The facts behind the controversy over breastfeeding

Under the Affordable Care Act, new insurance policies will be required to pay for lactation counseling and breast pumps � without cost sharing. Blogger Maggie Mahar says this is a good thing: the benefits last a lifetime � and stand to reduce health care spending by $13 billion each year.

Note to readers: I welcome reader comments and questions, and will try my best to reply in a timely manner. I ask only that you do your part to keep our discussion both reasoned and polite. � MM� ��

First, a purposefully salacious TIME�cover featuring a mother nursing her three-year-old stirred controversy. Then a photo of Air Force moms breastfeeding while in uniform sparked outrage.

What few critics mention is that the law of the land now supports nursing mothers. The Affordable Care Act (ACA) stipulates that, beginning this August, new insurance policies are required to pay for lactation counseling and breast pumps � without cost sharing.

Breast pumps?? sputter conservatives.�Since when did pumps become an "essential benefit?"

Answer? Since we realized that if 90 percent of women nursed their babies for six months, giving them breast milk only, we could save 900 lives per year, and reduce health care spending by $13 billion annually.

This explains why savvy insurers reimbursed for pumps well before Congress passed the new law.

Benefits of breastfeeding

The May cover of TIME made some subscribers squirm and ignited controversy over the topic of breastfeeding.

For women, the health benefits are well known. Women who nurse are less likely to develop breast cancer, ovarian cancer, type 2 diabetes, postpartum depression, and cardiovascular disease. Nursing also helps new moms shed weight. And, if a woman nurses for six months, she enjoys 98 percent protection against pregnancy, which helps her space her babies.

For the child, the benefits last a lifetime. This is why the American Academy of Pediatrics (AAP) recommends that women nurse for at least 12 months, and thereafter for as long as mother and baby desire. First, breast milk provides antibodies that defend infants against illnesses such as pneumonia, diarrhea, and, respiratory infections. Nursing also reduces the risk of �sudden infant death syndrome.� Over the longer term, breastfeeding makes it less likely that a child will suffer from type 1 and type 2 diabetes, asthma and childhood leukemia.

Perhaps most importantly, if a child is breastfed for nine months, the odds that he will become obese are cut by nearly one-third. For each month of breastfeeding up to nine months, the odds of obesity fall by 4 percent. The benefit increases if the child receives breast milk only rather than breast milk and formula.

Responding to the evidence, last month the New York City health department began a campaign to encourage hospitals to stop handing out free formula. �Twenty-four institutions are participating, despite the cost.� The chairman of� ObGyn at Maimonides Medical Center explained: the hospital gets free baby bottles from the formula companies, saving it hundreds of thousands of dollars a year. "It is an act of will to decide that … the well-being of the next generation is more important than that money," he acknowledged.

The battle against childhood obesity

Crystal Scott, a military spouse, commissioned this photo as part of Breastfeeding Awareness Month. She was later fired from her civilian job as an x-ray technician.

Seventy-seven percent of obese children become obese adults. �Nursing offers an very inexpensive way to head off the problem.

Skeptics have suggested that perhaps breastfed babies are less likely to be overweight later because, typically, they are the offspring of more affluent mothers who have access to healthier lifestyles for themselves and their children.� But when researchers adjust for parents' weight, dietary factors, physical activity, parents' socio-economic status, and education, they find that the relationship between� breastfeeding and reduced risk of obesity held.

Why?

When children nurse, they have more control over how much milk they consume. This may make them better at responding to internal cues that they are full. "Research also reveals that formula-fed infants show higher plasma insulin concentrations … which stimulate more fat tissue," the CDC observes. �Meanwhile "concentrations of leptin (the hormone that is thought to inhibit appetite), may be lower in breastfed babies."

Breastfeeding: a personal decision

Let me be clear: despite the health benefits, no woman should be pressured into nursing her baby. Some mothers cannot breastfeed; others are not comfortable with the idea, or find nursing painful.� Some just don�t have the time.

Mothers should know that breastfeeding "only incrementally alters the health picture for any one child." �The goal of reform is to increase breastfeeding rates. It is the cumulative effect that could dramatically improve health nationwide.

Removing barriers to breastfeeding in the U.S.

That said, women who are eager to breastfeed need support. Research published in the July issue of Pediatrics shows that out of the 85 percent of new mothers who said they wanted to try exclusively breastfeeding their children for three months or longer, only 32.4 percent actually met their goal. Forty-two percent stopped in the first month.

In a larger study, the CDC found that while 74 percent of mothers tried nursing, when their babies reached six months only 13.6 percent were exclusively breastfed.

Why do so many women give up?

The U.S. is the only economically advanced country � and one of just a handful of countries worldwide � where employers are not required to provide any paid maternity leave.

This is one reason why low-income women are much less likely to nurse:� They cannot afford an unpaid leave.� And if a mother is away from her child for hours each day, she must express her milk. Breast pumps make this much easier, but until the new law passed, many mothers could not afford them.

Despite doubts about finances, hospitals moving forward with EHRs

NEW YORK – A new study from KPMG finds nearly half of business leaders at hospitals and health systems are more than halfway through full EHR deployments, even as many harbor doubts about how much funding their organizations have planned to support the initiatives.
 
Some 49 percent of hospital and health system business administrators who participated in the poll said they were more than 50 percent of the way to completing EHR deployment.

Only 25 percent said they were "very comfortable."
 
"There is a level of uneasiness as to whether there is adequate funding to complete these projects," said Gary Anthony, principal with KPMG Healthcare. "In most organizations, EHR deployment will most likely be one of the most transformational projects that they've ever undertaken, as well as one of the largest investments outside of the construction of a new hospital they've ever made."

Nonetheless, he added, many hospitals still look at EHR deployments as "just an IT project, and that may be why we are seeing multiple extensions to scope, timeline and budget."

In terms of resource strategies used to complete EHR deployment, 46 percent of hospital and health system execs said they're using a multiple-resource strategy. This was followed by leveraging existing staff (16 percent), hiring new or additional staff (13 percent) and securing third party assistance (10 percent). Fifteen percent said they didn't know.
 
When asked whether their organization had a mobility access strategy that provides clinicians and patients with "anywhere" access to EHRs, roughly half of the administrators said they didn't know.
 
"EHR deployment isn't an end point," said Jerry Howell, principal with KPMG Healthcare. "It's an important step in an organization's journey to automate the clinical functions within the hospital or health system and improvement to quality and patient safety. There needs to be continued focus on resourcing and having the correct sponsorship and commitment to deploy an EHR and to continue to support and use it."

St. Paul Regional Labor Federation Endorses HR 676

From Unions for Single Payer Health Care –

The St. Paul Regional Labor Federation, AFL-CIO, is the latest labor federation to endorse HR 676, Congressman John Conyers� single payer healthcare bill.

Robert �Bobby� Kasper, President of the St Paul Federation, reports that delegates unanimously endorsed the Conyers bill at their regularly scheduled meeting on Wednesday May 9th. The resolution to support HR 676 was brought to the Federation by Mike Madden, Chair of the Chisago Labor Assembly, AFL-CIO, and a representative of IAMAW Local Lodge 112.

The Federation represents 117 local unions with over 50,000 members in Chisago, Southern Dakota, Ramsey, and Washington counties of Minnesota.

The St. Paul Federation is the 141st Central Labor Council/Area Labor Federation and the 592nd union organization to endorse Conyers’ “Expanded and Improved Medicare for All” legislation.

See the full text of the resolution here.

If the individual mandate’s struck down, what next?

In Sunday's edition of the New York Times, blogger Maggie Mahar responded briefly to the question, "What would the future hold if the Supreme Court strikes down the most controversial part of the health care law, the individual mandate?" We asked Mahar to elaborate on the question in this post.

Betting the individual mandate will be upheld

If the Affordable Care Act's individual mandate is ruled unconstitutional by the Supreme Court this month, Maggie Mahar says, the government will have to take a carrot-and-stick approach to attracting healthy Americans to buy individual insurance - and it will likely have to focus much more on carrots.

Ezekiel Emanuel says he has been betting on how the Supreme Court will decide the case challenging the constitutionality of the Patient Protection and Affordable Care Act�(PPACA).

Speaking at the annual meeting of the Jewish Social Policy Action Network in Philadelphia not long ago, Emanuel, who served as Special Advisor on Health Policy to the Obama administration when the bill was being drafted, confided that he has placed five wagers expressing his optimism that "the mandate will survive" along with the rest of the legislation.

"I think the vote will be 6:3 in favor with Kennedy and Roberts voting for."�There is "No doubt it is constitutional," he declared. "Legally, this is an open and shut case."

Emanuel, now chair of the Department of Medical Ethics and Vice Provost for Global Initiatives at the University of Pennsylvania, also revealed that he recently had dinner with Supreme Court Justice Antonin Scalia. Emanuel says Scalia will not vote for the reform bill. (No surprise there.)

For reasons I have explained in earlier posts here and here, I tend to share Emanuel's optimism. Nevertheless, I could easily be wrong.

As Emanuel observes, there remains the danger that the Justices will overturn the mandate. In that case, the vote "will be 5:4 against. If that happens, the country will have bigger problems because then it will be a partisan ruling along party lines," he noted, referring to polls showing that the American public is losing confidence in the integrity of the Supreme Court as an institution that stands above the political fray.

Fat carrots and skinny sticks

If the Justices do declare the mandate unconstitutional, what happens next? Will this spell the end of reform? Absolutely not.

The goal of the mandate is to draw more healthy people into the insurance pool, so that the cost of care when we become sick can be spread over a larger group. But the mandate is only one of many provisions in the PPACA that makes health insurance more attractive and more affordable.

