)[/caption]

“It’s a $300 million hole in our budget,” said Toni Preckwinkle, president of the Cook County Board of Commissioners. “There aren’t a lot of options other than raising more revenue. It’s a nightmare for us.”

In Waukegan, Ill., near the Wisconsin border, Vista Health System chief executive Barbara Martin said that with more patients covered and additional reimbursement from the ACA, she has invested in new equipment and hired hundreds of new employees across Vista’s two for-profit hospitals.

She said if the 900,000 Illinois residents who gained insurance under the law lose coverage — and hospital revenue drops suddenly — hospital executives estimate 95,000 jobs could be lost.

“That certainly would impact jobs at Vista,” Martin said. “We’re going to go back to those days where hospitals were closing.”

But Edmund Haislmaier, a senior fellow at the Heritage Foundation, a conservative think tank, said the U.S. already pays too much for health care. A member of President Donald Trump’s transition team on health policy, Haislmaier said communities — and states and local governments — shouldn’t rely on hospitals to create jobs and fill budget holes.

“Hospitals, in particular, have become economic development projects,” he said. “If you’re paying tax dollars for Medicare or Medicaid, treating that as an economic development project is a problem, not a benefit.”

[caption id="attachment_704097" align="alignright" width="370"] Earl Williams is diligent about seeing his doctor, but worries whether he will have health insurance after Republican changes to the ACA. (Screenshot/PBS)[/caption]

More than a dozen top Republican lawmakers declined to be interviewed for this story. But a spokeswoman for Sen. Lamar Alexander, the Tennessee Republican who chairs the Senate Committee on Health, Education, Labor and Pensions, said in a statement that Alexander “is listening to hospitals, doctors, patients, state insurance commissioners, governors” as they draft the replacement plan.

The most recent draft of the Republican’s proposal would eliminate the Medicaid expansion, which covers 14 million people, by 2020. To offset the increase in uninsured patients, the plan would reverse some of the payment cuts to hospital.

Back in Chicago, patients like Earl Williams have been bringing their questions to their doctors, with the hope of some clarity.

At a recent checkup, Williams asked pointedly, “Am I going to have insurance in a month or two? That’s kind of scary for brothers that’s in the community.”

“You and I have been knowing each other for a long time, and I’m going to give it to you straight,” responded William’s physician, Dr. Pete Thomas. “And that is: It’s likely that it’s going to change. It’s not going to be the same.”

PBS NewsHour producer Jason Kane contributed to this story.

For Some Hospice Patients, A 911 Call Saves A Trip To The ER

FORT WORTH, Texas — Her mother’s breathing had become labored in the wee hours of the night, during what would prove to be the Fort Worth woman’s final days living with lung cancer. Distraught, the daughter called 911.

“Her mother was having some pretty severe shortness of breath,” said Tim Gattis, the third paramedic to arrive on scene late last year. “She was certainly working very hard to obtain a breath, and was just not being successful.”

Gattis pulled up in a sports utility vehicle shortly after the ambulance had arrived, and the first two responders were already loading the 64-year-old woman into the back. The daughter was insisting that her mother go straight to the hospital, Gattis said.

But the role of Gattis and other Fort Worth paramedics trained for this type of hospice support — part of a local partnership with VITAS Healthcare, the country’s largest hospice organization — is to spend a longer stretch of time on the scene to determine if the symptoms that triggered the 911 call can be addressed without a trip to the emergency room. MedStar Mobile Healthcare, a governmental agency created to provide ambulance services for Fort Worth and 14 nearby cities, is one of several ambulance providers nationwide that have teamed up with local hospice agencies. The paramedic backup, enthusiasts argue, not only helps more hospice patients remain at home, but also reduces the potential for costlier and likely unnecessary care.

On average, 18 percent of hospice patients go to the emergency room at least once before their death, according to an analysis of Medicare data published last year in the journal Medicare data published last year in the journal Medical Care. Melissa Aldridge, the study’s lead researcher and an associate professor at New York City’s Icahn School of Medicine at Mount Sinai, describes paramedic-hospice partnerships such as Fort Worth’s as “forward-thinking” in promoting better patient care.

