Audit Of MassHealth Finds Problems With $4M In Spending

A new state audit takes issue with how MassHealth, the state’s health insurance for low-income residents, spent $4 million, WBUR reports.

State Auditor Suzanne Bump says she found problems with how payments for wheelchairs and wheelchair parts were authorized.  “We found that there were not proper authorizations for claims, we also found that nursing homes had submitted duplicative bills,” she said in an interview.

Bump says that more controls need to be put in place to make sure only necessary payments are made. MassHealth, with a budget over $12 billion that accounts for about one-third of the state budget, says it’s implementing new oversight programs to prevent and recoup the excess payments.

Here are more findings, from the state auditor’s news release:

•MassHealth regulations require it pay providers for wheelchairs and component parts at a rate equal to the lowest usual and customary amount the provider accepts from any other insurance carrier. By failing to do so, it spent $1 million more than was necessary during the audit period.

•MassHealth paid $2.9 million in repair claims for wheelchairs and components without proper authorization. Prior authorization is required for claims for wheelchair repairs exceeding $1,000. Because the Prior Authorization Unit improperly calculated total repair costs, including labor and costs, $2.9 million in claims were not properly authorized.

•MassHealth made payments totaling $540,801 for improperly authorized, provided, or billed wheelchair components because the agency’s claims system could not detect when limits and restrictions on equipment had been reached. For example, auditors identified $40,206 in duplicative payments and $158,594 for components or repairs to manual wheelchairs used by members residing in nursing homes.

Correction: An earlier version of this story put the MassHealth budget at “over $12 million” however the correct figure is “over $12 billion.”

Why To Do Yoga Today: Some Relief For Arthritis Sufferers

Santa Catalina School/Flickr

Santa Catalina School/Flickr

A relative in her 90s recently mentioned she does “floor yoga” at the local YMCA. When I asked what that was, she replied: “We stay on the floor and don’t stand up.” Hey, whatever works.

Yoga is inescapable: A 2012 estimate puts the number of people who practice yoga in the U.S. at 1 in 10 adults or about 20 million people. But these are mostly fit women in snug, stylish pants. What about people who have a lot more trouble moving?

A recent report by researchers at Johns Hopkins found that yoga may benefit the not-so-fit as well: a randomized trial of 75 adults (mostly white, educated women) afflicted with two common forms of arthritis found yoga can be both safe and effective for improving pain, energy, mood and for carrying out daily activities. This is not trivial. While exercise has been found to greatly improve some of the symptoms on arthritis, the leading cause of disability affecting 1 in 5 adults, many sufferers aren’t exercising. From the study, published in the Journal of Rheumatology: “…despite the well-known benefits of physical activity, up to 44% of people with arthritis report no leisure time physical activity and 76% are inadequately active.”

Researchers report improvements after just 8 weeks. From the news release:

Compared with the control group, those doing yoga reported a 20% improvement in pain, energy levels, mood and physical function, including their ability to complete physical tasks at work and home. Walking speed also improved to a smaller extent, though there was little difference between the groups in tests of balance and upper body strength. Improvements in those who completed yoga was still apparent nine months later.

There here is one big caveat: 24% of participants dropped out of yoga, but, as the researchers note, “persistence was still higher than in many exercise programs, with most attending the majority of classes.”

I asked study author Dr. Susan Bartlett, an associate professor in the department of medicine at Johns Hopkins School of Medicine and McGill University Health Centre, what she would tell patients with arthritis who are currently sedentary about how to approach yoga. Here’s what she wrote:

I would tell them that physical activity is important for everyone, but especially important for people with arthritis, who tend to be less active than the average American.

Often people with arthritis worry that they will aggravate their joints and be in worse pain as a result of being active.  While it is true that certain types of activity (anything percussive like jogging, tennis, skiing) are probably not advisable, keeping muscles moving and joints limber is very important. We’re learning how dangerous under-activity can be (emerging evidence suggests that a sedentary lifestyle is as problematic to health as smoking).

