Dean Schillinger is a primary-care physician at San Francisco General Hospital. He first came to the city in 1990 at the peak of the AIDS epidemic. “At that point, one out of every two patients we admitted was a young man dying of AIDS,” he says.

Today, that same ward is filled with diabetes patients.

“I feel like we are with diabetes where we were in 1990 with the AIDS epidemic,” Schillinger said. “The ward is overwhelmed with diabetes — they’re getting their limbs amputated, they’re on dialysis. And these are young people. They are suffering the ravages of diabetes in the prime of their lives. We’re at the point where we need a public health response to it.”

Schillinger and other researchers at the University of California at San Francisco are setting up a project called Sugar Science, to spell out the health dangers of too much added sugar in our diets. The project aimed at consumers includes a user-friendly Web site and materials such as television commercials that public health officials can use for outreach. Health departments from San Francisco to New York City have agreed to participate.

There’s a reason the word “science” is part of the project’s name. The UCSF team distilled 8,000 studies and research papers and found strong evidence that the consumption of too much added sugar overloads vital organs and contributes not just to Type 2 diabetes but also to heart disease and liver disease.

Although there are no federal guidelines that recommend a limit on sugar consumption, the American Heart Association (AHA) urges cutting back dramatically. The average American consumes the equivalent of 19.5 teaspoons a day in added sugar. The AHA says men should reduce that to no more than nine teaspoons and women should consume less than six teaspoons. The World Health Organization (WHO) is proposing similar limits.

Laura Schmidt, a professor of health policy at UCSF’s medical school, is also part of the Sugar Science team. “Right now, the reality is that our consumption of sugar is out of whack,” she says, “and until we bring things back into balance, we need to focus on helping people understand what the consequences are.”

Schmidt is quick to point to the food environment as a driver of the increase in obesity over the past generation. “The only major change in the diet that explains the obesity epidemic is this steep rise in added sugar consumption that started in the 1980s,” she says.

That sugar isn’t just making us fat, she says, “it’s making us sick.”

The Sugar Association, however, says that some of the information presented by Sugar Science conflicts with a 2002 Institute of Medicine report and conclusions by the European Food Safety Authority in 2010. Andy Briscoe, president and chief executive of the association, notes that federal data shows that the per capita consumption of natural sugar, which comes from sugar cane or sugar beets and is called sucrose, is 34 percent lower than it was 40 years ago. He adds that sugar critics often lump together the consumption of sucrose and high-fructose corn syrup, which is used extensively in sugar-sweetened beverages, such as soda, sports drinks and energy drinks.

“Natural sugar in moderation can be part of a balanced, healthful diet and lifestyle — and has been safely used by our grandmothers and their grandmothers for decades,” he said in a statement.

John Bode, president and chief executive of the Corn Refiners Association, said in a statement, “The focus on any one particular food or ingredient is a disservice to consumers and distracts from the broader need for balanced diet and exercise.”

Although Schmidt says the Sugar Science team, which includes researchers from the University of California at Davis and Emory University, is not “anti-sugar,” she says that it looked at all the evidence, including the reports cited by the Sugar Alliance. Schmidt says more recent reports from the AHA and the WHO reflect the newest health findings. Sugar Science is funded by a grant from the Laura and John Arnold Foundation, a Houston-based philanthropic organization.

Schillinger concurs, saying Sugar Science has no political agenda and wants to generate “credible science, what we understand and don’t understand about sugar.”

It’s about knowing how much sugar is too much, researchers say.

But knowing how much sugar you’re eating can be challenging. Some key facts on the Sugar Science Web site are these:

– Added sugar is hiding in 74 percent of packaged foods, including some products that are considered healthful and may not be viewed as sweet, such as yogurt, pasta sauce and salad dressing. (Proposed changes to nutrition labels would include a separate line for added sugars.)

– Overloading on fructose, a common type of added sugar, can damage your liver — just like too much alcohol.

– One 12-ounce can of soda a day can increase your risk of dying of heart disease by one-third. That same soda can have as many as nine teaspoons of sugar. (Sugar is listed by grams on nutrition labels; four grams of sugar equals one teaspoon.)

The site also includes tips for cutting down on sugar. The easiest way to do so, the researchers say, is to stop drinking sugar-sweetened beverages.