Hospices also can financially benefit, she said, since they’re paid a flat rate — typically just under $200 a day — regardless of where their patients are treated. So, any hospital treatment related to the patient’s condition, such as pain stemming from advanced cancer, would come out of that payment, she said. “For [the agencies], it could definitely be worth it, particularly for the one or two outlier families who seem to be using the emergency department fairly heavily during a hospice stay,” Aldridge said.

An Expanding Role 

These emerging programs rely upon a new type of emergency responder. Dubbed community paramedics, they can offer a range of in-home care and support for home health patients, frequent 911 callers and others to reduce unnecessary ambulance trips. MedStar’s community paramedicine program had already been launched, when VITAS got in touch.

The Affordable Care Act had been passed, and with it the inclusion of financial penalties for hospitals if their patients return too quickly to the hospital. John Mezo, senior general manager for the Fort Worth region of VITAS, said that since many VITAS patients come from hospital referrals, it’s important that the hospice not become “a big problem for our referral sources,” he said.

So in 2012, Fort Worth’s VITAS program began contracting with MedStar, targeting patients who have been flagged during the hospice admissions process as moderately to highly likely to call 911 or end up in the hospital. (VITAS pays a flat monthly fee to MedStar for each patient enrolled.)

Once signed up, hospice patients calling 911 can be identified through various routes, including their address, name or phone number. Then a community paramedic like Gattis, who is available for home health and other types of calls, including hospice, is dispatched along with the traditional ambulance response, said Matt Zavadsky, MedStar’s chief strategic integration officer. The ambulance provider now contracts with two hospice agencies and is in talks to add others, he said.

In Ventura, Calif., a similar hospice initiative is being piloted through a state agency — part of a larger multicity effort there to study the use of community paramedics. That pilot, which has worked with some 20 hospice agencies since 2015, sends out a community paramedic to any 911 call involving a hospice patient. Also, a large Long Island, N.Y.-based health care system added similar paramedic backup last year for a portion of its hospice patients living in Queens under a grant-funded project.

If any of those nearly 180 patients or their family members calls the 24/7 hospice number with an urgent situation, a community paramedic can be immediately sent, said Jonathan Washko, assistant vice president of emergency medical services for the system, Northwell Health.

It’s “extremely rare” that patients call 911 directly, Washko said, “because we get them help, just as if they would have called 911.”

Navigating Final Days

The uncomfortable truth is that a patient on hospice can develop unsettling and sometimes scary symptoms during their final weeks or days. Secretions can accumulate in the throat, which might sound like choking, even though the patient is not, Mezo said. The patient might suffer a breathing crisis or a seizure.

VITAS stresses that a hospice nurse is available around-the-clock, by phone or to stop by. But family members can understandably be loath to wait for a nurse who might have to drive from an hour away, Mezo said.

“When it’s your loved one there and you’re in charge of them, it’s very frightening,” he said. “If you’ve ever had to call 911, even five minutes waiting on an ambulance seems like an eternity, right?”

For paramedics involved, the work has proven to be challenging and gratifying, requiring a mix of psychology and social work skills along with medicine. “You can’t Google what to do in these situations,” said Ambrose Stevens, a Ventura community paramedic, who has responded to about 40 hospice calls.

By the end of 2016, Ventura paramedics had responded to 258 hospice calls, but paramedics needed to access hospice-provided medications for pain, nausea and other symptoms in fewer than 2 percent of those calls, said Mike Taigman, project manager of Ventura County’s Hospice Community Paramedicine Pilot Project. “Most of what we do is really helping coordinate, talk people down from being upset, helping remind them of what hospice is all about,” he said.

Offering The Option 

Patients or their family members can still insist on going to the emergency room, and sometimes they do. Of the 287 patients enrolled in Fort Worth’s program for the first five years — all of whom had been prescreened as highly likely to go to the hospital — just 20 percent, or about 58 patients, were transported, according to MedStar data. In Ventura, ambulance transports for hospice patients calling 911 also have declined — from 80 percent shortly before the program’s start to 37 percent from August 2015 through December 2016, according to data provided by Taigman.