Here are some of the "carrots" that should draw people into the pool:

Under the law, middle-income and low-income families purchasing their own insurance will receive tax credits to help them pay premiums. The subsidies will be calculated on a sliding scale for households with income up to four times the poverty level ($92,200 for a family of four and $44,680 for a single person).The PPACA limits how much insurers can ask patients to pay out-of-pocket.Insurers selling policies to individuals and small groups will have to cover all "essential benefits." No more "Swiss cheese" policies filled with holes.Insurers won't be able to hike your premiums because you're sick.They also won't be able to charge you 30 percent more simply because you are a woman.When covering a large group, insurers must pay out 85 percent of the premiums they collect for medical care. When insuring a small group, administrative costs are higher, so they can keep 20 percent. If they don't spend the required percentage of premiums on care, customers will receive refunds.There will be no co-pays for preventive care, and the deductible will not apply.

These provisions should encourage many young, healthy Americans to purchase insurance. Research shows that younger people don't buy insurance � not because they think they're invincible, but because they can't afford it. Subsidies will help many of them.

Making the hard sell

But the majority of Americans are totally unaware of the ways that reform makes insurance more affordable and more attractive.�This is why Washington & Lee Law Professor Timothy Jost suggests that if the mandate is overturned, reformers should launch "an aggressive, televised marketing campaign." As Jost explained to me in a recent phone interview, "if you really look at who is subject to the mandate, a lot would have every reason in the world to get insurance, and no reason not to even if there is no mandate."

Would the carrots be as effective as the financial penalties in persuading healthy people to buy insurance? Probably not. Many observers argue that without the penalties, people just won't sign up ��no matter how many carrots you dangle under their noses.

I'm not convinced. It's impossible to predict human behavior, especially over a period of years. It remains to be seen how younger Americans will respond to the tax credits, and the rules that require insurers to offer more comprehensive protection, including maternity benefits and preventive care without co-pays.

Moreover, if you read the PPACA, the mandate was a pretty skinny stick. Those who oppose the mandate object that it "forces" Americans to buy insurance. But the truth is that in 2014, someone who decides to opt out would pay a fine of just $95 or 1 percent of taxable income ��whichever is higher � up to $285 per household.

This hardly constitutes "force." Even in 2016, when the penalty peaks, it amounts to only $695 or 2.5 percent of taxable income, up to $2,086 per household ��much less than the cost of insurance.

No question, if the mandate is eliminated, fewer people will be insured. But if reformers do a good job of communicating the benefits of reform, they could draw millions into the pool.

Losing the mandate may not be nearly as great a blow to reform as some suggest.

Note to readers: I welcome reader comments and questions, and will try my best to reply in a timely manner. I ask only that you do your part to keep our discussion both reasoned and polite. � MM� ��

If Health Law Falls, Coverage For Young Adults Gets Tricky

Enlarge Courtesy of June Blender

Jackson Cahn, who graduated from Whitman College in Walla Walla, Wash., is one of the 3 million young adults the Obama administration says would have risked going without insurance if the health care law hadn't allowed them to stay on their parents' policies. Because of the law, his mother, June Blender, was able to add him to her insurance.

Courtesy of June Blender

Jackson Cahn, who graduated from Whitman College in Walla Walla, Wash., is one of the 3 million young adults the Obama administration says would have risked going without insurance if the health care law hadn't allowed them to stay on their parents' policies. Because of the law, his mother, June Blender, was able to add him to her insurance.

When it comes to health care, even the seemingly easy things become hard.

Take coverage for young adults under the Affordable Care Act.

It's one of the most successful � and popular � provisions of the law that have taken effect so far. Earlier this week the Obama administration announced that between September 2010 and the end of 2011, more than 3 million young adults under age 26 who would otherwise have gone without insurance gained coverage by remaining on their parents' health plans.

Last week, major health insurance companies, including United Healthcare, Aetna and Humana, announced they would continue to offer the benefit even if the Supreme Court strikes down the law when it issues its ruling, which is expected next week. Even some Republicans say they support the idea of letting young people remain on their parents' health plans.

But it turns out that might not be so easy.

 

"This could have adverse tax consequences, both to the employee whose child is on the plan and to the employer, for purposes of payroll taxes," said James Klein, president of the American Benefits Council, which represents large-employer health plans and companies that provide services to those plans.

How's that? Well, says Klein, the problem is that lots of those young adults are no longer dependents of their parents for tax purposes. So if the employer continues to provide coverage to that adult child, the value of that insurance could be considered taxable income to the parent. Under the health law, such coverage is not treated as taxable income.

As an example, he says, "if the value of adding a child onto your policy is $500 a month, that's $6,000 a year. So that's $6,000 of extra income on which you would be taxed, plus the payroll taxes that you the employee and the employer would be paying on behalf of that $6,000."

And while that could be a lot of money for some people, he says, the money is only part of the problem.

"It's the utter confusion that this would cause for employers. Because after all, there would be some 24-year-old kids who are legal dependents, for whom there would be no income tax owed," Klein said. "And then there would be others for whom they're not legal dependents and so there would be tax that would be owed. It would be extraordinarily confusing."

Then there's the question of whether workers and employers might owe back taxes for coverage that's been provided already. Klein says the Obama administration could theoretically take care of the problem by having the IRS issue some sort of clarification. But he worries that like everything else to do with the health law, even that could get caught up in partisan politics.

"I'm just afraid that rather than a quick resolution that provides clarity, both sides could arguably use this for their political benefit," he said.

Xerox to build health insurance marketplace in Florida

DALLAS – Florida Health Choices, a corporation established by the state to improve access to care, has selected Xerox to administer its insurance marketplace.

According to Xerox officials, the program is designed to give small business and eligible individuals more flexibility in finding affordable health insurance and other services. The nine-year contract is valued at $68 million.

With partner CHOICE Administrators Exchange Solutions, Xerox will provide a cloud-based Web portal and online plan selection tool to give consumers and employers more information when making health insurance selections. The solution preserves the benefits of employer-sponsored insurance and eases the administrative burden for small businesses, officials said.

“We’re designing and supporting programs that increase access to health coverage for consumers,” said Will Saunders, group president, Government Healthcare Solutions, Xerox. “The solution we create in Florida will serve citizens and small business owners and help position the state as a leader in establishing a competitive and voluntary health insurance marketplace for small employers.”

Xerox will also provide eligibility determination and enrollment management services for the program, and operate a customer contact center to share information on marketplace offerings. These services will help Florida Health Choices handle the massive amounts of information involved with the marketplace quickly, efficiently and securely.

“We need a partner who can get a fully functional marketplace setup that is designed to serve Floridians now and into the future – delivering on both our short and long-term goals,” said Aaron Bean, chairman, board of directors, Florida Health Choices. “We’re confident Xerox will support us in establishing our marketplace quickly, while helping us to increase healthcare access to small business employees – one of our key priorities.”

Big 3, UAW Ask for Health Trust Help

The following article is from DetNews.com.

Cash-crunched automakers state need for payment help in their bid for federal financing.

By David Shepardson / Detroit News Washington Bureau

WASHINGTON — Detroit’s Big Three and the United Auto Workers are pressing the case for low-cost government loans to help automakers make required payments to trust funds to oversee hourly retiree health care starting in 2010.

The need for congressional support for the health care funding isn’t their most immediate concern, but it’s looming. The automakers are asking Congress for as much as $25 billion in “bridge financing” to help with their liquidity crisis, but that money also could be used for funding the health care trust.

Congress could consider that request, which is separate from the $25 billion already approved for low-cost loans for retooling plants to build more fuel-efficient cars, when it returns to work this month.

The topic of the health-care payments was addressed during an hour-long meeting of House Democrats convened by House Speaker Nancy Pelosi on Monday.

In total, Detroit’s Big Three automakers will make nearly $60 billion in payments to bankroll three trust funds to pay for hourly retiree health care.

In July, General Motors Corp. announced it had won permission from the UAW to push back $1.7 billion in payments owed in 2008 and 2009 to its Voluntary Employee Beneficiary Association fund that will cover health care for UAW retirees. GM will make the payments in 2010, when the UAW assumes responsibility for the fund.

That means GM will pay the $1.7 billion, plus accrued interest of 9 percent adding to the $5.3 billion already scheduled for 2010. They will be the first payments as part of a deal to give the UAW about $34 billion in cash and stock to assume $51 billion in GM’s retiree health care liabilities.

The shift to a VEBA to pay for retiree health care is the largest part of the 2007 labor contract that will reduce GM’s annual costs by $3 billion starting in 2010.

But GM faces a liquidity crisis now that analysts say may require outside help for it to survive beyond 2009, or to be able to make the payments to the trust fund.

Chrysler is to make payments totaling $9.8 billion into the fund, including $6.6 billion in 2010. A merged GM-Chrysler could face a staggering bill. Chrysler will also issue a note to the UAW worth $1.2 billion that’s due in 2016.

Ford is to pay between $13.2 billion to $15 billion into its retiree health care trust, based on the company’s future stock value. Ford took a $4.5 billion cash charge toward its retiree health care funding requirements this year, according to its second quarter filing.

UAW legislative director Alan Reuther said the financial ability of automakers to make the payments into the trust fund in 2010 is a concern, and one of the issues that should be addressed by Congress.

“If the federal government does not provide assistance to the Detroit-based auto companies to enable them to survive the economic downturn, hundreds of thousands of jobs at the auto companies and suppliers will be threatened,” UAW President Ron Gettelfinger wrote in an Oct. 27 letter to lawmakers. “The health care and pension benefits for the retirees and their families will be placed in jeopardy.” He noted that the government could be forced to assume a large increase in health care and retiree costs if the Big Three collapsed.

