The Alaska Nurses Association will have limited hours durings the weeks of December 22nd and December 29th.

AaNA will be closed on December 25th, and open by appointment only on December 24th and December 26th.

AaNA will be closed on January 1st, and open by appointment only on December 31st.

If you need assistance during the holidays, please contact either Andrea Nutty at andrea@aknurse.org or Donna Phillips at donna@aknurse.org.

AaNA wishes you and your family a joyful holiday season and a Merry Christmas. Thank you to all of the nurses who will make sacrifices to put others first and work on these holidays.

Just days before the requirement for most large employers to provide health insurance takes effect, a new poll finds the public easily swayed over arguments for and against the policy.

Six in 10 respondents to the monthly tracking poll from the Kaiser Family Foundation (Kaiser Health News is an editorially independent program of the foundation) said they generally favor the requirement that firms with more than 100 workers pay a fine if they do not offer workers coverage.

But minimal follow-up information can have a major effect on their viewpoint, the poll found.

For example, when people who support the “employer mandate” were told that employers might respond to the requirement by moving workers from full-time to part time, support dropped from 60 percent to 27 percent. And when people who disapprove of the policy were told that most large employers will not be affected because they already provide insurance, support surged to 76 percent.

Opinion also remains malleable about the requirement for most people to have health insurance – the so-called “individual mandate.”

It remains among the least popular aspects of the law – with just a 35 percent approval rating. But when people are told that the mandate doesn’t affect most Americans because they already have coverage through an employer, support jumps to 62 percent. Conversely, when supporters are told that the requirement means some people might have to purchase insurance “they find too expensive or don’t want,” opposition grows from 64 percent to 79 percent.

The poll also found that a year into full implementation, most Americans, and most of those without insurance, remain unaware about many of the health law’s major features.

Nearly four in 10 people say the law allows immigrants in the country illegally to get financial help to purchase insurance (it does not), and more than 40 percent say (incorrectly) that the law creates a government panel to make decisions about end-of-life care for Medicare recipients.

At the same time, only about 3 percent were able to correctly say what the fine will be in 2015 for lacking insurance (the greater of $325 or 2 percent of household income).  Among those without insurance, only 5 percent knew that the deadline for 2015 sign-ups is Feb. 15.

The poll was conducted between Dec. 2 and 9 among a nationally representative sample of 1,505 adults age 18 and over. The margin of error is plus or minus three percentage points for the full sample.

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

Sandra Lopez and her Chihuahua, Coco, were inseparable. He followed her everywhere, and kept Lopez’s mood up when she was in pain – which was often.

On Oct. 15, Lopez, died at age 49 of pancreatic and vaginal cancer that had slowly spread throughout her body over two years. She left behind a 15-year-old daughter and little Coco. But with hospice care, she spent her last weeks where she wanted to be — at home, with her pain under control.

Sandra was in and out of the hospital in 2014, but for the months she was home, a hospice nurse from Metropolitan Jewish Health System visited once a week to help manage the pain, backed up by a 24-hour, nurse-staffed phone line that Lopez called often.

“Some days the pain is so excruciating,” she told me in August from the couch in her Brooklyn apartment, “that the pain overrides the medication.”

But despite evidence that hospices can greatly relieve discomfort, extend life and save money, and despite a generous hospice benefit available through both Medicare and Medicaid, relatively few people in New York take advantage of it, compared to elsewhere in the country.

The reasons for this local gap are complicated, but Jeanne Dennis, senior vice president of hospice and palliative care at the Visiting Nurse Service of New York, says one place to start is with patients’ fears. “If you’re referred to hospice, it means no one expects you to get better,” Dennis says. “And that is, in my mind, a threshold that’s difficult for people to step over.”

Experts also focus on what they call medical culture, which can vary dramatically from region to region. According to this theory, physicians in the metropolitan area are specialists and sub-specialists, and institutions put a premium on treatments and tests. Even more than other places, the goal is to cure patients and not just care for them. Treating and testing is just what they do — letting go isn’t, says Dennis.

“Physicians put off the conversation [about hospice]: ‘It’s a little too soon;’ ‘it’s a little too early;’ ‘I don’t have enough time today;’ ‘I’m not sure they’re ready for it,’” Dennis says.