That difficult night in Fort Worth, Gattis put the VITAS nurse on speaker as they talked to the daughter about ways to keep her mother more comfortable at home. The daughter agreed to hold off on ambulance transport and see if anti-anxiety medication and morphine would ease her mother’s breathing struggles.

Within a half-hour, Gattis said, it was apparent that the medicine was helping. “She was feeling better to the point that she could eat a little bit of a sandwich.”

Gattis stayed for more than an hour until the hospice nurse arrived. The woman died several days later in her own bed.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation. Coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Advocates Of Flat-Fee Primary Care See Opening In GOP’s Market-Driven Approach

Back in the day, people paid for routine primary care on their own and used insurance only when something serious came up. Some primary care doctors are betting that model can thrive again through a monthly subscription for routine care and a high-deductible insurance policy to take care of the big stuff.

But the changes raise questions about whether the approach really leads to more effective and efficient health care.

It’s easy to understand the appeal of “direct primary care,” as it’s called, for doctors and patients. Doctors charge a monthly fee, generally from $50 to $150, to provide routine clinical care and consultation, sometimes including basic lab work and tests. Patients who need other care, an MRI or surgery, for example, would be covered by their insurance policy, if they have one.

Freed from having to devote time and money to manage insurance claims, doctors say they can accept fewer patients and spend more time with them without focusing on what services are paid for.

Patients, meanwhile, may get more personalized care. They also may save money on insurance if they can pair their primary care plan with a cheaper, high-deductible policy.

Although only a fraction of primary care doctors practice this way, the proportion has grown from 2 to 3 percent in the past year, according to data from the American Academy of Family Physicians, which supports this type of practice.

Advocates of direct primary care believe their prospects are bright because the new Republican administration favors market-driven approaches to health care. The plan introduced by Health and Human Services Secretary Tom Price when he was in Congress would allow people to pay monthly fees for direct primary care with funds from health savings accounts. A bipartisan bill introduced in January for the current Congress would amend Internal Revenue Service rules to permit that.

William Bayne joined MedLion direct primary care last October. For $300 a month, the Las Vegas commercial real estate developer gets routine primary care for himself, his wife and their five children. “It’s great for the little stuff that comes up with five kids,” said Bayne, 41. They also have a comprehensive family insurance plan.

When Bayne’s 8-year-old son woke up with what looked like a big pimple on the side of his eye one morning, they called MedLion and made an appointment for 12:30 that day. But their doctor, Samir Qamar, called that morning, having seen their names on the schedule, and asked for a photo of the boy’s eye. Qamar said it looked like an oil gland in an eyelid was clogged and suggested they wait a day before coming in, because it would probably clear up on its own. It did.

Qamar used to have a high-end concierge practice in Pebble Beach, Calif., where he provided on-call primary care services. When the Great Recession hit in 2007, he and his wife, a physician with a traditional primary care practice, decided to offer concierge-style primary care at a lower price point, Qamar said. They moved to Las Vegas and opened MedLion, which is now available in seven locations in the Las Vegas area and works with 429 affiliated physicians in 25 states.

Like many direct primary care practices, MedLion has shifted its focus from individuals to the employers who offer the service as a benefit. Workers typically pick one of their company’s regular insurance plans and add the direct primary care service if they wish to. The company pays the monthly fee for those who choose the option and may or may not pass that cost along to workers.

In perhaps the largest effort of its kind, the state of New Jersey recently kicked off a pilot program with Philadelphia-based direct primary care provider R-Health that aims to enroll at least 60,000 state employees in the first three years.

Not surprisingly, the program is particularly appealing to people with chronic conditions, said Mason Reiner, CEO of R-Health.

“Those are the folks who really need and can benefit from relationship-based primary care,” he said. “It can make a big difference for them and for the state, since so much of the cost of care is driven by these folks.”

