Children in California increasingly are flocking to emergency rooms for treatment of asthma, despite millions of dollars spent on programs to control the disease.

Statewide, the rates of ER visits for asthma symptoms rose by about 18 percent for California children ages 5 to 17 and by 6 percent for children under 5 between 2005 and 2012, according to a Kaiser Health News analysis of the latest available rates by county.

In some parts of the state, especially the Central Valley, the increases were far higher. The rate of emergency room visits for children 5 and older more than doubled in rural Madera County and nearly doubled In Merced. In Sacramento County, they rose by 48 percent and in Los Angeles, the largest county in the nation, by 17 percent.

All told, more than 72,000 California children under 18 visited the ER for asthma in 2012.

“There’s clearly more work to be done if this many kids are going to the emergency department,” said Anne Kelsey Lamb, director of the Regional Asthma Management and Prevention program of the Oakland-based Public Health Institute. “We know a lot about what works. We absolutely should be able to reduce the rates we’re seeing.”

At the national level, asthma-related emergency room visit rates have declined in recent years, according to federal health data through 2010, the latest available.

Although ER visits declined in some counties, including Alameda, San Mateo and Marin, the overall rise in California has frustrated public health experts who have spent millions of dollars and countless hours to improve and expand asthma prevention programs around the state. The state and federal governments alone spend $1.54 million annually on such projects in California, including grants to schools to improve indoor air quality and  training community health workers.

The good news is fewer kids are actually being admitted into hospitals.  Overnight-or-longer stays are declining statewide and nationally. That’s due largely to better medicines and more aggressive treatment in the ER, asthma specialists say.

The reasons for the increase in ER visits are complex, experts say. They include parents not properly administering medications, poverty and inadequate insurance coverage, persistently high levels of indoor and outdoor pollution in some regions and the limited reach of programs that seek to manage symptoms or prevent them.

The rising rates don’t seem to reflect an actual increase in the respiratory disease – about 15 percent of California children have been diagnosed with asthma, a number that has remained fairly steady since 2001.

The rates of ER visits vary widely by county, from a high of 300 visits per 10,000 children under age 5 (Madera County) to a low of 32 (Sutter County) in 2012. Younger children visit the ER at higher rates because they are more likely to have undiagnosed asthma and because their lung function is more difficult to measure, complicating the task of finding the right combination of medicines, Kelsey Lamb said.

Some families  seek treatment in the ER for symptoms that easily could be dealt with in a clinic because they can’t get a timely doctor’s appointment or don’t have a regular doctor – especially those without health insurance. Sometimes, a bad cold and flu season can  aggravate asthma that is usually well-controlled.

Affected children often live in homes with dust, mold or pets, which trigger asthma symptoms. They may need two inhalers – one for school and one for home – but insurance sometimes only pays for one.

In the Central Valley, persistent poverty and outdoor air pollution levels combine to produce the highest rates of ER visits for childhood asthma in the state.

While particulate matter and ozone air pollution levels are declining somewhat in the region, they still can be high enough to trigger asthma attacks, said John Capitman, a California State University-Fresno public health professor and executive director of the Central Valley Health Policy Institute. In Los Angeles, the same holds true, although particulates are slightly lower than in parts of in the Central Valley.

Across California, local and regional asthma programs aim to educate families and doctors to help keep kids out of the hospital. In counties including Orange and Los Angeles, medically equipped vans called “Breathmobiles” provide comprehensive care in community settings and ensure children don’t end up repeatedly in the ER.

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It worked for Daniel Lee, 5, of Buena Park, who was still experiencing severe asthma symptoms after five trips to the ER last year. It turned out the doctors at the hospital had mixed his medications incorrectly — a common mistake when kids are treated in emergency rooms rather than by asthma-trained pediatricians, said Dr. Olga Guijon, associate medical director of the Breathmobile for Children’s Hospital of Orange County.

“All he wants to do is play soccer,” said his mother Young Lee, during a recent visit to the Breathmobile in Anaheim. “But every time he’s running around on the field, he says: ‘I feel weird’. So he has to stop.”

Daniel has improved drastically after being treated at the Breathmobile and having his medication adjusted, his mother said.

Though often effective, these programs are expensive and can’t serve enough children to make a real difference statewide, Capitman said.  And health outreach workers have found it difficult to get reimbursed by insurers, including Medi-Cal, for proven strategies including home visits to minimize risks, Capitman said.

Dr. Amy Harrison, a pediatric pulmonologist at Children’s Hospital Orange County, suggested that the recession had driven some families to her hospital’s ER, because they had lost their insurance or had high-deductible insurance that led them to forgo prescriptions and regular doctor visits.