New York has 7 out of the ten hospitals in the United States with the fewest hospice referrals. Local academic medical centers — national leaders in research — do better, but still lag behind the rest of the country in their referral rates. It’s a big contrast to some hospitals around the country — particularly several in Arizona, Utah and Florida, where more than 75 percent of dying patients take advantage of Medicare’s hospice benefit.

Further, most hospice referrals in New York are for brief stays — a week or less — 2.5 times shorter than the national average. Szoa Geng, a healthcare consultant from the firm Strategy&, says when hospitals move people to hospice with just a few days left to live, the patients don’t get the full hospice experience.

“They’re not getting the psychosocial support, and their families are not,” Geng says. “It can be a time of closure, and coming to peace with a lot of things in your life, and none of that can happen if you come onto hospice with a day left.”

Hospice care mostly takes place at home, but it can also occur in freestanding hospices, nursing homes or designated areas of hospitals. To receive the care, a doctor must predict a patient is in the last six months of life without hope of improving. There’s no penalty for outliving that prediction; some patients stabilize and go off hospice care, then return later when they start declining again.

About 25 percent of people in the New York metropolitan area use hospice care in their last six months of life, compared to close to 50 percent nationally. Statewide, the rate is closer to 30 percent. But that still makes New York 50th out of 51 states and the District of Columbia, according to the 2011 Dartmouth Health Atlas, the most recent statistics available.

Sandra Lopez said that before her oncologist told her about hospice care, she frequently called 911 to request an ambulance to take her to the hospital, where she would be admitted and spend days at a time. That happened “dozens and dozens of times,” in a year, Lopez said.

At around $210 a day, Lopez’s hospice care cost Medicaid tens of thousands of dollars — probably less than her revolving-door trips to the hospital (with their multi-night stays), but still a lot of money.

For Lopez, hospice helped her get ready to walk down the final road.

“I stopped worrying — like the worry box I used to be,” she told me in August. “I just live my life normally, like everybody else, because worrying will just probably get me more sick.”

Lopez knew that at some point her body would start shutting down, but she would never say how much time her doctors estimated she had remaining, because she didn’t dwell on that, she said. Facing death, she was at peace and knew she could stay that way — as long as someone was with her at home, at her bedside, helping subdue her pain.

This story is part of a reporting partnership between NPR, WNYC and Kaiser Health News. Special thanks to WYNC’s Data Team.

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

The National Children’s Study has been cancelled despite almost 10 years of work and $1.3 billion of funding after a National Institutes of Health working group concluded that the project had gotten too expensive to continue.

Researchers and children’s health advocates, meanwhile, fear that while funding for smaller projects will continue in 2015 with an already appropriated $165 million, NIH may use that money for research not related to children’s health.

The ambitious study, commissioned through the passage of the Children’s Health Act in 2000, set out to follow 100,000 children from birth to age 21 and track the effects of a broad range of environmental and biological factors on their health. However, concerns about the study’s design, research methodology and management, most recently detailed in a June 16 report by the National Academy of Sciences, led to questions about whether the effort should continue. An NIH working group was charged with evaluating these issues.

“Based on the working group’s findings and internal deliberation, I am accepting … findings that the NCS is not feasible,” said NIH Director Francis Collins in the Dec. 12 announcement of the program’s dismantlement. “I am disappointed that this study failed to achieve its goals. Yet I am optimistic that other approaches will provide answers to these important research questions.”

An NIH spokesperson said that the agency will use the experiences from the National Children’s Study, including best practices on data collection and recruitment, to examine the links between environmental factors and child health and development in the smaller studies to be started in 2015.

“NIH will work with Congress to address any questions that they may have about the NCS. It’s important to note that the Vanguard study [the pilot study that was the precursor to the NCS] did provide insights on best practices and strategies for conducting studies of this size and complexity,” the spokesperson said.

Dean Baker, director at the Center for Occupational and Environmental Health at the University of California Irvine, was disappointed with the decision and says there is cause for concern because NIH could use the $165 million for other research while still asserting that the agency has been doing what is required by the Children’s Health Act.

“I hope there’s something that could be used as the successor to National Children’s Study, otherwise the funding will evaporate in following years,” Baker said, who was involved in the initial study design and Vanguard Study.

NIH has 90 days to submit new research plans to Congress.