Results of our study suggest that yoga appears to be a safe and effective option for adults who wish to become more active. Further, many people who don’t enjoy traditional activity find that they really enjoy yoga. Yoga is a mind body activity, and while almost all forms of physical activity are associated with both mental and physical health benefits, yoga in particular helps with stress reduction, mood, learning to listen to and respect what your body is capable of doing today. Continue reading

Vaginal Mesh Study: Complications More Likely With Lower-Volume Surgeons

How do you minimize risk when undergoing surgery, an inherently risky endeavor?

If you happen to be one of the thousands of women facing surgery to treat stress urinary incontinence (SUI) — that uncontrollable leakiness due to weakened pelvic muscles, and yet another injustice of middle-age — there’s one pretty clear path to lower risk: Find a surgeon who performs many, many of these operations.

In a new analysis, Canadian researchers reviewed 10 years of data from nearly 60,000 patients who had vaginal mesh surgically implanted to treat stress urinary incontinence. The study concludes: “Ten years after SUI mesh surgery, 1 of every 30 women may require a second procedure for mesh removal or revision. Patients of lower-volume surgeons have a 37% increased likelihood of having a complication.”

The findings, published in the journal JAMA Surgery, “support the regulatory statements that suggest that patients should be counseled regarding serious complications that can occur with mesh-based procedures for SUI and that surgeons should achieve expertise in their chosen procedure,” the researchers write.

In case you’ve missed it, vaginal mesh implants have been in the news lately — and the news isn’t good. In May, a Delaware jury awarded $100 million to a woman who sued Boston Scientific, one of the manufacturers of vaginal mesh devices, for negligence, breach of warranty and fraud. Many more cases are pending and regulators continue to scrutinize the devices.

Patients and advocacy groups have also raised major concerns about the safety of vaginal mesh, the study authors note, citing complications ranging from chronic pain (and specifically, pain during sex) and fistula to erosion of the mesh into the vagina, which can require multiple followup surgeries and, needless to say, emotional and physical distress. More than 50,000 women have joined class action lawsuits related to vaginal mesh complications after SUI and prolapse procedures, the study says.

In an editorial accompanying the new analysis, Quoc-Dien Trinh, MD, a urologic surgeon at Boston’s Brigham and Women’s Hospital and assistant professor of surgery at Harvard Medical School, writes: “Although the lay press has focused on the judicial aspect and the potential financial fallout for manufacturers, little attention has been paid to understanding the factors associated with adverse events after vaginal mesh-based procedures. ”

In an interview, Trinh, who also studies health outcomes and patient safety, said the relationship between surgical volume and outcome is well established; that is, the more you do. the better you are. But while patients tend to shop around for high-volume surgeons when considering very complex procedures, like for cancer or heart surgery, that scrutiny doesn’t always carry over for simpler surgeries. “It’s something that people often don’t think about,” Trinh said, “but the same relationship [high volume equals better outcomes] applies to the less complex, same day procedures. Though the complications from vaginal mesh surgery may not be life threatening, erosions and fistulas, these things can make your recovery and quality of life miserable.”

Of course, Trinh said, it’s sometimes unrealistic for people to demand the very best, most experienced surgeon for every procedure. Continue reading

New Electronic Cigarette Regulations Set To Go Into Effect In Mass.

Beginning Sept. 25, those under the age of 18 will no longer be allowed to purchase electronic cigarettes, like the one pictured here, in Massachusetts. (Nam Y. Huh/AP/File)

Beginning Sept. 25, those under the age of 18 will no longer be allowed to purchase electronic cigarettes, like the one pictured here, in Massachusetts. (Nam Y. Huh/AP/File)

Those under the age of 18 will no longer be allowed to purchase electronic cigarettes in Massachusetts under new regulations filed by Attorney General Maura Healey.

The regulations also ban promotional giveaways or other free distribution of e-cigarette products and require that any nicotine liquid or gel be sold in child-resistant packaging. Retailers must also move any e-cigarette products to locations only accessible to employees and all sales must be made through face-to-face exchanges — much like regular cigarettes.

“We want to do everything we can to prevent and to keep young people from starting to smoke cigarettes,” Healey told WBUR. “And it only makes sense that in the same way we ban the sale of cigarettes to minors, we should ban the sale of e-cigarettes to minors.”