Because the data don’t extend beyond 2012, it remains unclear how expanded coverage offered since last year under the Affordable Care Act and California’s Medicaid program  will affect emergency room visits. But experts like Capitman hope to see more funding for programs that manage or prevent asthma symptoms through the Affordable Care Act’s Prevention and Public Health Fund.

Asthma care for kids has improved markedly in recent years, in part because of the wider use of steroid inhalers. Influential asthma management guidelines released in 2007 also have helped.

But some families simply don’t know how to manage their child’s condition at home, or know when to seek medical care before an ER visit becomes necessary, said Dr. Rami Keisari, medical director of the Pediatric Asthma Disease Management Program at the county-run Santa Clara Valley Medical Center in San Jose.

“One of the biggest challenges we have is getting parents to use the medications every day,” Keisari said. “We have a really hard time convincing parents that this is a chronic condition.”

Some of the few large counties with declining ER visits have invested heavily in targeting kids who are at risk. Alameda County children who have been treated in ERs are referred to the county’s free Asthma Start program, which offers free home visits during which health workers identify asthma triggers, offer education and provide equipment such as spacers and nebulizers – even vacuum cleaners, said program director Brenda Yamashita of the Alameda County Department of Public Health.

Parents learn to freeze stuffed animals to kill asthma-triggering dust mites, track their children’s symptoms on a calendar, and clean surfaces without bleach, which can aggravate symptoms. Alameda Alliance for Health, the county’s public, nonprofit health insurance plan, reimburses Yamashita’s program for home visits.

For parents in substandard rental housing, staffers call on the county’s Healthy Homes department to press landlords to get rid of vermin, fix leaks and address other code violations.

In Santa Clara County, Keisari’s staff keeps tabs on kids for as long as three years. Every month, a public health nurse calls parents and ask about their children’s symptoms and medications.

The county’s overall child ER visit rates are low compared to other counties. Even so, the number of children the program serves is limited compared to the need. And while the county’s asthma ER visit rates declined by 21 percent for children under 5, they rose 12 percent for children aged 5 to 17.

“We’re doing better with all these programs, but is it adequate? No. Every time a kid winds up in the ER with bad exacerbation of asthma, it’s a failure,” said Stanford University child health policy researcher Dr. Paul Wise.

Heidi de Marco contributed reporting.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Douglas White knew high-deductible insurance is supposed to make patients feel the pain of medical prices and turn them into smart shoppers. So he shopped.

He called around for price quotes on the CT scan his doctor ordered. After all, his plan’s $2,000 deductible meant paying the full cost out of pocket. Using information from his insurer, he found a good deal —$473.53 at Coolidge Corner Imaging in Boston, a half hour from his house.

But the bill he got later was for $1,273.02 — more than twice as much — from a hospital he had no idea was connected to the imaging center.

“I was shocked,” said White, a doctor of physical therapy who thought he knew his way around the medical system. “If I get tripped up, the average consumer doesn’t have the slightest chance of effectively managing their health expenses.”

A national study by Consumers Union basically comes to the same conclusion, suggesting that there are millions of Douglas Whites lost in the medical billing maze.

Nearly one American in three with private health insurance surveyed by the research group got a surprise medical bill in the past two years — defined as when a plan paid less than expected and doctors and hospitals tried to recover the balance from the patient.

Of those with surprise bills, nearly a fourth got bills from doctors they had no idea were involved in their care and nearly two-thirds were charged more than they expected.

“When we talk about transparent health care and the need for consumers to shop around, it’s just not possible in many situations,” said Blake Hutson, a senior associate for Consumers Union, the policy arm of Consumer Reports. “Even if you work for a big company and have what you think is a good health insurance plan, you can get a surprise medical bill.”

The deductible is what patients pay before insurance kicks in. The higher the deductible, the more you pay out-of-pocket. Deductibles of $3,000 or $5,000 are not unusual these days, although the health law caps out of pocket costs at $6,600 for individuals and $13,200 for families.

Making plan members pay more in this way is supposed to prompt them to check prices and put competitive pressure on medical providers.

The problem is that you can’t buy medical services the way you buy a phone plan. Doctors, hospitals and other providers generally don’t advertise their prices and often keep them confidential, even when asked by patients about what to expect. Providers charge different amounts for the same service depending on the insurance.

One episode of treatment can generate bills from multiple caregivers, especially in the hospital.

A new study by the Employee Benefit Research Institute shows that members of high-deductible plans have higher incomes and are more educated on average than the typical American. But a post-grad degree from MIT might not be enough to figure out some bills.

The system is so complicated that one patient in three who got a surprise bill in the Consumers Union study didn’t investigate or fight it.

