CVS CMO outlined a plan for “complementary primary care.” You’ll be able to get it in your neighborhood drug store.

Troy Brennan spoke at an event in Boston on digital health and aging Wednesday.  He emphasized that the merger between CVS and Aetna has yet to be approved. But, he outlined the CVS plan to offer more than urgent care.

A few more from the meeting

 

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How to use interactive graphics to look at #Massachusetts #hospital #quality measures like infection rates. Data for individual hospitals, health care systems and the entire state.

KHN: We hear a lot about our Senator Elizabeth Warren. She wants people to be able to hear more by requiring #Medicare to pay providers to train people on how to use their #hearingaids

From Kaiser Health News:

Can You Hear Me Now? Senate Bill On Hearing Aids May Make The Answer ‘Yes’

Last December, Deb Wiese bought hearing aids for her parents, one for each of them. She ordered them online from a big-box retailer and paid $719 for the pair. But her parents, in their 80s and retired from farming in central Minnesota, couldn’t figure out how to adjust the volume or change the batteries. They soon set them aside.

“Technology is not only unfamiliar but unwelcome” to her parents, Wiese said. “I don’t know what the answer is for people like that.”

A bill introduced by Sen. Elizabeth Warren (D-Mass.) and Sen. Rand Paul (R-Ky.) in March could make it easier for her parents and millions like them to get assistance. It would allow Medicare to pay audiologists to teach beneficiaries how to adjust to and use their hearing aids as well as how to manage communication with other people, among other things.

Under current law, Medicare generally reimburses audiologists for diagnosing hearing loss in older adults but not for providing assistance to fit, adjust and learn to make the most of hearing aids.

The proposed bill comes on the heels of a law signed last summer by President Donald Trump that directs the Food and Drug Administration to establish and regulate a new category of hearing aid to be sold over the counter for people with mild to moderate hearing loss. People will be able to buy products off the shelf without consulting an audiologist or hearing aid dispenser, and standards for online sales will be tightened. The agency has three years to develop safety and other consumer protection standards.

The National Academies of Sciences, Engineering and Medicine recommended that the FDA take that step in a 2016 report.

Although it should improve access, the new law doesn’t address one of the biggest barriers faced by the nearly 50 million people with age-related hearing loss: insurance coverage.

Neither traditional Medicare nor most private insurers typically cover hearing aids. (Some Medicare Advantage plans provide some coverage, and some insurers may offer a discount if members use certain suppliers.)

“Cost has for many years been the No. 1 problem in the calls, emails and letters we get,” said Barbara Kelley, executive director and CEO of the Hearing Loss Association of America, a patient advocacy group. “People say, ‘I need hearing aids and I can’t afford them.’ It’s really heartbreaking.”

Only 10 to 20 percent of people with hearing loss have ever used hearing aids, according to studies. In addition to cost, lack of access to care and the stigma associated with wearing a hearing aid discourages people, Kelley said.

Losing the ability to hear well doesn’t just mean people have to turn the volume way up on their favorite TV shows. Hearing loss is associated with depression, social isolation and an increased risk for cognitive decline and dementia in older adults.

Hearing aid prices vary widely, ranging from an average $900 to $3,100 apiece, according to a survey of hearing care professionals by the Hearing Review. On the high end, devices may be Bluetooth-enabled to stream wirelessly from people’s cellphones to their hearing aids, among other perks.

But not everyone needs or wants that much help. “Some people are very mildly impaired,” said Kim Cavitt, a billing and reimbursement consultant and former president of the Academy of Doctors of Audiology who supports over-the-counter sales. “They don’t have a $3,000 problem, they have a $300 problem.”

Experts say they hope the over-the-counter hearing aid law will spur competition and product innovation and bring down prices.

One of the reasons hearing aid prices are often high is because the devices are typically bundled with a service package to fit, troubleshoot and maintain them.

Disentangling the service from the devices would benefit consumers, said Nicholas Reed, a faculty member at the Cochlear Center for Hearing and Public Health at Johns Hopkins Bloomberg School of Public Health who has studied over-the-counter hearing devices that provide results comparable to hearing aids.

In addition to basic hearing-aid fitting and maintenance, hearing care professionals can help people learn strategies to hear better, Reed said. For example, people learn to sit with their back to a wall at a restaurant to eliminate the sound behind them so they can focus on listening to the person in front of them.

“The over-the-counter law will lower the cost and make hearing aids more accessible,” Reed said. “But if the services aren’t covered, people, especially older adults with health literacy issues, will stop using them.”

KHN: “#Older Americans Are Hooked On #Vitamins Despite Scarce #Evidence They Work.” Not all Boston experts agree that’s a problem.