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Bugs And Kids: Indoor Insecticide Use Linked To Childhood Cancers, Study Finds

(Tom Simpson/Flickr)

(Tom Simpson/Flickr)

I just threw out my spray can of Raid for flying insects. With kids in the house, I never did like the idea of spewing toxic stuff around, and only ever used it when a bug was driving me to feral insanity. Now, after reading the paper just out in this week’s issue of the journal Pediatrics, I’ll stick with the flypaper and swatter no matter how intense my irritation.

The paper concludes that the sum of previous research suggests a significant link between indoor pesticide use and childhood cancer.

To be more exact, senior author Chensheng Lu says the results “suggest that when kids are exposed to pesticides — especially a group of pesticides we call insecticides — in the indoor residential environment, kids have 43 to 47 percent more chance of having childhood cancers, specifically leukemia and lymphoma.”

Dr. Lu is an associate professor of environmental exposure biology at the Harvard T.H. Chan School of Public Health. He acknowledges the study’s limitations, in particular that it could find only 16 relevant previous papers to analyze. But, he says, it showed “consistent results in terms of the positive correlation between exposure to insecticide indoors and childhood cancer.”

The study does not aim to “cause fear in parents,” Lu says. “But it’s to give you a precautionary principle that those exposures can be prevented, can be mitigated or can be completely removed.”

Of course, these findings only heighten the dilemma for households or schools that are tormented by pests, with infestations too fierce to be dented by anything but the big toxic guns. Are we supposed to just let the roaches and mosquitoes run wild?

Dr. Lu points out that preventive measures like window screens and hole-plugging can help, and among pesticides, some applications are safer than others — for example, “bait houses” that try to attract the pest inside a box-like structure to be poisoned.

“The worst-case scenario in terms of indoor pesticide use and human exposure it to use some kind of fogger,” he says. “Also, some kind of open-air application, a broadcast application, a spray can. Those are bound to significant exposures.” Continue reading

Story Of A Sexual Syndrome: New Clues, Possible Fix For Some With Relentless Arousal

Jeannie Allen first spoke about her condition a dozen years ago, and now her online support forum on Persistent Genital Arousal Disorder has hundreds of members. (Courtesy)

Jeannie Allen first spoke publicly about her condition a dozen years ago, and now her online support forum on Persistent Genital Arousal Disorder has hundreds of members. (Courtesy)

When last I spoke with Jeannie Allen a dozen years ago, her relentless pelvic torment had just been newly labeled as a rare but bona-fide condition affecting mainly older women: Persistent Sexual Arousal Syndrome.

Please, no quips about middle-aged women feeling like typical teenage boys. It’s no joke. More of a nightmare: genital congestion and pulsation, unwanted and wholly apart from sexual interest, that never subsides, no matter how many orgasms. It’s not nymphomania or sex addiction because it’s not about desire. It’s better compared to priapism in men: unwanted, often painful, prolonged erections.

One snickering doctor told Allen she was every man’s dream. “I wanted to punch him,” she recalled in 2003. “I’m suffering here, and he’s laughing, ‘Hardy-har-har.’ So I looked him in the face and said, ‘How would you like to walk around on the verge of orgasm every second?’ And he shut up.”

When she went public back then – “Sexual Syndrome That Takes Joy Out Of Life” — Allen was a lone voice, one of just a handful of women known to have the syndrome, and the only one willing to be public about it (under her pen name, Jean Lund).

She’s not so alone these days. The syndrome, no longer seeming so rare, has been featured on “20/20″ and “The Doctors.” Estimates of total prevalence range into the thousands. There are hundreds of women — and a few men — on her online support forum for what is now called PGAD — Persistent Genital Arousal Disorder.

And the existence of that network has helped spur research into the disorder. Most recently, a paper in a leading gynecology journal this week reports that in some cases, spinal cysts may cause the syndrome, and so spinal surgery may help.

“It’s not imaginary.”

– Dr. Barry Komisaruk

There’s likely no simple solution for the disorder, Allen said this week. “It’s not the same for everyone, and I really do not believe it’s one thing that’s causing it,” she said. “I think it’s a cocktail of things and different for every person.”

But research is beginning to cast light on possible biological causes — and possible treatments. It’s also offering new backing for patients who reject the “It’s all in your head” diagnosis.