More than one-third of added sugar in the American diet comes from sugary drinks. The Sugar Science researchers also recommend reading nutrition labels. Although there are 61 names for sugar on ingredient labels, the UCSF team says that “if the chemical name has an ‘ose’ at the end — as in dextrose, fructose, lactose — it’s likely to be added sugar.”

This article is part of a partnership that includes KQED, 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.

Many consumers who signed up for health coverage through online insurance exchanges discovered their doctors were not in their plans’ networks.

While narrow networks aren’t new, they have emerged as one of insurers’ major levers for keeping costs down under the Affordable Care Act. Consumers have been attracted by lower premiums, but are often distressed at the restrictions. Lawsuits in California allege that some insurers duped customers into thinking their networks were larger by posting inaccurate provider lists.

But such plans can be designed right, says Gary Cohen, a former Obama administration official who helped oversee the launch of the federal health website. As examples, he cites integrated systems, such as Kaiser Permanente, and also accountable care organizations which encourage coordination of patient care while providing incentives to reduce costs.

Cohen, who now runs his own consulting firm, was deputy administrator and director of the Center for Consumer Information and Insurance Oversight in the Centers for Medicare & Medicaid Services until March. He sat down recently with Kaiser Health News’ Julie Appleby. An edited version of their conversation follows:

Q: You’ve written recently that narrow network policies can be done correctly by focusing on quality as well as cost. What are the pros and cons of smaller networks?

COHEN: One [important aspect] is access. Everyone has to receive care for the services covered by their policies. We also want people to have choice — to be able to choose which doctors and hospitals they go to and have the highest quality of care. We also want to try to control costs. Those various objectives may run into conflict. So there has been a lot written, a lot of complaints about people who couldn’t go to the doctor they used to go to, or who couldn’t find a particular physician close to where they live. This has gotten a lot of attention and caused regulators to want to look at whether further regulation of networks is appropriate. [But] not all narrow networks are the same.

Q: Critics say the new marketplace plans rely mainly on insurers choosing network providers based on price. Do you share that concern?

COHEN: I do share that concern. We need to encourage types of networks like accountable care organizations where providers and hospitals and insurance companies are sharing in [financial] risk and working together in managing care to make sure higher quality [is delivered] and costs are controlled. That kind of network is fundamentally different than a network simply based on what the cost of reimbursement is from the insurance company.

The challenge to the insurance industry is greater transparency. People have got to know when they buy a plan what it is they are getting. So far it has proven very difficult for insurance companies and for some of the marketplaces that have tried to put up provider directories to provide accurate, up-to-date information on just who is in the network and who is taking new patients.

Q: What is being done in the federal and state marketplaces to make sure information on particular doctors and hospitals is available?

COHEN: Both the federal government and a number of states now are making a requirement that these directories be provided and updated on regular basis. The question is, what kind of enforcement will we see? If insurers can’t provide up-to-date information, that risks the whole concept of these narrow networks.

Q: In some states, all or most of the plans being sold on the marketplaces are narrow networks. Many don’t offer out-of-network coverage at all. Should regulators require insurers to offer both broad and narrow network plans?

COHEN: I think the market really is providing that choice. [Consultant] McKinsey & Company did a study showing that 90 percent of people have the choice of a broad network. Generally speaking, a lot of the BlueCross BlueShield plans do offer both a broad and a narrow network.

Q: How do insurers select these networks? Should they disclose that?

COHEN: If a network is designed not just to be lower cost, but is designed to be higher quality, more efficient and therefore lower cost, then it’s important people understand that. And the criteria used to select the physicians and hospitals in the network [should] be made known to the public. If I am convinced that one network I’m being offered has higher quality of care, I might choose that network even if it meant I had to travel a little further to see doctor or wait a little longer for an appointment.

Q: Are any insurers doing that yet?

COHEN: A lot of these new types of organizations are just beginning to happen now in the wake of the ACA and in wake of what Medicare is doing with its ACO program. We don’t have a lot of data yet but as time goes by, we will. We need to rethink our measures of what is an adequate network. Typically we look at the time it takes to get to a doctor’s office or to get an appointment, but with increased use of telemedicine where people will see physicians in video calls or by email, some of those measures may be less important. Not unimportant, but less important.

Q: You warn that regulators could get in the way of creating good narrow networks. How?