Improving access to primary care is important, said Dr. A. Mark Fendrick, an internist who directs the Center for Value-Based Insurance Design at the University of Michigan. But he cautions that while direct primary care doctors who get a flat monthly fee aren’t motivated to provide unnecessary, low-value care, patients don’t have the same incentive. For patients, an “all-you-can-eat model” may encourage them to get care they don’t need.

“By removing fee-for-service [payments], this model is positive on the provider side,” Fendrick said. “But it isn’t nuanced enough on the patient side to get the system where we need it to be.”

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

Thieves using new trick to lure victims at gas stations

Criminals are using decoys to rip off unsuspecting people at gas stations.

“It’s a new twist to an old crime,” Fairburn, Georgia, police Sgt. Mario Jones said.

The crime was caught on tape when three people threw a handbag out the window of a silver Lexus at a South Fulton County gas station and waited for their victim to take notice.

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“When he picked it up to take it inside the store here, that's when the crooks moved in,” Jones said.

Surveillance video captured the 54-year-old man as he stepped away from his car to take the purse inside. Within seconds, a man can be seen jumping from the back of the Lexus and into the victim’s car, stealing a wallet and iPhone.

Harold Byrd told WSBTV.com that he rents his basement apartment to the victim in the video.

“He thought he was being a good Samaritan by taking this handbag to a store clerk, thinking someone had dropped it at the gas station off Senoia Road. But the store’s surveillance video shows something different,” Byrd said.

>> Read more trending news

The Lexus also was stolen, and police believe the handbag tossed from the window was taken the same way just an hour before, Jones said.

“They got his pocketbook, all his information, my address on it. I worry about that. I’m 82 years old,” Byrd said.

Jones said this could become a new trend.

Byrd told us he won’t rest easy until the suspects are caught.

Anyone who may know the suspects are urged to call police. 

Oscars 'In Memoriam' tribute mistakenly uses photo of living producer

An Australian movie producer was accidentally featured in the "In Memoriam" segment at Sunday night’s Oscars despite the fact that she is “alive and well.”

According to People, an image of Jan Chapman was used to remember Janet Patterson, an Australian costume designer who died in October 2016.

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“I was devastated by the use of my image in place of my great friend and long-time collaborator Janet Patterson,” Chapman told Variety. “I had urged her agency to check any photograph which might be used and understand that they were told that the Academy had it covered.”

>> Steve Harvey reacts to epic Oscars gaffe

This came up in the In Memoriam section at #Oscars2017. But isn't this (living) Australian film producer Jan Chapman? pic.twitter.com/YKIMGBUv5E— David Berthold (@DavidBerthold) February 27, 2017

Chapman, who reportedly worked with Patterson on “The Piano” and “The Last Days of Chez Nous,” was “very disappointed” that the mistake wasn’t realized ahead of the ceremony.

>> Read more trending stories

“I am alive and well and an active producer,” she said.