Nigel Paneth, a professor of epidemiology and pediatrics at the University of Michigan, was involved with designing the study from its inception in 2000, and although he views the cancellation as the right decision, he doesn’t agree with the way NIH dismantled the work at the original 40 sites and doesn’t think the communications via email and letters with participants is being handled correctly. Researchers put a large effort into engaging communities and getting buy-in from participants.

“They [NIH] had no concept that they were real people out there,” he said. As the research was being slowed down and the number of sites was constricting, researchers were expected to turn over individuals’ information to other researchers without consulting participants. “It was mismanaged, from the conceptual idea to actualization in the field,” he 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.

More than 1 million people selected a health plan during the fourth week of the health law’s open enrollment and nearly 2.5 million have done so since it began Nov. 15, federal officials said Tuesday.

“And this was before an extremely busy weekend,” said Andy Slavitt, principal deputy administrator of the Centers for Medicare & Medicaid Services, which oversees the federal online marketplace used by 37 states.

Tuesday’s report did not include enrollment for the final three days before the Dec. 15 deadline for people to enroll if they want coverage to begin Jan. 1.

Just over half of those individuals who have selected plans since the health law’s second open enrollment season began are returning customers. Enrollment in the states running their own exchanges is not yet available.

As expected, interest in healthcare.gov soared in the final days before the mid-December deadline, with 1.6 million people phoning the call center from Dec. 13 through Dec. 15, officials told reporters.

To avoid longer waiting times, nearly 500,000 people who called just hours before the Dec. 15 midnight PST deadline left their contact information. Website officials have begun to call them back, Slavitt said, and they will be able to enroll in coverage to begin Jan. 1.

At its peak volume Monday, healthcare.gov had more than 125,000 concurrent users but “we did not run into capacity constraints,” Slavitt said. “In other words, we are able to handle even more volume in the coming months ahead.” One website “waiting room” was used for about 90 minutes for “several thousand” individuals creating new accounts, Slavitt said. Their average wait time was about three minutes. Returning customers or those doing “window shopping” were not affected, Slavitt added.

In a call with reporters, Slavitt and Kevin Counihan, the CEO of healthcare.gov, said federal officials have begun to automatically re-enroll 2014 customers who have not selected a new plan for 2015. For consumers whose current coverage won’t be offered next year – less than 5 percent of current enrollees – an automated matching process has begun to place individuals in similar coverage, Counihan said.

Counihan said the website has been sending daily updates to insurers to let them know about people that have switched health plans, helping to avoid confusion that could lead to insurers double-billing consumers. Separately Tuesday, America’s Health Insurance Plans said they would give consumers additional time to pay premiums due Jan. 1 and would provide prompt refunds if individuals were mistakenly billed for two health plans.

Several states, including California and Minnesota, have extended enrollment deadlines for coverage to begin Jan. 1.

Earlier Tuesday the consulting firm Avalere Health estimated that 10.5 million people would enroll in the health law’s state and federal exchanges by the end of 2015. Administration officials have estimated that about 9 million people would enroll in the exchanges while the Congressional Budget Office has estimated 13 million.

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

Department of Health and Human Services collaborates with top technology platforms to reach consumers about the Health Insurance Marketplace

Wendy Salo was alarmed when she learned where her doctor had scheduled her gynecologic operation: at an outpatient surgery center. “My first thought was ‘Am I not important enough to go to a real hospital?’ ” recalled Salo, 48, a supermarket department manager who said she felt “very trepidatious” about having her ovaries removed outside a hospital.

Before the Sept. 30 procedure, Salo drove 20 miles from her home in Germantown, Md., to the Massachusetts Avenue Surgery Center in Bethesda for a tour. Her fears were allayed, she said, by the facility’s cleanliness and its empathic staff. Salo later joked that the main difference between the multi-specialty center and Shady Grove Adventist Hospital — where she underwent breast cancer surgery last year — was that the former had “better parking.”

Salo’s initial concerns mirror questions about the safety of outpatient surgery centers that have mushroomed since the highly publicized death of Joan Rivers. The 81-year-old comedian died Sept. 4 after suffering brain damage while undergoing routine throat procedures at Yorkville Endoscopy, a year-old free-standing center located in Manhattan.