The moral here may be, “Doctors should believe what their patients tell them. First of all, and before assuming that it’s a psychological problem, make sure that any physical problem is ruled out,” said Dr. Barry Komisaruk, distinguished professor of psychology at Rutgers.

He has scanned the brains of patients with the syndrome and found activation patterns that mean “it’s not imaginary.”

Almost every woman with the syndrome he’s met has been prescribed antidepressants, Komisaruk added.

“Well, if you had a thorn in your toe for 10 years causing you continuous pain, you’d be depressed and frustrated, and an antidepressant would not exactly be the treatment of choice,” he said.

This week’s research also suggests that doctors should consider checking for cysts that could be causing the disorder in some patients, Dr. Frank Feigenbaum, the paper’s lead author, said.

“The take-home is that a gynecologic practitioner should think about getting an MRI in the lumbar spine in the patient who presents with Persistent Genital Arousal Disorder,” Feigenbaum said, “particularly in the setting of other symptoms of compression of the sacral nerve roots.”

Brain Scans and Obscure Cysts

Sacral nerve roots? Yes, the research suggests that the disorder can arise from problems with the sensory nerves that run from the genitals up to the brain. The sacrum, a bone at the base of the spine just above the tailbone, could be key here. Continue reading


Health Connector Sees Rate Hikes For Some, Reductions For Others

Health insurance premiums for Massachusetts residents who purchase unsubsidized health insurance through the Health Connector Authority will see average increases next year of between 2.2 percent and 9.3 percent, according to rates approved by a state board Thursday.

Those who enroll in the state-subsidized private health insurance, known as Connector Care, and those enrolled in dental plans through the Connector can expect to see average premium decreases of 2.1 percent and 1.4 percent, respectively.

The Commonwealth Health Insurance Connector Authority Board on Thursday voted to give its final seal of approval to 15 health insurance companies offering a total of 83 plans for small group and non-group coverage.

Among the plans approved Thursday were the “bronze plans” offered through the Connector, which have low monthly premiums and some pre-deductible doctor visits but come with higher co-pays.

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Is It Possible To Prevent Suicide? 2 Psychiatrists Map Out The Ways

By Gene Beresin and Steve Schlozman

Suicide is awful, more common than you’d think and, in many cases, highly preventable.

Perhaps most important, in virtually every culture and every ethnic group on the planet, suicide is highly stigmatized. It therefore makes sense for the international health community to designate a day when we stop to actively contemplate this potent cause of misery and death. That’s today: World Suicide Prevention Day, though the harsh facts surrounding suicide are so much bigger than a single day.

The statistics, from the International Association for Suicide Prevention, are staggering:

*There are an estimated 800,000 deaths every year throughout the world that are directly attributable to suicide.

*This number is probably under-reported, given the stigma associated with suicide, and the fact that deliberate, self-harming behavior is often misclassified as an accident. The teen that drives into a street lamp at 100 mph could very well be attempting suicide, and not be the victim of an automobile mishap.

*Suicide is the 15th leading cause of death on the planet.

*Suicide is more common among older people (70 years of age and up), but also occurs in middle-aged and younger individuals at alarming rates.

*Lower income nations endure more suicides, but suicide remains a major cause of death in developed nations as well.

*Suicide has been tied to numerous psychiatric illnesses (mostly mood disorders), to difficult economic or traumatic situations and environments, to substance use disorders (both with and without addiction), to the loss of loved ones, and to a lack of good follow-up care following suicide attempts.

*The number one predictor of death by suicide is a previous attempt.

2013 U.S. suicide rate by age group, via CDC

Why So Common?

In other words, we know a lot about suicide. So if we know so much, why does suicide remain so stubbornly common?

The answer to this question is actually much less concrete than we might think. Studies on post-suicide-attempt intervention are lacking and under-represented. Studies on pre-suicide-attempt intervention are also insufficient in generating a simple and generalizable prevention methodology. Moreover, the likelihood of creating a one-size-fits-all approach is minimal. This might be why we know less than we’d like to.