4 Easy Ways to Assess Your Well-Being

You're committed to a healthy lifestyle. You hit the gym every day when they open their doors, ditch soda for water, and brought healthy fruits and vegetables back to the center of your plate. Then you step on the scale, only to find that you haven't lost a single pound after all your hard work. Is it even worth it? Of course, the answer is yes. Although weight loss can take time, there are other changes happening in your body—and mind—that you can't ignore. After just a few days of sticking with your healthy lifestyle plan, you might start to notice a difference in your energy level, stress level, quality of sleep and overall feelings about yourself. By tracking your progress in these areas, you can stay motivated and learn to appreciate all the little improvements you are seeing, regardless of what the scale tells you. Taking a daily stock of your energy level, stress level, sleep quality and self-esteem is important for everyone who is trying to live a healthier life. It will help you notice trends and patterns (you tend to eat more on high-stress days or sleep better when you exercise in the morning) so that you can tweak your plan for optimal results. And it can help you appreciate the small achievements—like feeling more confident when you exercise regularly. That's why we recommend recording these wellness measurements on a daily basis. Here are some tips for assessing your daily wellness in each of these four areas. Energy Level On a scale of 1-5 (5 being the highest), how is your energy level today? Do you feel full of vigor and ready to tackle the challenges of the day (5), as if you can barely drag yourself out of bed (1) or somewhere in between? Many factors can affect your energy: how much you slept the night before, how stressed you are, whether you're exercising too much or too little (both of which can zap energy), and the quality of your diet (too many sweets and not enough nutrient-rich foods can both be culprits). Serious health conditions like depression or anemia can also affect your energy levels, so talk to your doctor if you notice a long-term trend of tiredness. Stress Level On a scale of 1-5 (5 being the highest), how would you rate your stress level today? Do you feel like you're about to bite someone's head off (5), like everything just rolls off your back (1) or something in the middle? Stress affects more than your quality of life. It can contribute to high blood pressure and hinder your weight loss, making you want to eat more or causing you to eat as a way to relieve stress. There are many ways to reduce stress, from exercising and meditating to simply relaxing or practicing breathing exercises. Looking for some easy ways to reduce the stress in your life? If you notice a problem with stress, learn how to deal with it in a healthy way before it gets the best of you. Quality of Sleep On a scale of 1-5 (5 being the highest), how well did you sleep last night? Did you feel well-rested when you woke up this morning (5)? Did you toss and turn all night and feel terrible today because of it (1)? Something in the middle? Like stress, poor sleep can lead to a host of other health problems, from weight gain to a suppressed immune system. SparkPeople's Better Sleep Resources can help identify your sleep problems and suggest ways to improve the quality of your shut-eye. Self-Esteem On a scale of 1-5 (5 being the highest), how good do you feel about yourself today? Do you feel confident and self-assured like a rock star (5), like you don't matter and there's nothing good about you (1) or something in the middle? Your self-esteem goes hand in hand with a healthy lifestyle. If you don't think you're worthy of good nutrition, moderate exercise, and a better body, then you can lose your motivation to make the right choices. When you feel like you're worthwhile, you're more likely to make the best possible choices to care for yourself. It isn't easy to go from chronically low self-esteem to high confidence, but it is possible. Learn how you can use exercise, positive self-talk, and yoga to feel better about yourself and your body. It's easy to get caught up in the numbers—calories, pounds and pants size. But taking these daily wellness measurements is a good reminder that your overall feelings of health and well-being are just as important!Article Source: http://www.sparkpeople.com/resource/wellness_articles.asp?id=1358

Allergy-Proofing Your Home

Allergic reactions to everyday substance in the home can make life uncomfortable, no matter how much medication you take. Avoiding known allergens and making your home as allergen-free as possible can help minimize your symptoms and increase your quality of life. While no home can ever be 100% allergen-free, with the right steps you can reduce your exposure to common substances like dust mites, pet dander, mold and pollen. Reducing Dust Mites Dust mites are microscopic, eight-legged insects that are mainly found in bedding, curtains and carpeting. Dust mites are a significant cause of indoor allergies—up to 10% of the U.S. population is sensitive to these tiny organisms. An allergic reaction to dust mites can include itchy eyes, a runny or chronically-stuffy nose and other symptoms that often worsen during the night. The first step to reducing your exposure to dust mites is to remove the carpet from your home, especially in the bedroom. A hard surface such as hardwood is ideal, as it can be cleaned with a damp cloth or a sponge mop. If you can’t remove all the carpeting, you should vacuum daily and use special carpet treatments that inactivate the accumulated allergens and reduce the dust mite population. Frequent vacuuming is needed to remove surface allergens from carpets, however many vacuums simply blow allergens into the air. Replace your standard vacuum bag with a high filtration multi-layer bag and add a vacuum exhaust filter. To reduce the number of dust mites in your bedroom:

  • Use zippered covers on all mattresses, box springs, and pillows.
  • Wash all blankets, sheets, and pillowcases in hot water (set your water heater for one hundred and thirty degrees) at least every two weeks.
  • Replace down comforters and feather pillows with synthetic fibers.
  • Keep your bedroom as dry as possible by using an air conditioner during hot, humid weather. (Dust mites need humidity to thrive.)
Control Animal Dander Contrary to popular belief, it’s not animal fur itself that causes allergies, but a protein in the saliva, urine and skin flakes (dander) that remain on an animal's coat. To minimize your exposure to this protein:
  • Keep your pet out of the rooms you use most frequently, such as the bedroom and the living room.
  • Have other family members bathe and brush your pet as often as possible.
  • If you are severely allergic, you may have to keep your pet outside or separated from you more often.
Minimize Mold Mold spores thrive in warm, moist, and humid areas. Take the following steps to reduce the amount of mold in your home:
  • Remove and discard any curtains, carpeting, or wallpaper that show visible signs of mold.
  • Install exhaust fans in the kitchen and bathroom and use them frequently.
  • Use dehumidifiers in damp areas like basements to remove water from the air. Keep the humidity in your home below 50% to prevent the growth of mold. Humidity gauges are available at any hardware store.
  • Clean shower curtains, tiles and grout regularly to prevent mold from building up.
  • Avoid storing clothing or other items in damp areas like the basement.
  • Don’t lay carpet in damp areas such as kitchens or bathrooms. Use ceramic tiles, vinyl flooring or laminates instead.
  • Use interior paints that contain an added mold inhibitor whenever you paint in a damp area, especially in the bathroom, kitchen and basement walls made of brick or cinderblock.
  • Place a chemical moisture-remover, such as calcium carbonate, in moist closets to prevent mold growth, or add it directly to damp shoes and boots.
  • Store firewood outside, as it is naturally covered in mold.
Mold can be removed from surfaces and walls by using a solution of one part bleach to 20 parts water. Dead mold can still cause an allergic reaction, but bleach has been found to reduce the severity of the reaction in susceptible people. Limit Pollen Even if you don’t have plants and flowers in your home, pollen can still be carried in from outdoors. The following steps will help to minimize the amount of pollen in your home:
  • Keep windows and doors closed as much as possible during pollen season and use an air conditioner to cool the indoors.
  • Install an air filtration system with a High Efficiency Particulate Air (HEPA) filter to remove pollen from circulating air.
  • Bathe pets often to reduce the amount of pollen they carry into the home.
  • Dry your clothes and bedding in a dryer instead of using an outdoor line since pollen can cling to fabric and be transferred into your home.
Nearly all allergens thrive in moist, damp environments, so keep your home as cool and dry as possible. While it’s virtually impossible to completely remove all allergens, regular cleaning and taking preventative action will make your home as comfortable as possible for allergy sufferers.Article Source: http://www.sparkpeople.com/resource/wellness_articles.asp?id=843

Depression in Men: Why It's Different

For many years, mental health professionals viewed depression as primarily a women’s disease. Of the 11 million Americans diagnosed with clinical depression every year, less than 1 in 10 were men; and an even larger percentage of people actively seeking treatment for this problem were women. Likewise, the majority of reported suicide attempts were made by women. But there was one troubling statistic that made this stereotype of depression as a woman’s condition a little hard to swallow—that 80 percent of the people who actually died by suicide were men. As researchers began to dig a little deeper, trying to understand this apparent contradiction, it gradually became clear that depression is just as common among men, but men simply weren’t seeking or receiving treatment in proportion to their numbers. Many factors, including both cultural stereotypes and biological differences, made men less likely to report symptoms of depression, and their health professionals less likely to identify the problems they did report as symptoms of depression. This situation has changed quite a bit recently. Last year, more than six million men were diagnosed with depression. But many men (and the people around them) may still have trouble recognizing that their problems are caused by depression that needs to be treated. Here are some things you need to know to avoid this problem. Depression can look different in men. Most experts believe that although the basic symptoms of depression are very similar in men and women, men express them very differently. Here are the differences most often seen:

  • Depressed men are more likely to notice and report the physical symptoms of depression:
    • Tiredness
    • Sleep problems (trouble falling or staying asleep, insomnia, sleeping more)
    • Lack of energy
    • Changes in appetite (increased or decreased)
    • Chronic muscle tension  
  • Depressed men are less likely to exhibit and report the emotional symptoms of depression. This may be due mostly to cultural stereotypes that view the expression of certain emotions as “feminine." In some cases, men may be aware of their feelings of sadness, hopelessness and guilt, but feel compelled not to talk about them. In others, these feelings may be suppressed and go unrecognized. In either case, depression may go unrecognized because the tell-tale symptom of low mood appears to be missing.  
  • Depressed men are more likely to display behavioral signs that aren't easily recognized as signs of depression:
    • Unusual degrees of irritability, anger, and/or aggression
    • Blaming others for problems
    • Alcohol and drug abuse
    • Attempt to manage their moods by taking on more activities, like working overtime
    • Engaging in high-risk behaviors such as dangerous sports, gambling, or compulsive sexual activity  
  • Depressed men are less likely to display the behavioral signs that are commonly associated with depression, such as spontaneous crying, loss of interest in usual activities, and thoughts or talk of death or suicide.
These patterns are not rigid. Many men will experience the same basic symptoms common among women, just as women may experience the symptom patterns described above. And any given individual may experience a combination of “male” and “female” symptoms. If you or someone you know seems to be experiencing unusual or unexplained increases in the physical or behavioral problems mentioned above for two weeks or more, talk to your doctor. There’s a good chance that those problems are signs of depression, and effective treatments are available.Article Source: http://www.sparkpeople.com/resource/wellness_articles.asp?id=828

6 Ways to Prevent Snoring

Snoring—that loud, hoarse breathing during sleep—is a nuisance, whether it affects you personally or the person you share a bed with. And that's a lot of people, since 37 million people are consistent snorers, according to the National Sleep Foundation. The sound originates in the very back of the mouth, where the soft tissues of many structures meet. When these tissues vibrate together, snoring occurs. This phenomenon is much more common in men than in women, and usually increases with age. Generally, snoring is not a cause for concern, unless it interferes with the sleep of others. But in some cases, it can be a sign of a serious medical condition called sleep apnea. In sleep apnea, people actually stop breathing for about 10 seconds at a time throughout the night, causing dangerous dips in blood-oxygen levels. According to the National Institutes of Health, this disorder may contribute to high blood pressure and even stroke. Anyone who snores on a regular basis should be medically evaluated to rule out this condition. If sleep apnea is not involved in your snoring, then there are lots of techniques to try that may help reduce or even eliminate snoring. Here are six simple suggestions that may help to reduce snoring: 1. Lose weight if you're overweight. Excess weight can contribute to a host of health problems, but it also narrows the airway, increasing the likelihood that those tissues will rub together. 2. Limit or avoid alcohol and other sedatives at bedtime. These substances relax the airway, leading to snoring. Limit yourself to less than one drink daily for women, or less than two drinks daily for men, and consume your last drink at least four hours before bedtime. 3. Avoid sleeping flat on your back. Back-sleepers are more prone to snoring since this position allows the flesh of your throat to relax and block the airway. If you are a habitual back-sleeper, try this method to retrain yourself: Stuff a tennis ball into a sock, and safety-pin the sock to the back of your pajamas. Each time you roll to your back during the night, you'll feel uncomfortable and turn back to your side. 4. Don't smoke. Besides contributing to other respiratory problems, smoking also leads to nasal and lung congestion, which can result in snoring. Take steps to quit today. 5. Avoid secondhand smoke. Secondhand smoke is just as harmful, and causes snoring in the same ways actual smoking does. Encourage your loved ones to quit, and avoid smoky restaurants and bars. 6. Improve your fitness level. When you have poor muscle tone, you're more likely to snore. Exercising tones and strengthens muscles all over the body, while also regulating your sleeping patterns. Aim for at least three cardio sessions and two strength training sessions each week. In most cases, snoring isn't caused by one single factor, but a combination of many. If these suggestions don’t work, see you doctor for more ideas. There are lots of products and procedures designed to reduce snoring, from removable plastic nasal dilators to nasal surgery. If you or your loved ones are suffering from snoring, a good night’s sleep may be just a doctor’s visit away.Article Source: http://www.sparkpeople.com/resource/wellness_articles.asp?id=853

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