 

When she was a young physician, Dr. Martha Gulati noticed that many of her mentors were prescribing vitamin E and folic acid to patients. Preliminary studies in the early 1990s had linked both supplements to a lower risk of heart disease.

She urged her father to pop the pills as well: “Dad, you should be on these vitamins, because every cardiologist is taking them or putting their patients on [them],” recalled Gulati, now chief of cardiology for the University of Arizona College of Medicine-Phoenix.

But just a few years later, she found herself reversing course, after rigorous clinical trials found neither vitamin E nor folic acid supplements did anything to protect the heart. Even worse, studies linked high-dose vitamin E to a higher risk of heart failure, prostate cancer and death from any cause.

“‘You might want to stop taking [these],’” Gulati told her father.

More than half of Americans take vitamin supplements, including 68 percent of those age 65 and older, according to a 2013 Gallup poll. Among older adults, 29 percent take four or more supplements of any kind, according to a Journal of Nutrition study published in 2017.

greetings-from-bostonOften, preliminary studies fuel irrational exuberance about a promising dietary supplement, leading millions of people to buy in to the trend. Many never stop. They continue even though more rigorous studies — which can take many years to complete — almost never find that vitamins prevent disease, and in some cases cause harm.

“The enthusiasm does tend to outpace the evidence,” said Dr. JoAnn Manson, chief of preventive medicine at Boston’s Brigham and Women’s Hospital.

There’s no conclusive evidence that dietary supplements prevent chronic disease in the average American, Manson said. And while a handful of vitamin and mineral studies have had positive results, those findings haven’t been strong enough to recommend supplements to the general U.S. public, she said.

The National Institutes of Health has spent more than $2.4 billion since 1999 studying vitamins and minerals. Yet for “all the research we’ve done, we don’t have much to show for it,” said Dr. Barnett Kramer, director of cancer prevention at the National Cancer Institute.

In Search Of The Magic Bullet

A big part of the problem, Kramer said, could be that much nutrition research has been based on faulty assumptions, including the notion that people need more vitamins and minerals than a typical diet provides; that megadoses are always safe; and that scientists can boil down the benefits of vegetables like broccoli into a daily pill.

Vitamin-rich foods can cure diseases related to vitamin deficiency. Oranges and limes were famously shown to prevent scurvy in vitamin-deprived 18th-century sailors. And research has long shown that populations that eat a lot of fruits and vegetables tend to be healthier than others.

But when researchers tried to deliver the key ingredients of a healthy diet in a capsule, Kramer said, those efforts nearly always failed.

It’s possible that the chemicals in the fruits and vegetables on your plate work together in ways that scientists don’t fully understand — and which can’t be replicated in a t

ablet, said Marjorie McCullough, strategic director of nutritional epidemiology for the American Cancer Society.

And although there are more than 90,000 dietary supplements from which to choose, federal health agencies and advisers still recommend that Americans meet their nutritional needs with food, especially fruits and vegetables.

Also, American food is highly fortified — with vitamin D in milk, iodine in salt, B vitamins in flour, even calcium in some brands of orange juice.

Without even realizing it, someone who eats a typical lunch or breakfast “is essentially eating a multivitamin,” said journalist Catherine Price, author of “Vitamania: How Vitamins Revolutionized the Way We Think About Food.”

That can make studying vitamins even more complicated, Price said. Researchers may have trouble finding a true control group, with no exposure to supplemental vitamins. If everyone in a study is consuming fortified food, vitamins may appear less effective.

The body naturally regulates the levels of many nutrients, such as vitamin C and many B vitamins, Kramer said, by excreting what it doesn’t need in urine. He added: “It’s hard to avoid getting the full range of vitamins.”

Not all experts agree. Dr. Walter Willett, a professor at the Harvard T.H. Chan School of Public Health, says it’s reasonable to take a daily multivitamin “for insurance.” Willett said that clinical trials underestimate supplements’ true benefits because they aren’t long enough, often lasting five to 10 years. It could take decades to notice a lower rate of cancer or heart disease in vitamin takers, he said.

Vitamin Users Start Out Healthier

For Charlsa Bentley, 67, keeping up with the latest nutrition research can be frustrating. She stopped taking calcium, for example, after studies found it doesn’t protect against bone fractures. Additional studies suggest that calcium supplements increase the risk of kidney stones and heart disease.

“I faithfully chewed those calcium supplements, and then a study said they didn’t do any good at all,” said Bentley, from Austin, Texas. “It’s hard to know what’s effective and what’s not.”