“I didn’t think it would make a difference,” or “I was confused about what to do” were common reasons for inaction.

That’s the wrong response, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation who studies how the health system affects consumers. (Kaiser Health News is an editorially independent project of the foundation.)

“It’s always advisable to ask questions if you receive a surprise bill or if insurance pays less than you expect,” she said. “Mistakes happen and following up can save you money. If it gets too confusing or frustrating, ask for help.”

Consumers Union offers an online tool for finding the relevant agency in your state and its contact information.

White’s billing problems were cleared up — many months and phone calls later and after a reporter started inquiring.

His plan, Harvard Pilgrim Health Care, said it had given him an incorrect quote for the CT scan last fall. The plan eventually paid the imaging center the full $1,273, saying it wasn’t White’s fault that the plan’s quote was wrong.

The bill had come from Brigham and Women’s Hospital, which owned the radiology center, even though White said there was no indication of that when he went to get the scan.

Harvard Pilgrim said it didn’t know Brigham and Women’s was affiliated with the center, either. Hospital-owned facilities are often far more expensive than independently owned doctors’ offices.

So how does he like the transparency revolution in health care, boosting competition and empowering patients?

“There is nothing transparent about most health care billing,” said White.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

New Affordable Care Act payment model seeks to reduce cardiovascular disease

You can’t tell by looking which med students at Mount Sinai were traditional pre-meds in college and which weren’t. And that’s exactly the point.

Most of the class majored in biology or chemistry or some other “hard” science; crammed for the MCAT (the Medical College Admissions Test) and did well at both.

But a growing percentage came through Mount Sinai’s “Hu-Med” program, which stands for Humanities in Medicine. They majored in things like English, history or medieval studies. And they didn’t even take the MCAT because Mount Sinai guaranteed them admission after their sophomore year of college.

Adding students who are educated in more than science to the mix is a serious philosophy at Mount Sinai.

David Muller is Mount Sinai’s Dean for Medical Education.  One full wall of his cluttered office is a massive whiteboard almost totally full with to-do tasks and memorable quotes. One reads: “Science is the foundation of an excellent medical education, but a well-rounded humanist is best suited to make the most of that education.”

The Hu-Med program dates back to 1987, when then-Dean Nathan Kase wanted to do something about what had become known as “pre-med syndrome.” That’s the idea that the drive for straight As and high test scores was actually producing sub-par doctors. Students were too single-minded.

Kase “really had a firm belief that you couldn’t be a good doctor and a well-rounded doctor and relate to patients and communicate with them unless you really had a good grounding in the liberal arts,” says Muller.   

So the medical school began accepting humanities majors from a handful of top-flight liberal arts schools after their second year of college. They continue to follow their non-scientific interests for the remainder of their college careers.

Mount Sinai takes care of teaching them the science they need during the summers. It’s often not the science studied in pre-med programs.

The current required pre-med sciences – including basic chemistry, physics, and calculus – date from the early 1900s, when an educator named Abraham Flexner revolutionized medical school by turning it into a truly scientific endeavor.

But those core science courses haven’t changed much since Flexner, Muller says, while science has.

“The science for 1910 is only nominally relevant today; yet that’s the filter through which everyone has to come,” he said.

And it often weeds out people who could make excellent practitioners. Too frequently, he says, “if you can’t get an A minus in organic chemistry, you’re not going to be a doctor.”

Such artificial barriers “exclude people from medical school that we desperately need,” he says.

Studies have shown that the Humanities in Medicine students are just as successful in med school as any other student. And they are slightly more likely to choose primary care or psychiatry as a specialty – both areas where more physicians are needed.

At a recent end-of-year party thrown by the students for professors and administrators, even the teachers had trouble remembering who was a “Hu-Med” and who wasn’t.

Take Virginia Flatow, for instance. She’s a second-year student from New York. She majored in psychology at Bates College in Maine. Because she was also on the debate team, which meant lots of travelling to tournaments, she says she never would have been able to follow the classical pre-med track.

“There are very few courses – maybe I can think of one off the top of my head – where doing a lot of science in college helps you,” she says. “The rest of it is just a matter of how well do you study.”

Flatow agrees with a growing number of medical educators, for example, that organic chemistry is irrelevant for medical school. And that its difficulty discourages many students.

“I know so many people who took one semester of organic chemistry [and] dropped pre-med,” she said. “My brother was one of them.”

John Rhee, another second-year Hu-Med student, majored in public policy at Cornell. He was thinking about going into hotel management, but he decided to become a doctor after taking a summer job at a hospice.

“The experience was so deep for me,” he said, “partnering with a patient through end-of-life care.”