COHEN: We have to recognize we have a physician shortage in this country that has nothing to do with the ACA or with what networks insurers create. When you listen to regulators from very rural states, what they will say is, “We don’t have enough doctors, regardless of what the network looks like.” We need to be sensitive to local conditions. Travel time to see a doctor is different in a densely populated urban area than in a rural area. We should look at what is the quality of care being provided in this network and is it serving the population well, rather than just looking at time and distance.

Q: What about data on how many patients had to go out of network for coverage? Are any insurers reporting that?

COHEN: That data is required and will be reported. We are still in the first year of people going to see their doctors with policies they purchased through the marketplaces. We will learn a lot more as we go forward as to what their experience really has been that will help inform what steps industry should take and regulators should take to make sure people are getting access to the care they need.
Q: This time last year, open enrollment had just begun through the state and federal marketplaces. The rollout for many was disastrous, marred by a myriad of technical problems. What’s different this year?

COHEN: Ironically, one of the biggest concerns going into open enrollment [last time was] polls showing people didn’t even know what the program was about. As a result of all the publicity we got because of the problems, we certainly cured that in a hurry. Everyone in the country was aware of healthcare.gov as a result of what happened.

We have broader knowledge of the ACA and the marketplaces in general [this time]. On other hand, folks who didn’t sign up the first time around may be a little harder to reach than the ones who did. One thing that emerged from the first open enrollment [is] it does matter if people have contact with someone in their community they trust to get information, as opposed to just getting it over the internet, or from radio or TV.

Q: What’s the biggest challenge facing the Obama administration concerning the health law in the next year?

COHEN: The challenge facing all of us, including the Obama administration, is really to make the case for what has been called the triple aim: better [health care] access for more people, better customer experiences and better outcomes at lower cost.
A lot of interesting things are being done, some prompted by the ACA, some prompted just by changes in the health market. We need to look at what works and what doesn’t [and] encourage what works. That’s why this whole question of narrow networks is critical. We need to see if we can make the case that smarter networks result in better outcomes, more efficient care, less overtreatment and lower costs.

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

2014 Providence Registered Nurses (PRN) Election Biographical Information

Three years ago, the Obama administration offered hope to millions of overweight seniors when it announced Medicare would offer free weight-loss counseling.

Officials estimated that about 30 percent of seniors are obese and therefore eligible for counseling services, which studies have shown improve the odds of significant weight loss.

But less than 1 percent of Medicare’s 50 million beneficiaries have used the benefit so far. Experts blame the government’s failure to promote the program, rules that limit where and when patients can go for counseling as well as the low fees for providers.

Since November 2011, about 120,000 seniors have participated, including about 50,000 last year, according to federal data.

“It’s very disappointing,” said Dr. Scott Kahan, an obesity medicine specialist at George Washington University.

“It’s a huge lost opportunity,” said Bonnie Modugno, a registered dietician in Santa Monica, Calif., who advises doctors how to provide weight loss counseling.

By  comparison, about 250,000 seniors last year used Medicare’s tobacco cessation counseling benefit, which started in 2005 and offers greater flexibility about how providers can offer it. Nationally, 9 percent of seniors smoke, while 30 percent are obese.

Obesity and smoking are the two leading causes of preventable death in the United States. Obesity, which is defined as being 35 pounds or more overweight or having a body mass index above 30, increases the risk of many diseases, including diabetes, heart disease and cancer.

Still, physicians typically offer little more than lip service to helping patients lose weight.

“Doctors get little or no training in weight loss in medical school or residency training, and many doctors tend to view obesity as a matter of appearance and self-control, instead of health,” said Kahan, director of the Strategies to Overcome and Prevent Obesity Alliance, a coalition working to combat obesity.

In Medicare, many of the most knowledgeable providers are not even eligible to participate. For instance, Kahan, a board-certified doctor in preventive medicine, obesity medicine and clinical nutrition, is excluded. That’s because only primary care providers and nurse practitioners or physician assistants working in doctors’ offices, can be reimbursed under the regulations.

Medicare officials say they did that so weight loss counseling could be coordinated with the rest of a patient’s health care. Yet, critics say, the policy cuts out providers with deeper expertise in weight loss, most notably,  registered dieticians, diabetes nurse educators, psychologists and obesity medicine specialists. Bills have been introduced in Congress to expand the list of those eligible to participate, but they have gone nowhere.

Another challenge is the requirement that counseling be provided during a separate appointment, rather than when the patient comes in for other services.