Bentley still takes five supplements a day: a multivitamin to prevent dry eyes, magnesium to prevent cramps while exercising, red yeast rice to prevent diabetes, coenzyme Q10 for overall health and vitamin D based on her doctor’s recommendation.

Like many people who take dietary supplements, Bentley also exercises regularly — playing tennis three to four times a week — and watches what she eats.

People who take vitamins tend to be healthier, wealthier and better educated than those who don’t, Kramer said. They are probably less likely to succumb to heart disease or cancer, whether they take supplements or not. That can skew research results, making vitamin pills seem more effective than they really are.

Faulty Assumptions

Preliminary findings can also lead researchers to the wrong conclusions.

For example, scientists have long observed that people with high levels of an amino acid called homocysteine are more likely to have heart attacks. Because folic acid can lower homocysteine levels, researchers once hoped that folic acid supplements would prevent heart attacks and strokes.

In a series of clinical trials, folic acid pills lowered homocysteine levels but had no overall benefit for heart disease, Lichtenstein said.

Studies of fish oil also may have led researchers astray.

When studies of large populations showed that people who eat lots of seafood had fewer heart attacks, many assumed that the benefits came from the omega-3 fatty acids in fish oil, Lichtenstein said.

Rigorous studies have failed to show that fish oil supplements prevent heart attacks. A clinical trial of fish oil pills and vitamin D, whose results are expected to be released within the year, may provide clearer questions about whether they prevent disease.

But it’s possible the benefits of sardines and salmon have nothing to do with fish oil, Lichtenstein said. People who have fish for dinner may be healthier due to what they don’t eat, such as meatloaf and cheeseburgers.

“Eating fish is probably a good thing, but we haven’t been able to show that taking fish oil [supplements] does anything for you,” said Dr. Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic Foundation.

(Story continues below.)

Too Much Of A Good Thing?

Taking megadoses of vitamins and minerals, using amounts that people could never consume through food alone, could be even more problematic.

“There’s something appealing about taking a natural product, even if you’re taking it in a way that is totally unnatural,” Price said.

Early studies, for example, suggested that beta carotene, a substance found in carrots, might help prevent cancer.

In the tiny amounts provided by fruits and vegetables, beta carotene and similar substances appear to protect the body from a process called oxidation, which damages healthy cells, said Dr. Edgar Miller, a professor of medicine at Johns Hopkins School of Medicine.

Experts were shocked when two large, well-designed studies in the 1990s found that beta carotene pills actually increased lung cancer rates. Likewise, a clinical trial published in 2011 found that vitamin E, also an antioxidant, increased the risk of prostate cancer in men by 17 percent. Such studies reminded researchers that oxidation isn’t all bad; it helps kill bacteria and malignant cells, wiping them out before they can grow into tumors, Miller said.

“Vitamins are not inert,” said Dr. Eric Klein, a prostate cancer expert at the Cleveland Clinic who led the vitamin E study. “They are biologically active agents. We have to think of them in the same way as drugs. If you take too high a dose of them, they cause side effects.”

Gulati, the physician in Phoenix, said her early experience with recommending supplements to her father taught her to be more cautious. She said she’s waiting for the results of large studies — such as the trial of fish oil and vitamin D — to guide her advice on vitamins and supplements.

“We should be responsible physicians,” she said, “and wait for the data.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

 

STAT: Meet Boston Children’s #Hospital #specialeffects guy

Three-printers and more. Gregory Loan is a simulation engineer at Boston Children’s Hospital Simulator Program. He makes artificial body parts and mannequins for clinicians to practice on.

More great video from STAT here. 

When should aging doctors retire? Does it depend on the doctor?

When should doctors retire? Depends on the doctor.

Two pieces about aging docs. One story from STAT, one column from the Globe.

 

From Medscape:

“There are many older physicians who have a wealth of experience and who are practicing very well, and the last thing on earth we want to do is discourage those physicians from continuing to practice,” Dr Dellinger said. Among the consequences of that, he added, would be worsening the physician shortage.

“On the other hand, the data are unequivocal that there is, on average, a reduction in cognitive and physical abilities with age…and we need to kindly encourage those who should be reducing their practice to do so,” he said.

According to the review, published online July 19 in JAMA Surgery, research shows that between ages 40 and 75 years, mean cognitive ability drops by more than 20%, but there is large variability individually. Dr Dellinger notes that although the journal is for surgeons, the review is meant for all physicians.

KHN: Now that the Massachusetts Medical Society has”rescinded its longstanding opposition to physician-assisted suicide,” others may follow

As Doctors Drop Opposition, Aid-In-Dying Advocates Target Next Battleground States

khn_logo_facebookWhen the end draws near, Dr. Roger Kligler, a retired physician with incurable, metastatic prostate cancer, wants the option to use a lethal prescription to die peacefully in his sleep. As he fights for the legal right to do that, an influential doctors group in Massachusetts has agreed to stop trying to block the way.