Detroit’s Big Three automakers spent $8.9 billion on health care in 2007, compared with a record $11 billion in 2005.

Automakers have said they think Congress should consider all available options to assist automakers.

About 1 million retirees and spouses receive health care and pensions from Detroit’s Big Three automakers, typically getting less than $20,000 per year.

Harley Shaiken, a professor specializing in labor studies at the University of California-Berkeley, said automakers need help with the impending costs.

“Without assistance, this is going to be a serious problem for automakers,” Shaiken said.

5 basics of big data

At the recent HIMSS Virtual Conference and Expo, Chris Gough, solutions architect at Intel Healthcare Information Technology and Alan Stein, MD, vice president of healthcare technology Autonomy, an HP company, presented a webinar titled, "Big Data and Analytics in Healthcare."

Gough and Stein outlined five basics of big data. 

1.The main problem is the fragmentation of data. The separation of data among labs, hospital systems, and even clinical components, like financial IT and EHRs, serves as the main issue with leveraging the data, said Stein. "All of these are separate repositories for information," he said. "Their single use in nature is to provide clinical care or provide scheduling information or operational information, and this is a problem if we want systems to talk to each other." Sometimes, he added, an organization can also end up with redundant information due to a legacy system. "So we also have this normalization problem," he said. "And this is where we want to go: we want to improve quality of care and lower costs…we need a shift from best practices to a culture of best practices – if we have them available – but also best experiences and using data from various components of health IT to improve care and lower costs in a holistic way."

2.Big data is all about real or near-real time. Traditional analytics, said Gough, use ETL processes that upload data nightly or weekly to a data warehouse. Processing takes place in the warehouse, yet, the trend of big data is moving toward real or near-real time. "It's not waiting for batch processes but is driving value from data more immediately," he said. "In healthcare, it's clinical decision support, so at the point of care, being able to understand data to make a decision." With traditional analytics, Gough said, reporting focuses on the past, but with big data, "it's more predictive, and it looks forward to what may happen in the future."

[See also: Big data: opportunity and challenge.]

3.Processing is moving to the data. Another trend Gough pointed out is the processing coming to the data, instead of the other way around. "So traditionally, you move data out of a production database to a warehouse, and you pull from different repositories." At the rate data is increasing in healthcare though, he said, whether it's from medical imaging, EHRs, etc., moving this data around is becoming more of a challenge. "So the trend we're seeing is moving processing to the data," said Gough. "That's a large job, that's split up into a number of parts and split across a system. The infrastructure knows where the data resides, and processing happens as close to it as possible to improve performance."

4."Scale-up" is shifting to "scale-out." Typically, said Gough, the industry leans toward a "scale-up" mentality.  "So, [they say] 'Get me a bigger server, a more powerful server,' but instead, the trend is 'scale-out,'" he said. "So don't leave behind or get rid of older hardware nodes – just add them over time and improve performance and scalability of a system by adding nodes." The same notion is true from a storage point of view, he added. "So being able to much more easily scale with the architecture, where you can add another node to the solution and it adds to the system more memory." This makes systems more easy to manage, he said, and are," the kinds of solutions the industry is moving toward, instead of a 'rip and replace' mentality."

[See also: 6 keys to the future of analytics and big data in healthcare.]

5.For smaller organizations, it's all about software-as-a-service (SaaS.) Most of the trends Gough said he's seeing are for smaller hospitals that are leaning toward SaaS. "So an EHR vendor basically posting the solution on behalf of clients and customers, and something we're seeing is, many of those vendors are looking to add services alongside EHRs and other types of applications, more specifically, analytics," he said. A lot of those analytics solutions, he continued, focus on meaningful use and quality metrics. "I expect that trend to accelerate over time toward SaaS, especially for smaller organizations," he said. "It makes sense [for them] to look at hosted analytics solutions and hosted services." 

Tele-ICU initiative improves care, increases employee satisfaction

HIGH POINT, NC – High Point Regional Health System has seen big benefits from a three-year tele-ICU pilot with St. Louis-based Advanced ICU Care, officials say – improving care while alleviating clinicians' workload.

High Point's intensivist-led team is based in the Advanced ICU Care Monitoring Center and receives constant information on the patient’s condition through sophisticated software that notifies them of any change in the patient’s health that might require immediate intervention, officials say.

Two-way video in the patient’s room can be activated to conduct a conference between the bedside care team and the Advanced ICU Care team at any time of the day or night. This constant surveillance improves patient safety and health outcomes by avoiding complications and adverse situations with prompt, proactive interventions.

Key to the High Point collaboration is the strong alliance between its staff and the Advanced ICU Care team, officials say. During the three-year partnership, this team has successfully implemented quality care initiatives for better patient management and safety measures to avoid potential complications that can occur in an ICU, such as blood clots, deep vein thrombosis, gastric ulcers and sepsis. A significant achievement is the implementation of an innovative “patient cooling” process for people with cardiac arrest. Patients who have received this treatment have awakened after the arrest with no cognitive impairment.

“Three years ago, we partnered with Advanced ICU Care to bring around-the-clock intensivist care to ICU patients in our community,” said Greg Taylor, MD, High Point's COO. “From a seamless implementation to the quality enhancements we continue to achieve, the collaboration between our hospital staff and Advanced ICU Care has been a success. We are able to offer our patients the highest level of care available in the ICU today and to continue to improve on that level of care every day.”

Research has shown that patients in intensive care do better when they are monitored around-the-clock by intensivists, physicians specially trained in critical care medicine. Constant surveillance by these specialists is now the recommended standard of care for hospital ICUs.

But a severe shortage of intensivists means it’s simply not possible for most hospitals to meet this standard and have intensivists on staff at the hospital at all times. Advanced ICU Care, the nation’s largest independent provider of tele-ICU programs, helps hospitals overcome this barrier and achieve optimal care in the ICU through a tele-ICU program combining sophisticated telemedicine technology, 24-hour-monitoring by Board-certified intensivist physicians and continuous quality improvement initiatives.

In addition to quality patient care initiatives and protocols, staff satisfaction and working conditions have improved since the implementation of the tele-ICU program, and High Point has seen a reduction in nursing turnover, officials say.

“Our nurses have really embraced this program," said Cindy Stewart, RN, director of critical care and cardiovascular services at High Point Regional. "Being able to speak with Advanced ICU Care in the middle of the night has improved employee satisfaction among our nursing staff. We find that when we recruit, many nurses have heard of remote monitoring, and they’re excited to learn something new.”

Physicians at the hospital say they're comforted that their ICU patients have an intensivist-led team available when they are not in the hospital, making sure their care plans are followed and available should any situation arise that needs immediate attention.

“The Advanced ICU Care program relieves the pressure of having to perform around-the-clock ICU coverage by existing staff and avoids burnout,” said intensivist Peter Brath, MD, medical director of High Point’s Intensive Care Unit and Respiratory Therapy. “There are more doctors available to provide weekend and night backup coverage. From a quality of life standpoint, it’s wonderful.”

“High Point has been a great partner and we are very excited by the strong results that we have been able to achieve together,” said Mary Jo Gorman, MD, CEO of Advanced ICU Care. “We feel very confident the hospital will continue to see additional benefits stemming from our collaboration, from improved patient care to staff satisfaction.”

Health Wonk Review

This week, Maggie Mahar edits the Health Wonk Review, a biweekly compendium of the best of the health policy blogs.

Voices from the Blogosphere, May 21-June 6

I've decided to let the "Voices" of healthcare bloggers become the theme of this edition of Health Wonk Review. Some are passionate; others are dispassionate; some are disarmingly candid; others are angry.

I'm not going to try to "rate" the posts, or tell you which ones I like. Instead, I want to let you hear those voices, as directly as possible, and decide for yourself.� To that end, I'm quoting liberally from the posts submitted to HWR.

A right to health care?

One of the most provocative entries that I received comes from the Center for Objective Health Policy (COHP), a group that reaches out to medical students while arguing that health care reform violates individual rights.

Nathan Fatal explains: "The problem with [the] assumption" that everyone has a "right to health care … is that a right to a good or service would require that somebody provide it, i.e., that somebody be forced to provide it."

He objects to the individual mandate: "Just as one cannot kick down a neighbor's door and hold a family hostage until all members pay a small fee toward his healthcare costs, a large number of citizens cannot properly hand the role of hostage-taker to the … government in order to exact indirect but forced payments from all fellow citizens … all such actions are the same since they violate freedom of action by initiating force against innocent people in order to provide ‘basic security' to those who ‘need' it."

Fatal also defends the rights of insurers and doctors:

"As Richard Salsman explains in Forbes, health insurance is�'a valuable service provided by intelligent, hard-working professionals . . . people who, like other Americans, … have a right to their own life, liberty, property and the pursuit of their own happiness. Doctors, nurses, hospitals, drug-makers, and health insurers are no more servants of the masses, or even of those in need of health care, than are businessmen, bankers, teachers, journalists, or truck drivers …'"

Supreme Court's ruling on health reform law

Here, on healthinsurance.org, Linda Bergthold also considers the mandate, and suggests that it's "worth reviewing again what's at stake" if the Supremes strike down the entire ACA. She writes:

"We could lose things that have already been implemented" including "free preventive services; children's access to coverage regardless of pre-existing conditions; tax credits for small businesses; and the provision that lets "children under 26 stay on their parents' plan." Meanwhile, "lifetime limits on your insurance plan would probably be reinstated."

If just the individual mandate is overturned, "Most economists and business analysts predict that health care costs would increase, because the uninsured would continue to use the system as a last resort, shifting the costs to those of us who are covered."�But, she notes, "There are a number of ways to get around the overturning of the individual mandate."