Keith Love, a first-year Hu-Med from Colby College in Maine, said he originally gave himself a “zero percent chance” of going to medical school. He studied environmental science and anthropology in college, and still escapes Manhattan some early mornings to go birding. But, eventually, as he thought about how he wanted to make a difference with his career, he realized, “it was medicine.”

These non-traditional students also serve yet another role – they round out what could otherwise be a class full of science wonks.

“I think the cross fertilization of ideas that goes on between people of an exclusive science background – ultimately everyone benefits from it,” said Harsh Chawla, a third year student from Danville, California. He did the traditional pre-med program – majoring in biology at University of Southern California.

The effort has worked so well, in fact, that Mt. Sinai is expanding it, opening it to students in any major from any college or university. Eventually half the class will be admitted from a slightly reconfigured program, which goes by the new name “Flex-med.”

Back in his office, Muller shows visitors his commanding view of the East River and East Harlem, “which is sort of the core community we serve as a medical school.”

And while he describes his own pre-med training as “cookie cutter,” Muller has done his own share of thinking out of the box. Among other things, he is nationally recognized for helping create the largest academic home-visiting program for patients in the nation.

But what would he have pursued in college had he not headed straight onto the science track?

He thinks for a moment. “Literature, English lit,” he says in a wistful kind of way. “I read voraciously as a kid and that almost came to a complete standstill in college because there was just no time to breathe.”

And can pursuing different interests really make a better doctor? Of that Muller is confident.

“People who look at the same problems through different lenses will make us better in the long run,” he says. “Now can I prove that’s going to be the case?  No, but I’d like to believe that it is.”

This story is part of a reporting partnership between NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

With her children grown and husband nearing retirement, Amy Reynolds was ready to leave behind snowy Flagstaff, Ariz., to travel but she wasn’t ready to give up her nursing career.

She didn’t have to.

For the past three years, Reynolds, 55, has been a travel nurse — working for about three months at a time at hospitals in California, Washington, Texas and Idaho, among other states. Her husband accompanies her on the assignments. “It’s been wonderful,” she said in May after starting a stint in Sacramento. “It’s given us a chance to try out other parts of the country.”

Reynolds is one of thousands of registered nurses who travel the country helping hospitals and other health care facilities in need of experienced, temporary staff.

With an invigorated national economy and millions of people gaining health coverage under the Affordable Care Act, demand for nurses such as Reynolds is at a 20-year high, say industry analysts. That’s meant Reynolds has her pick of hospitals and cities when it’s time for her next assignment. And it’s driven up stock prices of the largest publicly traded travel-nurses companies, including San Diego-based AMN Healthcare Services and Cross Country Healthcare of Boca Raton, Fla.

“We’ve seen a broad uptick in health care employment, which the staffing agencies are riding,” said Randle Reece, an analyst with investment firm Avondale Partners.  He estimates the demand for nurses and other health care personnel is at its highest level since the mid-1990s.

Demand for travel nursing is expected to increase by 10 percent this year “due to declining unemployment which raises demand by increasing commercial admissions to hospitals,” according to Staffing Industry Analysts, a research firm. That trend is expected to accelerate, the report said, because of higher hospital admissions propelled by the health law.

Improved profits—particularly in states that expanded Medicaid—have also made hospitals more amenable to hiring travel nurses to help them keep up with rising admissions, analysts say.

At AMN Healthcare, the nation’s largest travel nurse company, demand for nurses is up significantly in the past year: CEO Susan Salka said orders from many hospitals have doubled or tripled in recent years. Much of the demand is for nurses with experience in intensive care, emergency departments and other specialty areas. “We can’t fill all the jobs that are out there,” she said.

Northside Hospital in Atlanta is among hospitals that have recently increased demand for travel nurses, said David Votta, manager of human resources.  “It’s a love-hate relationship,” he said. From a financial viewpoint, the travel nurses can cost significantly more per hour than regular nurses. But the travel nurses provide a vital role to help the hospital fills gaps in staffing so they can serve more patients.

Northside is using 40 travel nurses at its three hospitals, an increase of about 52 percent since last year. The system employs about 4,000 nurses overall.

Historically, the most common reason why hospitals turn to traveling nurses is seasonal demand, according to a 2011 study by accounting firm KPMG. Nearly half of hospitals surveyed said seasonal influxes in places such as Arizona or Florida, where large numbers of retirees flock every winter, led them to hire traveling nurses.