That’s a problem for Dr. Reid Blackwelder, board chairman of the American Academy of Family Physicians, who has many obese seniors in his practice in Kingsport, Tenn. But he’s yet to offer obesity counseling because of the burden of bringing patients in for a separate visit. “That is not how family doctors work,” he said. “It’s not the best use of my time.”

Another deterrent is that Medicare pays doctors about $26 for a 15-minute counseling session. Many primary care doctors can earn three or four times that delivering other services.

“Doctors have too many other competing priorities, and Medicare beneficiaries have so many other medical problems that obesity tracks down to last on the priority list,” said Dr. Robert Kushner, clinical director of the Northwestern Comprehensive Center on Obesity in Chicago.

Originally, Medicare coverage for weight-loss counseling was promising to many obesity providers especially since few insurers, public or private, pay for it.

Under Medicare rules, beneficiaries are eligible for one, 15-minute, face-to-face counseling visit per week for one month, then every other week for an additional five months.  Patients who lose at least 6.6 pounds during the first six months are eligible for once-a-month visits for an additional six months.

The federal government has done little to publicize the benefit. A spokeswoman for the Centers for Medicare & Medicaid Services said there has been no publicity except for a mention in the Medicare handbook mailed to seniors’ homes.

While many doctors shy away from discussing obesity issues, regular counseling sessions done in a physician’s office do increase the likelihood of weight loss, according to a 2011 study in the New England Journal of Medicine.

Another study published in the journal Obesity, which was cited by the government when it launched the new benefit, found counseling along with dietary and exercise changes can produce average weight loss of 7 to 8 pounds over one to three years and the change improved blood sugar levels and mobility and reduces the incidence of diabetes.

It worked for Randall Roberts, an 86-year-old retired banker in Valparaiso, Fla., who said he lost 32 pounds after starting counseling at his physician’s office in 2012. He’s now down to 187 pounds and credits his physician’s constant encouragement to change his eating and exercise habits.

“I did not have stamina to go on long walks but he encouraged me to get back on my treadmill,” he said.

Roberts said food helped him cope after his wife passed away a few years ago. Today, he’s learned to cut out fast food, eat salads without fattening ranch dressing and look to nuts for snacks.

Dr. Thomas McKnight, Roberts’ family physician in Niceville, Fla., said he and his staff have provided weight loss counseling to about 30 Medicare patients in the past three years —those who they deem motivated to change.

He said doctors won’t get rich providing the benefit but “when you break it down, the $26 is not as bad a hit as it may seem.” He stresses to patients that weight loss is a gradual process done through small steps, such as limiting portion size and eliminating sodas.

Harry Herrlinger, 74, a retired marketing manager in Santa Rosa Beach, Fla., who calls himself “a former fat guy,” said McKnight taught him the importance of keeping a diary of everything he eats and of exercising.

He has lost 35 pounds in the past year and his diabetes is now under better control, along with his cholesterol. “I’m glad to see Medicare step up and offer this because the country is really obese and the cheeseburger generation is marching in.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

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

After several years of modest increases, American spending on medications is projected to shoot up by 12 percent this year, pushing the nation’s drug bill to between $375 billion and $385 billion, according to a report by the IMS Institute for Healthcare Informatics.

Several factors are driving the spending spike, including the introduction of expensive new hepatitis C drugs and fewer drug patent expirations than in previous years, the report found. Such expirations typically lead to savings as cheaper generics replace brand-name drugs.

The 11.7 percent rise is a dramatic departure from the more modest average increases of 3.6 percent in annual drug spending during the past five years.

The report anticipates the pace of spending increases will slow to 7 to 9 percent in 2015, as the impact of the new hepatitis C drugs declines, less expensive biosimilar products become available and several brand-name drugs — such as cancer drug Gleevac and the antipsychotic Abilify — are replaced by generics.

“We expect this bubble of innovation around hepatitis C will pass, so we won’t see such a contribution to growth in outer years,” said Murray Aitken, executive director of IMS Health. “We think the spike in growth will moderate next year, and further moderate in 2016.”

Drug costs are projected to increase between 3 percent and 5 percent in 2016, he said.
The new hepatitis C drug Sovaldi, made by Gilead Sciences and approved in December 2013, costs $1,000 a pill, with a 12-week course of treatment running about $84,000. Another hepatitis C drug — Harvoni — approved by the FDA in October, costs $1,125 a pill, or $94,500 for a 12-week course of treatment.