Federal officials who investigated Rivers’ death, which has been classified by the medical examiner as a “therapeutic complication,” found numerous violations at the accredited clinic, including a failure to notice or take action to correct Rivers’ deteriorating vital signs for 15 minutes; a discrepancy in the medical record about the amount of anesthesia she received; an apparent failure to weigh Rivers, a critical factor in calculating an anesthesia dose; and the performance of a procedure to which Rivers had not given written consent. In addition, one of the procedures was performed by a doctor who was not credentialed by the center.

Rivers’ gastroenterologist, who was the clinic’s medical director, has left the center. The clinic, which remains open, faces termination from the Medicare program in the wake of Rivers’ death; it must correct deficiencies and pass an unannounced inspection. Yorkville officials have said they have corrected the deficiencies and are cooperating with the investigation.

“Anytime there is a major or minor accident, people begin to question the safety record,” said anesthesiologist David Shapiro, past president of the Ambulatory Surgery Center Association, a national trade group and member of the board of an organization that accredits surgery centers. Rivers’ death, Shapiro said, is an aberration. “We have an exceptional, exceptional success rate,” he said, adding that his industry is “very, very tightly regulated.” Since 2006, he noted, an industry group called the ASC Quality Collaboration has been reporting aggregate data on complications including burns, falls and surgery on the wrong site or wrong patient.

A 2013 study by University of Michigan researchers who analyzed 244,000 outpatient surgeries between 2005 and 2010 found seven risk factors associated with serious complications or death within 72 hours of surgery. Among them: overweight, obstructive lung disease and hypertension. The overall rate of complications and deaths was 0.1 percent — about 1 in 1,000 patients — and involved 232 serious complications, such as kidney failure, including 21 deaths. Comparable statistics could not be obtained for hospitalized patients because most studies involve specific procedures.

Another study found that about 1 in 1,000 surgery center patients develops a complication that is serious enough to require transfer to a hospital during or immediately after a procedure.

Lisa McGiffert, director of Consumers Union’s Safe Patient Project, has a significantly less rosy view than Shapiro. Surgery centers, she said, largely operate under a patchwork of state laws of varying strictness. Detailed information about outcomes and quality measures is lacking, she said, and the Rivers case raises questions about “the relaxed attitude that might have prevailed.”

“There’s not much known about what happens within the walls of these places by regulators or by the public,” McGiffert said. “Hospitals are more tightly regulated” than outpatient surgery centers. “They have to report on many more aspects of what they do, such as errors and certain infections.

The unusual thing about Rivers’ death, she added, is “that she was a famous person and everyone found out about it.”

Dramatic Growth

The number of ambulatory surgery centers or ASCs — which perform procedures such as colonoscopies, cataract removal, joint repairs and spinal injections on patients who don’t require an overnight stay in a hospital — has increased dramatically in the past decade, for reasons both clinical and financial. More than two-thirds of operations performed in the United States now occur in outpatient centers, some of which are owned by hospitals. The number of centers that qualify for Medicare reimbursement increased by 41 percent between 2003 and 2011, from 3,779 to 5,344, according to federal statistics. In 2006 nearly 15 million procedures were performed in surgery centers; by 2011 the number had risen to 23 million.

Advances in surgical technique and improved anesthesia drugs have allowed many procedures to migrate out of full-service hospitals to free-standing centers, which offer doctors greater autonomy and increased income. Patients say the centers are cheaper, require less waiting and offer more personalized care.

Surgery centers are “a much more convenient, safe place to get quality health care,” Shapiro said, enabling patients to avoid exposure to “the infections, chaos and delay” that he said pervade many hospitals.

Nearly all ambulatory surgery centers are owned wholly or in part by doctors who refer patients to them. These doctors earn money by performing procedures and receive a share of the fee charged by the facility.

Recently some centers, including the Massachusetts Avenue facility, which is owned by 30 doctors, a third of whom are orthopedists, have begun performing total hip and knee replacements on selected patients, sending them home the same day. Such operations typically require several days in the hospital. Center officials say that a new drug they use to control postoperative pain has made expedited discharges possible.

Baltimore internist Matthew DeCamp said that as a result of Rivers’s death, patients have asked him whether they should avoid surgery centers.