Kligler, who lives in Falmouth, Mass., serves as one of the public faces for the national movement supporting medical aid in dying, which allows terminally ill people who are expected to die within six months to request a doctor’s prescription for medication to end their lives. Efforts to expand the practice, which is legal in six states and Washington, D.C., have met with powerful resistance from religious groups, disability advocates and the medical establishment.

But in Massachusetts and other states, doctors groups are dropping their opposition — a move that advocates and opponents agree helps pave the way to legalization of physician-assisted death.

The American Medical Association, the dominant voice for doctors nationwide, opposes allowing doctors to prescribe life-ending medications at a patient’s request, calling it “fundamentally incompatible with the physician’s role as healer.”

But in December, the Massachusetts Medical Society became the 10th chapter of the AMA to drop its opposition and take a neutral stance on medical aid in dying.

Most of those changes occurred in the past two years. They proved a pivotal precursor to getting laws passed in California, Colorado and Washington, D.C., said Kim Callinan, chief program officer for Compassion & Choices, an advocacy group that supports legalization efforts around the country. (The practice is also legal in Washington, Oregon, Vermont and Montana.)

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The shifts come as doctors’ views evolve: Fifty-seven percent of U.S. doctors supported medical aid in dying in a 2016 Medscape survey, up from 46 percent in 2010.

Because of the medical society’s vote, Massachusetts is the state most likely to legalize medical aid in dying this year, predicted David Stevens, CEO of the Christian Medical & Dental Associations, a national group of 19,000 health professionals that has opposed such laws in every state.

“I think a neutral stance is probably what’s going to push it over,” he said.

Doctors’ opinions are also playing a role in New York, where the New York State Academy of Family Physicians endorsed an aid-in-dying bill, and the state medical society is surveying its members on the subject.

Efforts to legalize the practice have faced pushback nationally: Last year, lawmakers in 27 states introduced aid-in-dying bills, and none passed. And in Congress, Republican lawmakers have launched several attempts to block the District of Columbia from implementing its law.

This year, Compassion & Choices’ Callinan identified New Jersey, New York and Massachusetts as its top three target states.

Peg Sandeen, executive director of Death With Dignity National Center, an aid-in-dying advocacy group based in Oregon, cited Hawaii as another top target. Advocates there are “trying to break the logjam in the legislature,” where the state Senate passed a bill in March, she said. Hawaii came close to legalizing the practice in 2000.

Massachusetts has been a fraught battleground for the right-to-die movement: In 2012, opponents narrowly defeated a referendum that would have legalized the practice. Home to a robust medical hub and Harvard Medical School, the state is a stronghold for academic medicine.

Kligler, who’s 66, has publicly described his interest in using lethal drugs to die on his own terms rather than endure what he expects to be several months of significant pain, fatigue and declining quality of life.

Kligler said he wants other dying people to have the same option: When he used to serve as a hospice physician to cancer patients, he said, patients used to “ask me to help them to die,” but he had no legal way to do so. Kligler is also suing Massachusetts, arguing that terminally ill patients have a constitutional right to medical aid in dying.

“It’s a question of justice,” Kligler said.

When the Massachusetts Medical Society surveyed members last year, 60 percent said they supported medical aid in dying, and 30 percent said they opposed it.

Dr. Barbara Rockett, a surgeon and past president of the medical society, urged fellow doctors to uphold the group’s long-standing opposition to the practice. Doctors should focus on helping dying patients through hospice and palliative medicine, she said.

“To intentionally help them commit suicide is wrong,” Rockett said. Proponents, meanwhile, say the practice is not “suicide” because the patient is already being killed by a terminal disease.

Rockett said she was disappointed that her fellow delegates in the society voted to adopt a neutral stance.

Even with the doctors group stepping out of the way, the latest aid-in-dying bill, dubbed the Massachusetts End of Life Options Act, faces formidable opposition. Catholic groups, a significant force opposing aid in dying nationally, have a robust base in Massachusetts: Over a third of residents are Catholic, second only to Rhode Island.

Catholic groups provided much of the $5.5 million that opponents spent to defeat Massachusetts’ ballot referendum in 2012, outspending proponents by nearly 5-to-1.

The Boston Archdiocese did not respond to repeated requests for comment for this story. But at the time the referendum failed, a spokesman said the church could not afford to lose on this issue in a Catholic stronghold: “If it passes in Massachusetts,” the spokesman said, “it’s a gateway to the rest of the country.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.