Though there have been rare reports of travel nurses involved in patient safety problems, a 2012 study by researchers at the University of Pennsylvania published in the Journal of Health Services Research found no link between travel nurses and patient mortality rates. The study examined more than 1.3 million patients and 40,000 nurses in more than 600 hospitals. “Our study showed these nurses could be lifesavers. Hiring temporary nurses can alleviate shortages that could produce higher patient mortality,” said Linda Aiken, director of the university’s Center for Health Outcomes and Policy Research. The study was funded by the National Institutes of Health and the American Staffing Association Foundation.

The staffing companies screen and interview nurses to make sure they are qualified, and some hospitals, such as Northside, also make their own checks. Nurses usually spend a couple days getting orientated to a hospital and its operations before beginning work. They have to be licensed in each state they practice, although about 20 states have reciprocity laws that expedite the process.

Cherisse Dillard, a labor and delivery room nurse, has been a traveler for nearly a decade.  In the past few years, she’s worked at hospitals in Chicago, Dallas, Houston, Pensacola and the San Francisco area.

While delivering a baby is relatively standard practice, she said she makes it a practice at each new hospital to talk to doctors and other staff to learn what their preferences are with drugs and other procedures. Dillard, 46, often can negotiate to be off on weekends and a high hourly rate. “When the economy crashed in 2008, hospitals became tight with their budget and it was tough to find jobs, but now it’s back to full swing and there are abundant jobs for travel nurses,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Tanning salons are already under siege – they got taxed by the health law, are newly regulated by the federal government and states, and have become dermatologists’ favorite bad guy. But some policymakers say that’s not enough. Pointing to rising skin cancer rates and increased marketing toward young people, these public health advocates want new national restrictions regarding who can get their indoor tan on.

“It’s time we started treating [tanning beds] just like they are cigarettes. They are carcinogen delivery systems,” said Rep. Rosa DeLauro, D-Conn., at a May 20 Capitol Hill briefing on the dangers of indoor tanning. “We do not allow our children to buy cigarettes, yet the tanning industry continues to target adolescent girls. And this is not unlike what we found with the tobacco industry.”

Experts at the briefing said young women may have vague ideas about the associated risks, but tanning beds are widely available at such low costs that their use is still widespread and contributing to the escalating prevalence of the deadliest form of skin cancer, melanoma. Melanoma rates among young white women have grown by 3 percent every year since 1992.

In response, DeLauro is pushing for a national ban on the use of tanning beds by minors younger than 18.

Melanoma is the most common form of cancer among people between 25 and 29, according to the National Cancer Institute. Just one indoor tanning session increases users’ chances of developing melanoma by 20 percent compared with that of someone who has never tanned indoors. Each additional session during the same year boosts that risk by another 2  percent, according to the Skin Cancer Foundation. And people who use tanning beds 10 or more times in their lifetime have a 34 percent increased chance of melanoma, compared with people who have never had that exposure.

The industry minimizes these findings, though, and maintains that the science behind the numbers isn’t solely focused on indoor tanning-bed outcomes. “The numbers that they have used to rationalize the [public health] decisions are not studies that isolate indoor tanning salons,” said Joe Levy, scientific adviser for the American Suntanning Association, the trade group representing tanning salons. They include categories like home-use and medical-use tanning, which both drive up the statistics, he added.

Still, in response to these and other warning signals, the Food and Drug Administration last year mandated that tanning beds have clear labels informing customers of the risks. Medical groups, including the American Academy of Dermatology, have for years targeted the use of tanning beds. And 43 states already have laws that either ban tanning-bed use to young people or require parental signatures.

Yet public health advocates say the availability of tanning beds near college campuses and marketing toward young people continue to go unchecked.

A 2014 study of 125 top colleges found that 48 percent had tanning facilities either on campus or in off-campus housing, and 14.4 percent allowed campus cash cards to be used for indoor tanning. Off-campus housing buildings often list tanning beds among amenities like cable TV and fitness centers.

And, though not included in this research, there have also been questions about supervision to ensure students who were using the tanning beds were older than age 18, according to Sherry Pagoto, associate professor of medicine at the University of Massachusetts Medical School, who spoke at the briefing.

“They’re [indoor tanning companies] finding young women in these settings and locating themselves near schools,” Pagoto said. She noted companies like Sun Tan City, with 250 salons mostly in Mid-Atlantic and Midwest states, give money to sponsor football games, expand stadiums and provide free tanning to cheerleaders. “They’re finding ways to become part of university life, one way or another.”

Lisa McGovern, executive director of the Prevent Cancer Foundation’s Congressional Families program, said her group is working on a grassroots campaign to reverse this trend by enticing colleges to not allow students to pay for tanning with college debit cards. The University of Pittsburgh and University of Illinois have already agreed.