Over at the Health Affairs Blog, Alan Weil and Sonya Schwartz each review the impact the Court's decision could have on the states:

Weil writes that "the States' responses" to the ACA "have unfolded in three acts." When the Court issues its decision, "we will see the opening of Act IV. "He offers a "visual representation" of those four acts.

"It is unclear how long Act IV will run," Weil adds. "If significant aspects of the law are struck down, states may have to wait a very long time before it is clear how Congress and the President will respond. States in search of a stable, unambiguous federal statutory and legal environment will almost certainly be frustrated."

Meanwhile, Schwartz grades the possible Supreme Court rulings on a "Richter Scale" of disruption, as she looks at "what each possible ruling would mean for the states that have been most active in implementing the ACA."

"If the Supreme Court invalidates components of the Affordable Care Act, active states will try to adapt to the shifting ground by designing new policies to mitigate adverse selection and cover the uninsured," she concludes. "However, their success in doing so will depend in part on how much the ground shifts."

On Colorado Health Insurance Insider,� Louise explains why Governor Hickenlooper Says Reform Can Succeed Without an Individual Mandate. She agrees that "that if you can make health insurance attractive enough and affordable enough, people will buy it without a mandate." She believes that the generous subsidy program" included in the ACA "should be a significant help."

But if the mandate is struck down, and the provision holds that insurers cannot turn down applicants because of a pre-existing condition, "this could quickly lead to out-of-reach premiums" because healthy people would wait until they were sick before joining the pool. If that happens, she says "the states will have to be creative, and get to work hammering out some sort of carrot and stick program to incentivize people to purchase insurance."

The business of medicine

Over at the Prepared Patient Forum, Jessie Gruman turns from the politics of healthcare to the business of medicine.

Her post begins:

"On Monday morning at 8:30 a.m. the pianist was playing Chopin in the beautiful but deserted four-story lobby of the new hospital where my father was being cared for … the contrast between that lovely lobby and the minimal attention my dad received over the weekend, combined with a report about the architectural ‘whimsy' of a new hospital at Johns Hopkins ("a football-field-size front entrance" with ‘manicured gardens and a rectangular water feature') make me cranky."

Why do hospitals indulge in "conspicuous spending" on amenities that the truly sick cannot possibly appreciate, while accepting "staff shortages" (nurses checked her father just once each shift) and "dangerous medical errors"? Gruman:

"We should probably just grow up and recognize that our na�ve notions of the beneficence of health care generally and hospital care specifically are outdated … Health care is big business" and "these new fabulous facilities and all this advertising constitute the cost of … competing for private payers."

Cancer, too, has become a big business. On Health News Review, Gary Schwitzer critiques the media hype surrounding news of an experimental cancer drug.

"When the New York Times reports something, the TV networks are soon to follow," Schwitzer observes. "So when the Times reported ‘A new class of cancer drugs may be less toxic,' featuring a single patient's experience with T-DM1 ��NBC followed closely – featuring the exact same patient in the exact same setting."

"One woman out of 1,000 in the trial. Who chose her?" asks Schwitzer. "The drug company PR people? "

By contrast, Schwitzer calls USA Today's piece "refreshing."�He offers "Excerpts:

2nd sentence: ‘The experimental drug, T-DM1, doesn't cure anyone.'"Later: ‘… statistically, it's possible that those findings could be due to chance, Horning says.'"

Roy Poses, founder of Health Care Renewal� also questions how the quest for earnings affects healthcare, zeroing in on the for-profit hospice industry:

"Remarkable public comments by some for-profit hospice marketers show their focus on increasing patient volumes, even if that means recruiting patients who are not really at the end of life."

Poses explains that this means that some patients suffering from "acute illnesses and injuries may not receive … treatment" they need, while profit-driven hospice care "ends up shortening their lives."

"It's funny that the people who were so alarmed by ‘death panels' do not seem so alarmed by this pathway to denying care for profit," Poses observes.

Rising costs of Medicare and Medicaid

Meanwhile, on Managed Care Matters, Joe Paduda compares how fast the costs of Medicare, Medicaid and commercial insurance have been growing.

"Medicare and Medicaid trends are looking better these days" he writes. "And this trend looks like it will continue. Note this is per-capita growth, which is more accurate when comparing different payer types."�But he reports, "employers' health care costs are up 5.9% this year, and would have increased more if not for a significant increase in cost-shifting to employees (up over 19% from 2011 – 2012)"

Giving physicians a check-up

But money does not drive all of the problems in our health care system � at least not among doctors � writes Brad Flamsbaum in Why We Lie�on the The Hospitalist Leader.)

Doctors sometimes fib, Flamsbaum acknowledges, to insurers, in order "to obtain pre-certification for patient testing perceived as necessary"���and, yes, they lie to patients: "We are humble folk and he says, physicians have the same foibles as the flock we oversee."�Yet, "it's not about the money," he explains, "but a host of other factors ���surprisingly more potent than financial rewards."

Flamsbaum points to research on why humans lie that begins with our "ability to rationalize," followed by "conflicts of interest," "creativity," "previous immoral acts," and "being depleted," all illustrated here.

On�Health Business Blog, David Williams expresses his own�concerns about physicians. �He quotes a doctor advising that�doctors should be candid with families�and "raise the issue of a grim prognosis early on," giving them "an opportunity to deal with it." Otherwise families may fall victim to "optimism bias."

Williams is "wary." The Physician may be "wrong, or unduly certain." He realizes that doctors "must find ways to deal with death" or "they can't practice medicine. But … I don't want a physician to make peace with my relative's death … while he's still alive."

By contrast, Michael Gavin and Mark Pew, executives at Prium, a worker's comp utilization company, worry that�doctors are too quick to give injured workers a heavy dose of pain-killers. �Writing on Evidence-Based, they point to "A new ruling from Texas … that finds payers liable for a range of opioid-related side effects ranging from addiction to death. Prediction: This is just the beginning."

Finally, over at�The New Health Dialogue, Joe Colucci and Shannon Brownlee turn to�how television depicts physicians. "The Fox show House ended last week," they write. "It was entertaining, but as far as health policy is concerned, we're not sorry to see it go … Dr. House exemplified the "cowboy doctor" as "hero" who is in fact a "hazard" … practicing "reckless, unscientific, non-evidence based medicine."

Just "one point in House's favor: he works with a team" and they "actually talk to each other … Unfortunately, that's as unrealistic as the rest of the show."

Thoughts on obesity

In another post,�The New Health Dialogue's�Colucci examines New York Mayor Mike Bloomberg's most recent public health proposal,�banning sugary beverages�"gigantic enough for a small marine mammal to do laps in." Bloomberg would limit sodas served in restaurants to 16 ounces.

"The reaction has included furious opposition from �people claiming this is the nanny state run amok," Colucci reports, but in fact, "There is extensive evidence from psychology and behavioral economics that people respond to larger portions by eating more."

Over at 365 Days of Wellness, Kat Haselkorn focuses on a different profit-driven problem. In Unstoppable Obesity Epidemic, she acknowledges that "obesity is a bigger issue in low-income communities and is more likely to affect minorities." But "marketing and advertising play a significant role in childhood obesity, nudging children towards processed foods and sugar. Government subsidies allow Big Agriculture and top manufacturers to aggressively market products to children … 77% of obese children become obese adults."

Uninsured veterans

The government might better be spending that money on Veterans. On the Healthcare Economist, Jason Shafrin's Memorial Day post�reports that "About 10 percent of U.S. veterans under the age of 65 lack health insurance and are not being taken care of by the VA."�Eligibility for VA services "is based on veteran status, service-related disabilities, income level, and other factors," Shafrin explains. "Proximity to VA facilities and cost-sharing requirements" also affect access.

High anxiety

On Workers' Comp Insider, Julie Ferguson reports on another group at risk. The "boom in cell phones has spawned" a huge demand for radio towers, and "brutal" schedules are leading to more fatalities among tower workers. �(See this video from a prior post.)�"Tower work is carried out by" layer after layer of subcontractors, she explains allowing large companies to "deflect responsibility for on-the-jobwork practices." In an era of sub-contracting, "this layering makes OSHA enforcement almost impossible."

Electronic health records

Jann Sidorov focuses his concern on Electronic Health Records (EHRs)�and "The Need for Legal Framework." Writing on Disease Management Blog�about a piece in the Economist that examines the need for legal reform for military drones and driverless cars, �Sidorov argues that "since robot-like artificial intelligence is involved in electronic health records, the same legal protections may be necessary there."

Age rating

Although I'm a fan of health reform, I too, have my worries. Under the Affordable Care Act, insurers can charge older Baby-boomers (in their 50s and early 60s) premiums three times higher than they would charge a 20-year-old for exactly the same coverage.

I explore the issue here, on HealthInsurance.org, where I've recently begun posting. (Soon, I�ll be re-launching HealthBeat thanks to technical assistance from HealthInsurance.org. In the future, I�ll be writing on both web sites.)

TEPR+ update: Oregon clinic showcases the advantages of patient-centered care

PALM SPRINGS, CA – In Jill Arena's opinion, medical offices can sometimes get too ... medical.

Arena, COO of Greenfield Health in Portland, Ore., sees the nine-physician, two-office practice as an example of patient-centered healthcare. Founded in 2000, the practice is designed - both physically and operationally - with the patient experience in mind.

"What do we think patients really want?" asked Arena. "How do patients experience the physician's office? We need to take apart how we think we're doing business."

Arena was a featured speaker at this past week's Towards the Electronic Patient Record (TEPR+) conference and show in Palm Springs, Calif. The conference, presented by the Boston-based Medical Records Institute, attracted roughly 750 attendees and focused on, among other things, the emerging concept of "participatory medicine."