An estimated 3 to 4 million Americans have hepatitis C and are potentially eligible for treatment. Hepatitis drug treatments accounted for $8 billion of the approximately $40 billion in projected increased drug spending this year.

“The hepatitis C drugs are Exhibit A when you look at escalating drug costs,” said Brian Henry, a spokesman for Express Scripts, the country’s largest pharmacy benefits manager. “You never had a drug that costs that much that can treat so many people.”
The price of Sovaldi “caught payers by surprise,” he said.

Innovative new therapies, especially in the area of cancer, have also pushed up costs. The Affordable Care Act, which expanded access to health care and medications, may also have played a role, along with a new emphasis on preventive care and adherence to medications, Aitken said.

Holly Campbell, director of communications for the drug industry trade group, PhRMA, said the cost of developing drugs has skyrocketed, pointing to a report this week by the Tufts Center for the Study of Drug Development that estimated the price of bringing a drug to market at $2.6 billion. The process can take a decade, the report said.

“These most recent findings underscore the ongoing challenges our industry faces,” Campbell said.

An AARP report noted the increase in prices of brand-name drugs. The report found that the prices of 227 brand name prescription drugs used by many older Americans increased by 12.9 percent on average last year, well above the 1.5 percent rate of inflation, bringing the average cost of a brand-name drug used regularly to $3,000.

“We have started to hear from members who have to decide between taking a drug they need and paying their electric bill,” said Leigh Purvis, director of health service research at the AARP Public Policy Institute and a co-author of the report.

But, she added, the impact goes beyond seniors. “This is a concern not just for our members but for everyone.”

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

Americans older than 65 are more likely to have chronic illnesses and to say they struggle to afford health care – despite qualifying for the federal Medicare program – than are seniors in other industrialized countries, according to a study by the Commonwealth Fund published Wednesday in the journal Health Affairs.

The findings, which are based on phone surveys conducted in 11 industrialized countries, highlight gaps in Medicare coverage that should be addressed, said Donald Moulds, one of the study’s authors and executive vice president for programs at the fund.
Among the specific findings:

– 87 percent of U.S. respondents 65 or older indicated having one chronic condition and 68 percent had two or more. Canada was the next highest, with 83 percent having one disease and 56 percent having two or more.

– 19 percent of United States respondents reported cost as an obstacle in getting care last year. The next highest rate was in New Zealand, with 10 percent.

– 55 percent said it “somewhat or very easy” to get care after hours, a figure that was higher in all countries but Sweden, Canada and Australia.

– American respondents were among the most likely to have discussed with a physician healthy lifestyles and end-of-life planning.

– While each nation’s health system had strengths, the survey highlighted room for improvement across the board.The study, which comes in the midst of Medicare’s open enrollment season, may provide beneficiaries with key factors to consider as they review their coverage choices.

On average, beneficiaries with traditional Medicare will end up spending more than $4,000 per year on out-of-pocket health costs, Moulds said, a level of cost-sharing much higher than that seen in comparable nations.

“That’s a lot of money, and it’s a high percentage of a lot of people’s incomes,” he said.
Beyond costs, older Americans also have a difficult time finding high quality care, the study found, specifically citing poor coordination between caretakers such as regular physicians and specialists and difficulty locating after-hours medical care.

That’s something that could change, as the health law tries to emphasize primary and preventive care, Moulds said.

“There is certainly a hope that the Affordable Care Act will be helpful in remedying that phenomenon over time,” he said, so that future beneficiaries have lower rates of chronic disease and consequently impose smaller costs on the health system.

In the meantime, though, costs could play a role in what kind of care seniors get, said Stuart Guterman, vice president for Medicare and cost control at the Commonwealth Fund.

People do pay some attention to costs when choosing either to stay on traditional Medicare or pick a Medicare Advantage plan, though that price tag doesn’t factor “tremendously ” into their decision making, he said.

But cost issues do come into play, added Guterman, who was not involved with the Health Affairs study, when decisions have to be made “about whether to get care and when to get care and from whom.” He also said that “we know there are sizable deductibles and copays and that that’s an issue that needs to be addressed.”

In addition, some plans can have more narrow physician networks that affect extended hours, and the ability to make same-day or next-day appointments.

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