“If we keep up that pressure, others will follow,” DeLauro said, noting that parents should know if there are free tanning facilities offered to their children in college, and if a university is allowing students to pay for tanning with those cards.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Sweeping proposals disclosed Tuesday would create profit guidelines for private Medicaid plans as well as new standards for the plans’ doctor and hospital networks and rules to coordinate Medicaid insurance more closely with other coverage.

“We are taking steps to align how these programs work,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, which proposed the rules.

Privatized Medicaid has grown rapidly as budget-pinched states have responded to commercial insurers’ promise to deliver care for a fixed price. Most beneficiaries of Medicaid — state programs for the poor run partly with federal dollars — now get care through contracted insurers.

The 653-page rule, which also would require states to establish quality ratings for Medicaid plans, constitutes the biggest regulation change to Medicaid managed care in more than a decade. The National Association of Medicaid Directors, a group of state officials, called it a “milestone.”

One proposal would require plans to assume, for rate-setting purposes, that they will spend at least 85 percent of their revenue on medical care.

Such a “medical loss ratio” target is similar to that required under the health law for other plans — but with a key difference. Unlike health plans sold through the law’s online marketplaces and elsewhere, Medicaid plans wouldn’t have to rebate the difference if they spend less than 85 percent.

But states would still “need to take that into account the next year” when they set new rates, thus limiting profits later, said Vikki Wachino, CMS deputy administrator. CMS is a division of the Department of Health and Human Services.

Jeff Myers, CEO of Medicaid Health Plans of America, an industry group, criticized the inclusion of the medical loss ratio standard, which supporters promote as ensuring plans spend a minimum amount on care instead of executive salaries and shareholder profits.

“We don’t believe a nationwide MLR is appropriate,” Myers said. A uniform profit standard across diverse states could limit plans’ ability to spend administrative dollars to fine-tune care coordination and quality, he said.

Generally, however, “we are very supportive of the direction they are going,” he said of CMS. He particularly praised the proposal to better align the Children’s Health Insurance Program, or CHIP, which aids families with children with moderate incomes, with Medicaid.

Led by giants such as UnitedHealthcare, Anthem, Aetna and Centene, private Medicaid plans generated nationwide operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.

Advocates for the poor have complained that HHS’ regulation of Medicaid managed care has lagged behind the industry’s growth. Industry profits have sometimes come at the expense of denied care and inadequate doctor networks, they say.

A study last year by HHS’ inspector general found that half the doctors listed in official plan directors weren’t taking new Medicaid patients. Among doctors who were, one fourth couldn’t see patients for a month.

In Tuesday’s rules CMS proposed new standards for network adequacy that also allow wide flexibility to states. States would have to certify at least annually that Medicaid managed-care patients have sufficient access to doctors and hospitals, based on standards for numbers of medical providers per member, maximum distances required to travel for care and other criteria.

“This latest proposed guidance ensures that health plans and states have the flexibility to structure their programs and benefits to meet the unique health needs of their enrollees,” Dan Durham, interim CEO of America’s Health Insurance Plans, an industry lobby, said in a prepared statement.

Sarah Somers, an attorney with the National Health Law Program, which has long urged updates to federal regulations, praised proposed safeguards for Medicaid members with disabilities and limited English ability.

“The regulations governing network adequacy have some positive aspects,” she added. “But we are concerned that they do not contain the specificity that we recommended.”

The proposal also would establish a quality-rating system, perhaps similar to the star scores assigned to Medicare coverage for seniors, so members could compare plan performance. However Wachino said it was too early to tell what the ratings would look like.

Margaret Murray, CEO of the Association for Community Affiliated Plans, a group of not-for-profit Medicaid companies, said she was disappointed the quality standards wouldn’t apply to traditional Medicaid run by the states as well as private Medicaid plans.

“We think that managed care will come out ahead in that comparison,” she said.

In a victory for industry, the rules also propose to loosen marketing restrictions on insurers that offer Medicaid coverage as well as plans sold through the health-law marketplaces.

Some companies are counting on capturing customers moving from Medicaid to commercial plans or vice versa as the members’ incomes fluctuate. The new regulation would make it easier for insurers to let Medicaid beneficiaries know that the same company sells a plan through the marketplace.

The rules published Tuesday are only proposals. HHS will take comments until late July and issue final rules later.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

NAPLES, Fla.— It wasn’t until the Maffuccis found themselves living on cups of coffee, and coffee alone, that they finally called a food pantry for help.

The couple had sold their suburban New Jersey home where they had raised three children and set out to pursue the glossy dream of an easy-going retirement in sunny southwest Florida. But Mina and Angelo Maffucci quickly ran out of money—overtaken by illness, bad luck and an economic crisis that claimed their Florida dream home to foreclosure. They soon found themselves staring at an empty cupboard.