Arena sees Greenfield Health as a beta test of that concept. The practice, she said, was designed so that the patient can walk right in and see a physician or staff member without having to waste time in a waiting room.

"It's similar to what happens when somebody comes into your home," she said. "It's a lot less clinical. We tend to 'overmedicalize' the experience" of visiting a doctor's office.

Beyond the makeup of the physician's office, Arena said Greenfield Health makes every effort to involve the patient in all aspects of his or her healthcare. The practice has hundreds of thousands of dollars invested in information technology services that connect physicians with patients through electronic medical records, e-mail and phone systems and other services. Among the vendors involved in the 22 "moving parts" of the practice's IT system are GE Healthcare (whose Centricity platform is used) and Kryptiq, which is based in nearby Hillsboro and has been associated with the practice since its inception.

Arena said the practice has been giving patients their personal health records (PHRs) in three-ring binders "because it's their information." They've now developed an electronic PHR, moving those records this past June to Microsoft's HealthVault platform.

In terms of communications, Greenfield Health has set up its telephone system so that if an incoming call isn't picked up by the third ring, every phone in the office rings ("then it's all hands on deck," Arena says). In addition, the practice allows its patients access to the physicians' e-mail addresses.

"We've found that, after eight years (of e-mail contact between patient and physician), the relationships are richer," she said. "People will say more in an e-mail than they might say in person or over the telephone."

Arena said Greenfield Health charges a retainer fee of between $250 and $650 a year for its patients, and makes sure to limit the number of patients each physician sees to ensure that neither the patient nor the provider feels overwhelmed or ignored. This setup, she says, amounts to a roughly 20 percent decrease in the average annual cost of healthcare.

All in all, Arena says, the use of healthcare IT, ranging from EMRs to e-mail, allows about 80 percent of a patient's healthcare needs to be met electronically. That said, there is a concern that a patient might try to have all of his or her healthcare needs handled without ever stepping foot in the doctor's office.

"We have to be mindful of that and say, 'You have to get your body in here,'" Arena said.

Physicians' EHR success recognized at White House event

WASHINGTON – Eighty-two healthcare providers from across the country will be recognized for their successful implementation of electronic health record (EHR) technology at Tuesday's White House Health IT Town Hall in Washington, DC.

At the town hall, senior White House and HHS officials will discuss progress and barriers on the road toward a national health IT system. The HHS Office of the National Coordinator for Health IT (ONC) is hosting a variety of healthcare professionals to share lessons learned in adopting, implementing, and meaningfully using EHRs.

Among the providers attending the meeting will be Jeff Hummel, MD, medical director for health informatics at Qualis Health and the Washington & Idaho Regional Extension Center (WIREC), and Gregory Reicks, MD, who will be representing Colorado Beacon.

Hummel has been an EHR user and advocate since 1998 and will be discussing leveraging health IT to promote better health in communities, including solutions to health IT barriers such as privacy and security and the challenges of building systems that can “talk to each other.”

One of these challenges is delivering a clinical summary to each patient after a visit, which is a requirement for meeting the first stage of Meaningful Use. Like most of his colleagues, says Hummel, “my effort to give my patients clinical summaries at the end of each visit were usually characterized by good intentions that were usually abandoned by mid morning each day in an attempt to stay on schedule.”

When he was handed an after-visit summary at the end of a visit to his own primary care physician, he was intrigued. “I spent the next year figuring out how to redesign my clinic workflow so that entering and updating the information for the clinical summary was built into the structure of the visit, and reviewing the clinical summary with the patient became the end of the visit ritual that my patients came to expect. Now over 80 percent of my patients receive clinical summaries, and I go home on time.”

Reicks, who has seen health IT transform care delivery at Colorado Beacon, said this is a "tremendous opportunity for someone in the trenches, working with practice transformation every day, to engage with high level staff who are involved in this transformational work at a national, big-picture level," Reicks continued, "I look forward to sharing the direct impact these federal dollars are having on my region and my practices."

In addition to discussing the meaningful use of EHRs, providers will likely share their insight on the important role that health IT programs, such as the Regional Extension Centers (RECs), have played in helping them implement EHRs. More than 132,000 primary care providers, almost half in the country are partnering with RECs to overcome the significant barriers that primary care and rural providers face in EHR adoption.

Many AIDS cases, few HIV specialists in South

ATLANTA�The South has emerged as ground zero in the HIV/AIDS crisis in the USA.

Roughly half of all new AIDS diagnoses are occurring in Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina and Tennessee, according to federal estimates.

Overlying that dismal reality is another: There's a severe shortage of HIV specialists in the South, which exacerbates access to treatment for people living with the disease in the region, according to one of the nation's leading AIDS advocacy organizations.

AIDS United, a Washington-based group that provides grants to community organizations, is starting a push to control AIDS in the South. The group seeks to spread awareness of the problem and highlight ways of providing access to care in a congressional roundtable Tuesday on Capitol Hill.

"This disease is no longer a metropolitan problem," says Sen. Jeff Sessions, R-Ala., a host of the roundtable. "In fact, infection rates in the rural South are among the fastest-growing in the country."

There are much higher concentrations of HIV specialists in traditional "epicenters" of the HIV epidemic � 411 in California; 275 in New York state � compared with 243 in the nine Southeast states, says Bruce Packett, deputy executive director of the American Academy of HIV Medicine. This concentration of expert care "just isn't rationally representative of HIV incidences by state," he says.

Sessions and Sen. Kay Hagan, D-N.C., are co-hosting the Senate session. Rep. Ileana Ros-Lehtinen, R-Fla., and Rep. Hank Johnson, D-Ga., are the House sponsors.

"Make no mistake � HIV/AIDS is devastating communities of color, women and young gay and bisexual men in the U.S., especially in the South," Johnson says.

Roundtable participants will hear from activists, patients and care providers, who will share information on programs that are overcoming hurdles to access.

One such effort: People in poor or rural communities with limited HIV specialists can meet with a doctor through a health program electronically with a video hook-up.

Montgomery AIDS Outreach, a group that has about 1,200 active medical patients in 26 counties of south-central Alabama, recently launched such a program, medical director Laurie Dill says. A doctor at the Montgomery hub consults via video with a patient and nurse at the satellite site in Selma, about 50 miles away.

"You're having a real-time, face-to-face conversation, except that it's electronic," Dill says.

According to the Centers for Disease Control and Prevention, 1.2 million people live with HIV in the USA; one in five are unaware that they have it. There are about 50,000 new infections a year.

Ronald Johnson, an AIDS United vice president, points to several reasons for higher incidence rates in the South, including "higher rates of poverty, racism that helps drive and fuel the problem, cultural conservatism that serves as a barrier, stigma around HIV, stigma toward � drug users and sexism."

Geisinger, Merck partner on patient engagement

DANVILLE, PA – Geisinger Health System and Merck have embarked on a multi-year collaboration to develop new methods and technology to spur shared decision making between patients and physicians and to improve adherence to treatment plans and clinical care processes.

First up is the development of an interactive Web application designed to help primary care clinicians assess and engage patients at risk for cardiometabolic syndrome. Cardiometabolic syndrome is a clustering of various risk factors that put an individual at risk of developing type 2 diabetes and cardiovascular disease.

[See also: Geisinger cuts readmissions with tech help]

“We believe that healthcare is most effective when patients are active partners in their care,” said Glenn Steele Jr., MD, president and chief executive officer of Geisinger Health System. “Our collaboration with Merck will allow both organizations to leverage our individual expertise and joint resources to improve patient engagement, including finding new interventions to increase the likelihood that patients will adhere to their treatment plans.”

Teams from Geisinger and Merck will work together to improve patient adherence, increase the role of patients in making decisions to help manage their conditions, share information among extended care teams and improve clinical care processes.

“When you have two leading healthcare companies that share a commitment to improve health outcomes and are focused on fundamental problems that have plagued the healthcare system for years, the results have the potential to be transformative," said Mark Timney, Merck's president of Global Human Health – U.S. Market. "We're excited about the opportunity to work with Geisinger to address these critical areas."

[See also: Geisinger cuts readmissions with tech help]

The Web application and other care management solutions that Merck and Geisinger develop will initially be tested within the Geisinger system. Geisinger has been at the forefront of the development of innovative healthcare delivery models focused on improving adherence and developing methods to better engage patients. Merck has conducted scientific research to better understand the drivers of non-adherence and develop evidence-based interventions.

”A rapid learning process will be used to integrate, evaluate and improve the performance of each solution in primary care clinical settings," said Steele. "We will closely monitor patient acceptance, treatment adherence, and other metrics to determine which tools and solutions have the ability to improve patient care and are ready to be deployed on a broader scale.”

ONC takes on mobile device security

WASHINGTON – The Office of the National Coordinator for Health IT (ONC) will help small providers who use smart phones and other mobile devices learn how to easily secure them using simple steps explained in plain language.

Research shows that about 81 percent of physicians use smart phones or tablet devices. The small size of these devices make them easy to lose on subways and airplanes or stolen. Yet very few safeguard them, such as using encryption, making it easy for unauthorized users to access information.

[See also: ONC puts spotlight on mobile security]

ONC has conducted research on mobile endpoint security, where they take devices out of the box from the local electronics stores and apply manual configuration for better controls to support security, said Will Phelps, an IT security specialist in ONC’s Office of the Chief Privacy Officer.

“You have to make sure that the devices are able to apply the appropriate security controls to make sure that the patient records are protected. We want to reach out to the provider community to make sure that they are able to do these things,” he said at the June 11 Government Health IT conference sponsored by HIMSS.