There are studies that show that email, phone and in-person communication following an attempt can make a positive difference, but these studies have relatively low numbers of participants and clearly need follow-up. We also have studies that show we can increase the understanding of suicide and its risk factors in high schools and colleges, but it isn’t clear whether this understanding leads to decreased suicide rates. We do know that treatment as usual — that is, telling someone to go to an appointment with a yet-to-be-met clinician following his or her discharge from an emergency room or hospital — falls short of other more personal interventions.

All of this points to a common flaw in the understanding of suicide.

Suicide isn’t a formal disease. We don’t treat suicide itself. We treat the causes of suicide.

Continue reading


No Blame, No Shame: Treating Heroin Addiction As A Chronic Condition

Ever heard of a diabetic patient who ate a large muffin before having a blood glucose test, was scolded for giving in to temptation, and then told to just say no to carbs?

How about a cardiac patient who has a worrisome stress test and is shown the door when she admits to eating a few Big Macs?

That kind of response is all too familiar for patients whose brains have been altered by heroin or other opiates.

“We blame patients for their disease,” says Dr. Sarah Wakeman. “We also kick people out of treatment for having symptoms of their disease with addiction, which would honestly be malpractice if we did that with other conditions.”

Wakeman runs the Substance Use Disorders Initiative at Massachusetts General Hospital, where treating addiction as a chronic condition, like diabetes or asthma or high blood pressure, is the norm.

Patients are screened using questions that determine if they are at risk for addiction. There’s an assessment. Then Wakeman and her patients work on lifestyle changes, decide what medication will help break the addiction, and meet frequently to monitor progress. Continue reading


Stressed-Out Undergrads And The College Mental Health Crisis

In case you missed it this morning taking your possibly stressed-out kids to school, check out On Point’s excellent segment about the mental health crisis among college students.

The bottom line: undergrads are struggling, many of them suffering from mild, moderate and severe mental illness. And colleges are scrambling to figure out ways to cope, from setting up automated counseling kiosks to launching campaigns promoting the message that it’s all right to ask for help.

A special report, “An Epidemic of Anguish,” published in The Chronicle of Education is featured on the show:

“Colleges are trying to meet the demand by hiring more counselors, creating group-therapy sessions to treat more students at once, and arranging for mental-health coordinators who help students manage their own care. A couple of colleges have even installed mental-health kiosks,which look like ATMs and allow students to get a quick screening for depression, bipolar disorder, anxiety, and post-traumatic stress.

Meanwhile, the Boston Globe reports that MIT, a well-known hotbed of stress, is enhancing its mental health services for students:

Starting this academic year, the Cambridge school will provide more mental health counselors, create a drop-in center for students to talk with professionals, and make it easier for students to seek professional services off campus.

The changes come after campus officials reviewed the results of a survey administered to students in April and May, which found that 24 percent of undergraduate respondents have been diagnosed with one or more mental health disorders by a health professional.

Alli Stancil/Flickr

Alli Stancil/Flickr

The reality that many college students suffer from mental illness isn’t exactly new. Earlier this year, for instance, researchers at UCLA surveyed 150,000 college freshman and found an increase in the number of students who report they were “frequently depressed.”

I asked child psychiatrist Dr. Steve Schlozman, associate director of The MGH Clay Center for Young Healthy Minds and an assistant professor of psychiatry at Harvard Medical School, about the UCLA report back in February and whether depression among college-age kids is getting worse, and he said: “We are reaping what we sow.” He added:

The pressure we put on high school kids to get into college and the pressure then that college follows up with is highly correlated with increased rates of emotional distress that can become full-blown depression. Also, the age of onset of depression is the exactly the age of onset of college — there’s a perfect storm of stressors. Finally, there’s a greater willingness to come forward, which is good. So, despite the fact that we’re using the word ‘depression’ a little more glibly, I’d rather have that and then rule out clinical depression through appropriate channels, like college health services, than miss cases that can lead to real suffering and possibly even death.

Now, Schlozman says, it makes sense for colleges to boost their efforts to make mental health services more accessible. In an email, he writes:

It makes sound ethical, medical and common sense for colleges and universities to increase their surveillance for mental health challenges as the school year begins, and to provide easy and unfettered access for ongoing care. Ideally, a comprehensive plan that has multiple and coordinated entry points and multiple and coordinated means by which care is delivered is the best way to provide the essential help that the last two decades have shown us is sorely needed on college campuses.

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