“You open up the closet and all we had was coffee,” said Angelo Maffucci, 82, who had been a drywall installer in New Jersey. “I never thought we would be down on our hands and knees like that, but it happened fast.”

While the U.S. economy adds jobs and the financial markets steadily improve, a growing number of seniors are having trouble keeping food on the table. In 2013, the most recent data available, 9.6 million Americans over the age of 60 —or one of every six older men and women—could not reliably buy or access food at least part of the year, according to an analysis from researchers at the University of Kentucky and the University of Illinois.

Enid Borden, president of the National Foundation to End Senior Hunger in Alexandria, Va., which commissioned the report, said the country was doing a “worse job in trying to end senior hunger in America,” noting that the number of seniors who “face the threat of hunger has gone up every single year since we started doing the research on this.”

“And that’s not good,” she said.

Across the country, the rate of food insecurity—the academic term for a disruption in the mundane yet vital task of maintaining a basic, nutritious diet—among seniors has more than doubled since 2001, according to the National Council on Aging. And it is projected to climb even further as the Baby Boom generation gets older.

The precise conditions fueling the increase in senior hunger are unclear: the poverty rate for seniors, in fact, fell from 2001 to 2005, though it has risen every year since, according to the Employee Benefit Research Institute. And, all the while, the rate of food insecurity among older Americans has ticked upward.

But researchers who study the trend say the causes are complicated and overlap. There are the logistical challenges of getting to a grocery store when many seniors can no longer drive, either because of physical disability or because they cannot afford a car. Long rides on public transportation are difficult to endure for seniors suffering from illness, disability and dementia. And those maladies alone can rob seniors of the ability to feed themselves.

Out-of-pocket medical expenses, which increase steadily as people age, often use up large portions of monthly income for seniors, monies that otherwise might be used on groceries.

The descent into privation for seniors accustomed to middle-class life is usually swift and unforgiving, say the advocates who aid them, and it is often also triggered by failing health, the inability to work or the death of a spouse.

For Sarah Knight, 75, that moment arrived when her husband, a former jeweler from New Jersey who has Alzheimer’s disease, left his job at a Naples supermarket. As his disease robbed her husband of his faculties, the couples’ budget also suffered.

“He’s just falling apart,” Knight said of her husband.

Just one of his medications costs $125 a month, she said, and there is little left from their Social Security check for essentials like food and toilet paper. She found assistance at Jewish Family and Community Services of Southwest Florida, which gives her $100 a month for food and gas and helped her apply for food stamps. Knight was awarded $16 a month, but she says that help comes with a psychological cost.

“All my life, I’ve struggled. So, now, in my 70s, I have to struggle all, all over again?” said Knight. “You know how ashamed I get?”

That sentiment is echoed by Joanne Bartolomeo, 95, who retired from Philadelphia to Naples and continued to work at an upscale dress shop in the tony Venetian Village until just a few years ago. But after an emergency surgery, Bartolomeo could no longer work; she couldn’t keep up with her rising rent and money for food became scarce. Her life was swept into disarray.

“That’s the thing that bothers me,” said Bartolomeo. “At one time, I was in control.”

Pride is one the central reasons, experts say, that only one-third of eligible seniors are enrolled in food stamps, compared to three-quarters of the eligible general population.

“It’s a different generation,” said Thomas Felke, an assistant professor of social work at Florida Gulf Coast University. The idea of relying on government benefits “may not be something that they admit to,” he added, especially after what “they thought was going to be their life in paradise.”

And many seniors, who have perhaps never before navigated the sometimes complicated public services safety net, don’t know where to look for help or mistakenly believe they don’t qualify for food stamps or other assistance programs, including the Commodity Supplemental Food Program.

“If you’re a single senior sitting in an apartment, you don’t know what to do, you don’t know where to go,” said Al Brislain, president of Harry Chapin Food Bank in Fort Myers, Florida.

To help reach potential hungry seniors, Brislain employs social workers who scour local apartment buildings, senior centers and elsewhere to get the word out about food pantries, home-delivery services like Meals on Wheels and government programs.

When the discussions reveal deep embarrassment over a senior’s plight, Brislain says he reassures older Americans “that they deserve this help, that it’s neighbors helping neighbors, that it’s the government supporting you in your time of need.”

In Naples, the prospect of poverty and hunger hiding amid the towering beachside condominiums and acres of golf courses has been a blow to the city’s image as a ritzy retirement destination and vacation playland. Just a short drive from the upscale Fifth Avenue shopping district, with its impressive palm trees and faux-colonial architecture, are gated communities where researchers, using Census data, have detected surprisingly high rates of poverty. But following up door-to-door to find out more about the well-being and food insecurity has proved challenging.