ONC studies of out-of-the-box security configuration found that most mobile phones did not meet more than 40 percent of security requirements, such as the ability to encrypt information, he said.

[See also: ONC puts spotlight on mobile security]

After manual configuration, test results improved significantly, especially for the iPhone and Blackberry models, which met 60 percent of the security requirements. Other phones did not fare as well after manual configuration.

Initially, ONC will focus on small and medium-sized providers. “They may not have an IT staff or third-party vendor to manage their devices for them. So we want to get them to a point where their devices are operating as securely as possible,” Phelps said, adding that the security configurations are available on the devices right out of the box but must be manually configured.

ONC will describe scenarios or use cases around which to offer practical information for mobile device security, said Kathryn Marchesini, an attorney in ONC’s Office of the Chief Privacy Officer. 

These will include remote use from a coffee shop, sending email, or what to do if providers bring their own devices, which may not necessarily be credentialed in the organization, and whether they should be allowed to connect to the system’s network or not.

Some providers may not realize they need a policy around the use of mobile devices, or that they need to take an inventory of mobile devices. “It may seem basic, but we hear every day that practicing providers are struggling with these issues,” she said.

The Health Insurance Portability and Accountability Act (HIPAA) provides security guidance around remote use. The proposed rule for meaningful use stage 2 also calls for encryption of data at rest.

In its next phase, ONC will test third-party vendor security tools applied to devices to see how well they score on information protection. Overall, ONC plans to design outreach for vendors, providers and patients for security awareness around mobile devices and training to follow.

ONC is also incorporating in its mobile security outreach the regional health IT extension centers, which offer technical assistance in providers’ offices “to make sure we identify real scenarios and practical solutions,” Marchesini said.

ONC plans to develop best practices for securing mobile devices to be available online in the fall.

[See also: Mobile health app market in growth mode]

Q&A: Be careful with your supplement regimen

So should you or shouldn't you take calcium and vitamin D supplements? Some recent developments may have left consumers confused.

The U.S. Preventive Services Task Force said Tuesday that healthy postmenopausal women should not take daily low doses of vitamin D and calcium to prevent bone fractures because they slightly increase risk for kidney stones. In its draft recommendation, the panel also said existing research is insufficient to assess the risks or benefits of taking vitamin D to prevent cancer.

A recent study found calcium supplements may raise some people's risk for heart attacks.

Yet for years, experts have touted both calcium and vitamin D as key nutrients for bone health.

The Institute of Medicine, which provides independent advice, recommends 600-800 international units (IU) of vitamin D daily and 700-1,300 milligrams of calcium, depending on your age.

Many foods are rich in calcium and fortified with vitamin D. Sunlight triggers production of vitamin D in the skin and is a major source.

But nutrition experts say many people still may need to fine-tune their diets to get enough.

Endocrinologist Bess Dawson-Hughes, director of the Bone Metabolism Laboratory at the USDA's Human Nutrition Research Center on Aging at Tufts University in Boston, answers questions about the new recommendations.

How much calcium?

Here are the current recommendations
for calcium intake based on age group,
in milligrams per day:

Children ages 1-3: 700

Children 4-8: 1,000

Adolescents 9-18: 1,300

All adults 19-50: 1,000

Men 51-70: 1,000

Women 51+: 1,200

Men 71+: 1,200

To get this amount of calcium in food, children and adults would need to consume at least three servings a day of calcium-rich foods such as low-fat milk, yogurt or fortified orange juice. Teens need four servings. A cup of milk has about 300 milligrams of calcium.

Source: Institute of Medicine,
USA TODAY research

Q: Why are calcium and vitamin D so critical?

A: They are both essential for the development and maintenance of healthy bones. Older people with adequate vitamin D levels have fewer falls than those with lower D levels. The U.S. Preventive Services Task Force said that.

Low levels of vitamin D have been associated with a range of chronic diseases, such as diabetes, hypertension, heart disease, some cancers, infections and autoimmune problems. These early findings warrant further investigation.

The National Institutes of Health is currently funding some very large trials to define the effects of vitamin D on the burden of many of these chronic diseases.

Q: Can people get enough vitamin D and calcium in their diets, or do they need to take supplements to meet the recommendations?

A: Many adults are not getting quite enough calcium in their diets. They have two choices. My first recommendation is to modify their food intake to include one more calcium-rich food a day. We have lots of foods to choose from, and calcium has been added to many foods, including orange juice and cereal.

If you can't get it through foods, then use supplements to bring your intake up to the 1,000 to 1,200 milligrams a day, the amount recommended for adults.

You need to get up into the recommended intake level of calcium, but there is no point in exceeding that level because there is no benefit. And there are potential risks, however low they might be, that there would be adverse consequences to exceeding those levels. So why spend more money and take more risks?

Vitamin D is more complicated, because we get it from sun exposure and from food. It's not easy to get 600 to 800 IU of vitamin D daily from food sources. You'd have to be eating a lot of wild salmon, and you'd have to do it every day. � If you're not getting any sun contribution, you are going to need a supplement.

Q: Is there is an increased risk of heart attack from taking calcium supplements?

A: I don't think we have a conclusive answer to that yet. There is certainly enough of a suggestion that high-dose calcium supplements may be detrimental. I recommend avoiding high-dose calcium supplement use, such as exceeding the institute recommendations for calcium by 500 to 1,000 milligrams a day.

People should use calcium supplements only as necessary to reach the institute requirements.

Q: If postmenopausal women are taking vitamin D and calcium supplements to prevent osteoporosis, do you think they should stop, based on this panel's advice?

A: You should estimate how much calcium and vitamin D you are getting through food, and if you are below the Institute of Medicine requirement, you should increase it with food if you can. If you can't, then you should take a supplement that fills in the gap.

Q: Any other advice?

A: We need to encourage food sources of calcium, vitamin D and all other nutrients. It's an old message, but it's timely again because we are getting a backlash on supplements.

Would single-payer healthcare be less vulnerable to the court than the ACA?

If the Supreme Court does decide to strike down any or all of the Affordable Health Care Act, the implications will range from the political to the medical to the economic.

For me, such a decision will take its place among the more supremely ironic of unintended consequences: a law designed to avoid greater government intrusion into health care will have been invalidated as an unconstitutional overreach of government power, while a far more intrusive approach would have clearly passed muster.

How could this be possible? Welcome to the wonderful world of constitutional interpretation.

Let�s begin by imagining that Congress and the president decided to adopt a genuinely radical health care plan�the kind in place in most of the industrialized world. They decide on a �single-payer� system, where the government raises revenue with taxes, and pays the doctor, hospital and lab bills for just about everyone.

Put aside the question of whether this is a good idea, or an economically sustainable notion. The question is: would such a law be constitutional?

The answer, unquestionably, is �yes.� In fact, it would be the simplest law in the world to enact. All the Congress would need to do is to take the Medicare law and strike out the words �over 65.� Why is it constitutional? For the same reason Medicare and Social Security are: the taxing power. Its reach is immense. During World War II, the maximum income tax rate was 91 per cent (it was paid by few, thanks to loopholes, but still). The same Congress that could abolish the estate tax could set just about whatever limit it chose; it could impose a 100 percent tax on estates over, say, $5 million. If it decided that a national sales tax was an answer to huge budget deficits, it could impose one at whatever level it chose.

(The remedy, of course, lies with the voters, who would be more than likely to send a powerful message at the next election, which is why the lack of constitutional limits on the taxing power do not lead to confiscatory rates.)

So why is Obama�s health care plan, with a far more modest use of government power, in serious jeopardy? It�s because the key element in the plan�the �mandate� to purchase health insurance or pay a penalty�was not based on the taxing power, but on Congress�s power, under Article I, Section 8, to regulate interstate commerce. And that power, while broad, has its limits…even if those limits are murky.

Up until the late 1930s, those limits were more like shackles. The Supreme Court repeatedly struck down sate and federal laws regulating wages, hours and working conditions on the grounds that the commerce power only touched the distribution of goods, not their manufacture. But once the court changed its mind�after an effort by FDR to �pack� the court with additional justices had failed�there seemed to be no limits at all. Back in 1942, the court said the government could stop a farmer from growing his own wheat for his own use, because of the potential effects on the wider market. But in 1995, for the first time in decades, the court said �no� to a federal law based on the Commerce clause�one banning firearms within school zones�because it could find no reasonable connection between the law and interstate commerce.

In the health care case, the questioning by several justices indicated strong skepticism about the mandate. If the commerce clause can compel a citizen to buy a specific product�in this case, health insurance�what couldn�t it do? Could it, as the now famous question had it, compel citizens to buy broccoli on health grounds? (Well, a defender might have pointed out, the government does compel taxpayers to �pay for� all kinds of things in the form of government subsidies, such as ethanol. It could clearly do the same with a broccoli subsidy.)

As a policy matter, it�s clear that a �mandate� is a much more modest extension of government power than a single-payer system. The citizen would choose which insurance to buy; in fact, under the law, a citizen could choose not to buy any insurance, and pay a penalty instead. The whole premise of a mandate is to spread risk as widely as possible; as Mitt Romney used to note when he was defending the Massachusetts plan he designed, the mandate to prevent �free riders� from benefitting from treatment once they are sick or injured. That�s why the genesis of the idea came from such conservative roots as the Heritage Foundation.

As a constitutional matter, however, the idea of compelling a citizen into a specific economic activity raises alarm bells. It evokes the specter of some bureaucrat inviting himself into your home, while checking the shelves to make sure you�ve purchased multigrain cereal and cage-free eggs. (It�s a specter the administration tried to avoid by arguing that the health-care market is unique, one in which we are all likely participants at some point, voluntarily or otherwise. Unlike life in a Robert Heinlien libertarian �utopia,� hospital ERs do not have the power to say to an uninsured heart attack or auto accident victim: “you chose not to buy insurance? Sorry…have a nice day.�)

So, for its effort to design a health care plan that moved in the direction of less government intrusion, the Obama administration faces the distinct prospect of having its signature domestic program shot down for exceeding the limits of the constitutional power it did choose to use.