“I don’t think there’s necessarily one answer for all patients,” said DeCamp, an assistant professor of bioethics and internal medicine at Johns Hopkins. “There is no doubt that these facilities can be more convenient and valuable for patients [and offer] a pleasant experience of care.” But DeCamp said he has advised prospective patients to ask about safety equipment. “I would say you would want to have what is colloquially known as a crash cart,” a wheeled cart containing a defibrillator, medicines and other lifesaving supplies that is standard in hospitals.

How Prepared?

Located in a boxy brick building in a leafy section of Bethesda, the Massachusetts Avenue center has ample free parking and is tastefully decorated with blond wood, ergonomic chairs and sleek counters. About 4,000 procedures are performed annually at the 10-year-old facility, which employs two full-time anesthesiologists and a nurse anesthetist.

Each year, about two or three patients develop complications serious enough to require transfer to a hospital, said the center’s executive director, Randall Gross. Most are taken by ambulance to Sibley Hospital, a mile away, where the center has a transfer agreement and the 50 doctors who practice at the center have admitting privileges. The closest rescue squad is also about a mile away.

“We’ve never had a Joan Rivers incident,” Gross said. “That’s not representative of what we do.”

Louis Levitt, an orthopedic surgeon who is chairman of the facility’s board, said that all procedures involving general anesthesia are performed with an anesthesiologist present. Pre-screening is designed to weed out unhealthier patients — such as those with obesity, sleep apnea and breathing problems — who might require a hospital.

“Patient selection and preoperative evaluation are really important,” said anesthesiologist Peter Shimm, who recently joined the staff after nearly two decades at Holy Cross Hospital. And while there is no absolute age cut-off — Gross said the center’s oldest patient was 90 — Shimm said that elderly patients require special consideration even though “many octogenarians are super-healthy and a lot of 40-year-olds are train wrecks.”

But Kenneth Rothfield, chairman of anesthesiology at St. Agnes Hospital in Baltimore, said that the staffs of surgery centers may not be as prepared as they think they are.

“I don’t think it’s the venue that’s the most important thing,” said Rothfield, a member of the board of the Physician-Patient Alliance for Health & Safety, a nonprofit group. “ASCs traditionally have done simpler procedures in healthy patients,” while hospitals have routinely dealt with a broader — and sicker — mix of people. Hospitals, he said, are more likely to be fully equipped and to have staff members with greater experience handling emergencies. “Unless you have drilled for it, and trained for it, it can be hard to pull off.”

Rothfield said that when one of his children underwent surgery in an ambulatory center several years ago, he brought his own resuscitation equipment and, as a precaution, sat in a corner during the uneventful procedure, which he declined to describe.

“Just having the equipment doesn’t guarantee they know how to use it. I worried that if something happened, the staff would have been quickly overwhelmed,” he said.

Infections After Surgery

Postoperative infections in hospitals have been a source of concern for years, but little is known about the rates in surgery centers.

A 2010 report by CDC researchers examined 68 centers in three states, including 32 in Maryland, and found that two-thirds had one or more lapses in infection control. These included improper cleaning and sterilization of surgical equipment and the failure to wear gloves. The following year, the federal agency issued infection control guidelines for outpatient settings similar to those that apply to hospitals. Researchers estimate that on any given day about 1 in 25 hospitalized patients has one health-care-associated infection.

Although Maryland is among the states that does not require reporting of postoperative infections by surgery centers, Gross said that doctors who practice at the Massachusetts Avenue center are required to submit monthly reports to him. The rate, he said, is “under 1 percent.” But this number may not capture all infections: If a patient develops an infection that is treated elsewhere and does not tell the doctor who performed the procedure, it would not be part of the tally, according to Gross.

McGiffert of Consumers Union recommends that surgery center patients ask open-ended questions such as “How are you going to make sure I don’t get an infection?”

Sharon Sprague, an assistant U.S. attorney who lives in the District, said that neither she, her daughter nor her husband — who have undergone a total of five orthopedic operations at the Massachusetts Avenue center — has experienced an infection or any other complication.

“I was convinced about the merits of the surgery center from the beginning,” said Sprague, whose soccer-playing daughter had a torn knee ligament repaired there in 2007.

Sprague said she liked the fact that there was less activity than in a hospital outpatient department. “It was a really good experience,” she said. “I never felt any hesitation about safety.”

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