“These gated communities don’t want people coming around asking questions about poverty,” said Felke. “It’s really hard to find out who is hungry, who is struggling.”

With the help of a Naples food pantry and a weekly ration of $34 in food stamps, the Maffuccis’ cupboards are no longer bare. But nor are they filled with nutritious food. A recent delivery included flavored Dunkin’ Donuts coffee, Uncle Ben’s rice, matzos and pasta.

Angelo Maffucci’s doctor has long urged him to lose weight, especially by eating more vegetables and fish, but it can be a challenge.

“Where you gonna get the money to buy the fish? Fish is expensive!” he said. “If you have it once a week, you’re lucky.”

So on most days, the couple eats pasta instead. “You can cook a pound of pasta for less than $2, and you get a meal,” he said. “So that and a cup of coffee, we get through the day.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Actress Rita Wilson, who was diagnosed with breast cancer and underwent a double mastectomy recently, told People magazine last month that she expects to make a full recovery “because I caught this early, have excellent doctors and because I got a second opinion.”

When confronted with the diagnosis of a serious illness or confusing treatment options, everyone agrees it can be useful to seek out another perspective. Even if the second physician agrees with the first one, knowing that can provide clarity and peace of mind.

A second set of eyes, however, may identify information that was missed or misinterpreted the first time. A study that reviewed existing published research found that 10 to 62 percent of second opinions resulted in major changes to diagnoses or recommended treatments.

Another study that examined nearly 6,800 second opinions provided by Best Doctors, a second-opinion service available as an employee benefit at some companies, found that more than 40 percent of second opinions resulted in diagnostic or treatment changes.

But here’s the rub: While it’s clear that second opinions can help individual patients make better medical decisions, there’s little hard data showing that second opinions lead to better health results overall.

“What we don’t know is the outcomes,” says Dr. Hardeep Singh, a patient safety researcher at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine in Houston, who co-authored both those studies. “What is the real diagnosis at the end? The first one or the second one? Or maybe both are wrong.”

That doesn’t mean second opinions are a bad idea. Experts estimate that diagnostic errors occur in 10 to 15 percent of cases.

“There’s no getting away from it, diagnosis is an imprecise thing,” says Dr. Mark Graber, a senior fellow at RTI International who also co-authored the studies. Graber is the founder and president of the Society to Improve Diagnosis in Medicine.

Second opinion requests were related to diagnosis questions in 34.8 percent of cases in the Best Doctors study. These included 22.5 percent of patients whose symptoms hadn’t improved, 6.3 percent who hadn’t gotten a diagnosis and 6 percent who had questions about their diagnosis.

In Wilson’s case, she wrote that after two breast biopsies she was relieved to learn that the pathology analysis didn’t find any cancer. But on the advice of a friend, she decided to get a second opinion, and that pathologist diagnosed invasive lobular carcinoma. Wilson then got a third opinion that confirmed the second pathologist’s diagnosis.

Getting a second opinion may not involve a face-to-face meeting with a new specialist, but it will certainly involve a close examination of the patient’s medical record, including clinical notes, imaging, pathology and lab test results, and any procedures that have been performed. Some people choose to have that second look done by physicians in their community, but other patients look for help elsewhere.

In addition to employer-based services like Best Doctors or Grand Rounds, medical centers such as the Cleveland Clinic and Johns Hopkins in Baltimore also offer individual patients online second opinions.

“It really does give people relatively easy access to expertise,” says Dr. C. Martin Harris, chief information officer at the Cleveland Clinic.

The medical center’s MyConsult service doesn’t accept insurance. A medical second opinion costs $565, while a consultation with a pathology review costs $745.

Face-to-face meetings with specialists who provide a second opinion and review a patient’s medical record are more likely to be covered by insurance than an online consult, but nothing is guaranteed.

“Usually it’s not the second opinion where the hiccup is,” says Erin Singleton, chief of mission delivery at the Patient Advocate Foundation, which helps people with appeals related to second opinions. “It may be that the MRI that they want to do again won’t be approved.”  Many insurers won’t pay for diagnostic or other tests to be redone, she notes.

Patients seeing an out-of-network specialist for a second opinion may encounter significantly higher out-of-pocket costs, particularly if they want to subsequently receive treatment from that provider. In those instances, the foundation can sometimes work with patients to make the case that no specialist in their network is equally experienced at treating their condition.

Of course, asking for a second opinion doesn’t necessarily mean accepting the advice. In the Best Doctors survey, 94.7 percent of patients said they were satisfied with their experience. But only 61.2 percent said they either agreed or strongly agreed that they would follow the recommendations that they received in the second opinion.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.