I somehow doubt the White House will appreciate the irony.

Calif. Runs With Health Law Without Waiting On Supreme Court

Enlarge iStockphoto.com

California lawmakers have been introducing legislation that would replicate key pieces of the federal law, including bills defining benefits and guaranteeing coverage to people with pre-existing conditions.

iStockphoto.com

California lawmakers have been introducing legislation that would replicate key pieces of the federal law, including bills defining benefits and guaranteeing coverage to people with pre-existing conditions.

Many states have done nothing to implement the health overhaul law, saying they'll wait to see how the Supreme Court rules.

Not California.

The country's most populous state got out in front first on implementing the law, and it hasn't slowed down in recent weeks as the rest of the country waits to hear from the high court.

"California has been moving ahead 100 percent assuming it will upheld," says Peter Lee, who left his Washington job as a health policy official in the Obama administration to lead California's Health Benefit Exchange. "We [aren't] doing anything in the way of contingency planning because it makes no sense to plan for what seems like an outer bounds of possibility, and rather, we've got a big job to do to get ready to cover what will be millions of Californians in 18 months."

 

Lee has a staff of 36 that is working feverishly to be ready � and he is optimistic about the exchange's future in California even if the court overturns the requirement that most people buy insurance. He argues that the tax subsidies to allow some people to buy insurance will be enough to entice customers to buy their insurance in the online marketplace his agency is setting up.

"The reason the exchange is going to have � we project � over 2 million people in it after a few years, [has] very little to do with the [individual] mandate," Lee says. "We're a place where people can get subsidies for care, and can make informed choices."

Without the requirement that everyone buy insurance, known as the individual mandate, Lee estimates that the exchange would lose a few hundred thousand people; it would still be a viable marketplace for California, however.

But Patrick Johnston, president and CEO of the California Association of Health Plans, says the federal law wouldn't work without the mandate.

"We need to have a group of people that is big enough and has enough people who for the most part are healthy to make sure that the insurance costs will be shared and not high," Johnston said. "States that decided to say 'Everybody gets insurance at the same price but you can buy it whenever you want,' found that prices just went way up and people dropped out."

Still, on the legislative side, California lawmakers have been introducing legislation that would replicate key pieces of the federal law, including bills defining standard health benefits and guaranteeing coverage to people with pre-existing conditions.

"I'm going to remain fully committed to figuring out how do we preserve and protect what was the vision of President Obama, to replicate that in California by any means necessary," says Assemblyman Bill Monning, chairman of the state assembly's health committee. "We will figure out how to do it."

Monning and his counterpart state Sen. Ed Hernandez, a Democrat, hesitate to say they'd propose a state health insurance mandate, without knowing the court decision. But Hernandez says he would author a bill that would "start the discussion" about compelling people into the market. Hernandez worries, though, that funding a new state marketplace without federal help would be difficult.

"The state just doesn't have any money," he said. "My biggest fear and concern is if we lose the federal subsidies, I just don't know how we can make it ... work."

Republican Assemblyman Dan Logue is a fierce opponent of the health law. He thinks the Democratic majority in California would succeed in passing a state mandate if the federal one goes down. But if a state mandate were proposed, he would take it to the voters.

"I think once they realize the dynamics and the cost and how it would put California at risk financially with the rest of the country, that it would go down in flames easily," Logue said.

Lee of the health exchange says he isn't losing any sleep over the thought of the mandate being thrown out . "I've seen community groups, I've seen hospitals, I've seen health plans, I've seen the business community, not throwing rocks at our effort but, rather, joining in to make this thing work," he says.

Despite Lee's optimism, a recent survey by the Public Policy Institute of California showed 63 percent of Californians were against the mandate.

This story is part of a project with the Capital Public Radio, NPR and Kaiser Health News.

Doctors Have Trouble Keeping Up With Painkiller Abusers

Sue Ogrocki/AP

A pharmacy technician counts generic Vicodin tablets at Oklahoma Hospital Discount Pharmacy in Edmond, Okla.

The growing awareness about the abuse of prescription painkillers hasn't kept the problem from skyrocketing. In 2008, 14,800 people died of an overdose, according to the Centers for Disease Control and Prevention, more than overdose deaths from cocaine and heroin combined.

Prescription drug monitoring programs that allow doctors to track who's prescribing and dispensing powerful painkillers, such as OxyContin and Vicodin, can help curb patients' so-called doctor shopping. That's when people go to lots of doctors to load up on painkiller prescriptions.

But the databases for checking up on patients only work if health care providers use them, and often that's not happening. Some insurers are taking matters into their own hands, including a big one in Massachusetts that will soon make doctors justify prescriptions for pain pills that exceed a 30-day supply.

More than 40 states have systems in place to monitor prescription drugs, according to the National Alliance for Model State Drug Laws. Typically, dispensing data from pharmacies is uploaded into a centralized database that physicians and other health care providers can query.

 

But the programs are voluntary, and many clinicians remain unaware of them, according to a recent article published in the New England Journal of Medicine.

There are other difficulties. The data may only be updated once a month. And the systems are often cumbersome to use, a sticking point for busy clinicians.

Utah anesthesiologist Perry Fine, a past president of the American Academy of Pain Medicine, says that it's in patients' best interest that their doctors know which drugs they're taking to ensure proper treatment.

The database in Utah is pretty easy to use, he says. But in many states, that's not the case. "Because they're not very functional or accessible or complete, overall utilization hasn't been very great," he says. As the state systems evolve, that may change, but for now, "They're not mainstream."

And the drug-monitoring systems in some states, such as California, have suffered from cuts in funding.

Still, there's traction in other states. New York Gov. Andrew Cuomo is expected to sign legislation that would require doctors in the state to prescribe drugs using computers rather than paper, the Associated Press reported. Pharmacists would be required to promptly enter information about painkiller prescriptions into a statewide database, too.

CUREXO to launch new robotic surgery technology

SACRAMENTO, CA – CUREXO Technology Corporation announced Monday it will launch ROBODOC, its new robotic orthopaedic surgical application at the American Association of Orthopaedic Surgeons Annual Conference at the Sands Expo Center in Las Vegas, Feb. 25-27.

CUREXO officials said for the first time the company will display the accuracy of ROBODOC through active demonstrations of hip and knee replacement surgeries. In addition, Dr. William Bargar, assistant clinical professor at the Department of Orthopedic Surgery at the University of California Davis School of Medicine will be sharing his clinical experiences using the system.

"I am very pleased to share my experience using ROBODOC with interested surgeons at the AAOS," Bargar said. "The ROBODOC system allows surgeons to be very accurate. By preoperatively planning and being able to execute what you plan, you can now address issues such as implant fit and sizing, as well as off-set and leg length which are very important in terms of how the hip functions. The system allows you to not only plan the surgery better, but more importantly, you can execute the plan with sub-millimeter accuracy."

Brent D. Mittelstadt, president and CEO of CUREXO said, "While the System has been in use for many years having completed more than 24,000 surgeries around the world, now with our recent FDA clearance for total hip arthroplasty, we can offer our products to U.S. surgeons. In addition, we are further developing strong technical and marketing initiatives, and are prepared to move forward into the U.S. market."
 

EHRs widely used but fall short of federal standards

SAN FRANCISCO – California physicians are finding themselves cornered in an EHR catch-22, a new report finds. The data shows that although a majority of the state’s physicians now use EHRs – technology pushed by the federal government – most of the implemented systems fail to meet new federal meaningful use requirements.  

The report, conducted by the University of California at San Francisco (UCSF) in conjunction with the California Medical Board and the California Department of Health Care Services, comes as a disappointment for the state's medical community. 

“We found that physicians are more likely to have electronic health records with functions that support individual patient visits rather than functions that support overall quality improvement,” said lead author Janet M. Coffman, assistant professor at the UCSF Philip R. Lee Institute for Health Policy Studies and UCSF Department of Family and Community Medicine.

Coffman pointed out that 61 percent of the surveyed physicians use EHRs that enable them to record clinical notes but only 45 percent are able to generate routine reports of quality indicators, such as the percentage of patients with diabetes who receive recommended lab tests, foot exams, and eye exams.

The research also showed the size of a physician’s practice to be the strongest predictor of having an EHR. Physicians who practice in Kaiser Permanente, other large medical groups, the Department of Veteran Affairs, or the military are much more likely to have EHRs than physicians in smaller practices.

Core objectives, menu objectives and electronic reporting on the quality of care are identified by federal regulations as the three categories of objectives aimed at achieving meaningful use of the technology. 

To encourage increased adoption of EHRs, incentive payments will be provided to hospitals and providers that achieve meaningful use of the technology.

The Health Information Technology for Economic and Clinical Health (HITECH) Act incentive payments could total up to $27 billion over 10 years, or as much as $44,000 (through Medicare) and $63,750 (through Medicaid, called Medi-Cal in California) per clinician. This funding also will provide the basis for the creation of a nationwide network of EHRs.

“The Medicare and Medicaid incentive payments will provide valuable resources to physician practices that do not yet have EHRs that will meet meaningful use standards,” said Coffman.  “Medicaid payments especially are important since we found that community health centers, rural health clinics, and other practices that primarily serve Medicaid beneficiaries and uninsured persons are less likely to have EHRs. Many of these practices are struggling to keep their doors open. Medicaid incentive payments give these practices an opportunity to purchase EHRs.”

This report summarizes a survey of California physicians about their current use of EHRs and their eligibility for the Medi-Cal EHR incentive program.

Some key findings:

Although 71 percent of physicians surveyed have an EHR system, only 30 percent have EHRs configured to meet all 12 of the meaningful use objectives measured in the study.Rates of EHR availability are lowest among physician solo practitioners, small partnerships, and community/public clinics. Office-based physicians are less likely to have EHRs than those in hospitals, and rural physicians are less likely to have them than urban physicians.Most physicians who, based on their survey responses, are eligible for incentive payments (70 percent) do not currently have EHRs that can meet all 12 of the meaningful use objectives measured.Many physicians are not familiar with the eligibility rules for the Medi-Cal EHR incentive payment program. A substantial percentage of survey respondents who are eligible for the payment program believe that they are not eligible, do not plan to apply, or need further information before deciding to apply. At the same time, a number of respondents who plan to apply do not appear to be eligible.

Clinicians turn to social media to find jobs

SAN DIEGO – Respondents to a 2011 AMN Healthcare survey indicate that healthcare professions are increasingly taking advantage of social media and mobile devices for job searching purposes and shifting away from some traditional job search methods.

In fact, nearly one-third of the 2,790 respondents of the "Use of Social Media and Mobile by Healthcare Professionals: 2011 Results" said they are using social media for job searching compared to 21 percent in 2010. Close to half of those surveyed are also using social media for professional networking compared to 37 percent in 2010.

[See also: Healthcare outpaces all other sectors in jobs growth]

“In our own recruitment with clinicians there’s been an increase in the desire to use social media and mobile devices,” said Susan Salka, president and CEO of AMN Healthcare. “It’s the whole digital world and how they want to use the available technologies to be more efficient in accomplishing what they’d like to accomplish, whether that be searching for information or a job.”

In addition, according to the survey, more hospitals are joining the social media revolution. In 2011, 1,229 hospitals used social media compared to 391 in 2009.

“We’re hearing more and more appetite to be able to access jobs- and service-related information. We go beyond that and our clients go beyond that when it comes to how they use social media to manage their online reputation,” said Salka. “We use all of these to connect clinicians and clients with general healthcare industry information.”

[See also: Demand exceeds supply for some health IT jobs]

There’s evidence that the use of social media for job seekers is also becoming more efficient, according to the survey. Six percent of the respondents who used social media for job searching said they were able to find a new job. While this number is still low, only 3 percent found jobs this way in 2010.

As far as which social media sites are favored by respondents, 74 percent cited Facebook, followed by LinkedIn.

When it comes to mobile devices, in 2011, 32 percent of clinicians reported using mobile devices for accessing healthcare-related content or jobs compared to 12 percent in 2010.

Participants were also asked about their use of social media for work-related purposes. The top reason respondents cited for using social media was to access healthcare-related education (54 percent) followed by sharing of research or articles with colleagues (33 percent), and to communicate with employers (18 percent).

Healthcare-NOW! Activist, Alison Landes, on the air

Yesterday, Alison Landes, a single-payer activist with Healthcare-NOW! and Floridians for Health Care was interviewed on WMNF 88.5 by Rob Lorei. Listen to the full show.

The show’s topic was “Does the Nation Need Health Care Reform?”

Excerpt from the show: Today we�ll talk about health care reform. It�s near the top of the agenda of the incoming president. Obama supporters will soon be holding house parties to discuss what people at the grassroots level would like to see done about health care. Also, Pinellas Democrats will soon hold a series of meetings to talk about health care reform.

Our first guests today are nearing a financial crisis because they don�t have health insurance. They are Joycelyn and Jim Elliott. He is a chiropractor by profession. She has been unable to work due to stress. In 2004, they moved from Tampa to Nebraska to restart their lives. I spoke with them yesterday.

Allison Landes lives in Boca Raton and she�s a volunteer with Floridian�s for Health Care, a group that advocates a single payer style health care system.

Read the full article here.

Panel to postmenopausal women: Don't take vitamin D, calcium

A government advisory panel's recommendation Tuesday that healthy postmenopausal women should not take daily low doses of vitamin D and calcium to prevent bone fractures is a wakeup call to millions of Baby Boomer women that more is not always better.

The panel said there is insufficient evidence to evaluate larger doses, easy to overdo with chewy chocolate supplements that can seem like candy.

In its draft recommendations, the U.S. Preventive Services Task Force also said existing research is insufficient to assess the risks or benefits of taking vitamin D � with or without calcium � to prevent cancer in adults.

Some studies link higher levels of vitamin D with lower rates of colorectal cancer and reduced risks for other cancers, including breast, prostate and pancreatic cancer. These reports are mixed and therefore inconclusive, the advisory panel said.

This is the same panel that grabbed headlines recently by recommending against PSA (prostate-specific antigen) tests to screen for prostate cancer in healthy men and told women ages 50 to 74 to have a mammogram every other year, instead of annually.

This latest report adds to many conflicting messages about the benefits and risks of vitamin D and calcium supplements.

For years, experts have been touting the health benefits of these nutrients. Both calcium and vitamin D are key nutrients for bone health.

The Institute of Medicine, which provides independent advice on health, recommends that people daily get 600-800 IUs (international units) of vitamin D and 700-1,300 milligrams of calcium, depending on their age.

Many foods, such as milk and yogurt products, are rich in calcium and fortified with vitamin D. Sunlight triggers the production of vitamin D in skin and is a major source of the vitamin for many people.

The task force's draft recommendation looked at doses up to 400 IUs (international units) of vitamin D and 1,000 milligrams of calcium for fracture prevention, and recommended against taking them, saying the nutrients slightly increase the risk for kidney stones. The authors add that there is insufficient evidence to draw conclusions about taking larger doses to prevent fractures.

Fractures are a significant health problem, the task force says; every year approximately 1.5 million fractures occur in the U.S. Nearly half of all women older than 50 will have an osteoporosis-related fracture during their lifetime.

"The science is still out for pre-menopausal women and men," with regard to low-dose supplements and fractures, says Timothy Wilt, the lead author on the panel report. "Many people take the supplements, but the science was insufficient to make recommendations for everyone."

Some health experts don't agree with the task force recommendation and say women should weigh options with their physicians based on their own ethnicity, diet and sun exposure, a major source of vitamin D.

The studies analyzed by the government panel have important limitations, says Jen Sacheck, an assistant professor and researcher in the antioxidants research laboratory at Tufts University in Boston. The research largely involved white people and no accommodation was made for how nutritional needs may vary by where a person lives, she says.

"It's a more complex picture than they're painting," she says. "If you live in New England there are many months of the year when you're not getting adequate amounts of vitamin D from the sun. I check blood levels of young and older people and find them to be low in New England."

If you're Hispanic, Asian or black, says Sacheck, or are lactose intolerant, you might not get enough calcium from dairy products. She says being overweight or obese also can also compromise the levels of the nutrients.

Taylor Wallace, senior director of scientific and regulatory affairs for the Council for Responsible Nutrition, a trade group that represents supplement makers, says research shows that supplementation with calcium and vitamin D is beneficial for bone health, particularly in post-menopausal women and the elderly. "You want try to your best to get your calcium and vitamin D from food, but most Americans do not, so when there is a gap, they can fill that gap with supplements."

He points out that last month this same government task force said supplementation with vitamin D was beneficial in preventing incidences of falls among adults ages 65 and older. "Since falls commonly result in fractures, it's common sense for the elderly to consider supplementing with vitamin D and calcium."

About 22% of U.S. adults report taking calcium supplements and 22% reporting using vitamin D supplements, the industry group says.

Most calcium supplements also contain vitamin D because the two nutrients work together, Wallace says. "Vitamin D helps pull calcium into the bones."

"We recommend consumers read the labels," on supplements, he adds. "More is not always better, including for the tasty stuff like the soft chews where people might be tempted to eat a bit more."

Suzanne Steinbaum, director of women and heart disease at Lenox Hill Hospital in New York and an American Heart Association spokeswoman, says the recommendation "changes everything. There seems to be no place for calcium for preventing cancer and fractures.

"To tell people, 'Take calcium and vitamin D to prevent fractures as you get older,' that's not panning out anymore," she says. "Even if you are at risk for a fracture, maybe you have to try other lifestyle changes, like diet and weight-bearing exercise."

Clifford Rosen, a spokesman for the Society of Bone and Mineral Research, notes that the task force discounts a finding from the Women's Health Initiative, a study of 36,282 healthy postmenopausal women, that supplements offer a 10%-11% reduced risk of fractures.

"I think the government panel's report is a little confusing," Rosen says.

JoAnn Manson, one of the Women's Health Initiative investigators, says in addition to reporting the lower fracture rate, the initiative found "bone density improved among postmenopausal women taking supplements."

Recent research has linked calcium supplements to increased risk of heart attacks, Manson says; she adds that it is best to get calcium from the diet, but some may want to add a low-dose supplement to reach recommended levels.

"The key point about calcium is that more is not better," says Manson, chief of the division of preventive medicine at Brigham and Women's Hospital in Boston.

The National Cancer Institute is funding a 20,000-person study to find whether taking a daily dietary supplement of 2,000 IU of vitamin D or one gram of omega 3 fatty acids reduces the risk of cancer, heart disease and stroke. Manson is directing the study and recruiting men and women for it through this year.

"The science is still out on cancer prevention," says Wilt.

Steinbaum acknowledges that consumers may feel confused and frustrated by changing recommendations. She hopes that people won't give up and feel there's nothing they can do to improve their health. The two old standbys � "eating better and exercising" � still have the greatest impact, she says.