Never Too Late To Operate? Surgery Near End Of Life Is Common, Costly

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

Stanich, at age 87, had signed a “do not resuscitate” directive, ordering doctors to not revive her should her heart stop, but doctors gave her a defibrillator anyway. (Photo courtesy of Susan Giaquinto)

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly 1 in 3 Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Dr. Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital.

“We have a culture that believes in very aggressive care,” said Redberg, who at the University of California-San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.”

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.

The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people over 65 — involve more than money, said Dr. Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week, according to a 2011 study in The Lancet.

More than 12 percent of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total cost of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

Research led by Dr. Eleni Linos has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her 2013 study in JAMA Internal Medicine.

When Less Is More

Maxine Stanich celebrated her 90th birthday with friends and family in 2010 more than two years after Dr. Rita Redberg had deactivated a defibrillator and discharged her with home hospice service. Stanich, at age 87, had signed a “do not resuscitate” directive, ordering doctors to not revive her should her heart stop, but doctors gave her a defibrillator anyway. (Photo courtesy of Susan Giaquinto)

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20 percent die within 30 days, studies show.

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God … They never questioned doctors — ever.”

Dr. Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said that older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”

Even as a doctor, Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Redberg said doctors recently treated her mother for melanoma — the most serious type of skin cancer. After the cancer was removed from her leg, Redberg’s mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

“Every time she went in, the dermatologist wanted to refer her to a surgeon,” Redberg said. And “Medicare would have been happy to pay for it.”

But her mother often has problems with wounds healing, she said, and recovery would likely have taken three months. When Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within three to five years.

Redberg said her mother laughed and said, “I’m not interested in doing something that will help me in three to five years. I doubt I’ll be here.”

Dr. Rita Redberg, director of women’s cardiovascular services at the University of California-San Francisco Division of Cardiology, tends to her mother, Mae Redberg, in Mae’s apartment in Manhattan. (Yana Paskova for Kaiser Health News)

Mae Redberg rests in her apartment in Manhattan. (Photo by Yana Paskova for Kaiser Health News)

Finding Solutions

The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.

The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Dr. Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.

Many hospitals and health systems are developing “decision aids,” easy-to-understand written materials and videos to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

We have a culture that believes in very aggressive care. We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.

Dr. Rita Redberg, director of women’s cardiovascular services at the University of California-San Francisco Division of Cardiology

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.

Schwarze said, “If someone says they can’t tolerate the best-case scenario — which involves them being in a nursing home — then maybe we shouldn’t be doing this.”

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test —not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.

After Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another two years and three months, dying at home just after her 90th birthday in 2010.

KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

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AstraZeneca spins off autoimmune drugs into new biotech company

LONDON (Reuters) – AstraZeneca is spinning off six early-stage experimental drugs into a new $250 million standalone biotech company focused on severe autoimmune diseases.

The spin-off of the three clinical and three pre-clinical biological compounds, announced on Wednesday, is the latest example of the British drugmaker pruning its non-core drug development work to focus on priority areas, notably in cancer.

Chief Executive Pascal Soriot said earlier this month that AstraZeneca had a drug pipeline that was “over-sized relative to the current size of our company”.

It has already divested a number of medicines in recent years. In 2017, so-called externalization deals, involving asset sales and partnerships, contributed $2.3 billion out of total revenue of $22.5 billion, prompting criticism from some analysts who argue such transactions unduly flatter results.

In the case of the new inflammation and autoimmunity company, called Viela Bio, AstraZeneca will retain a significant interest as the new company’s largest minority shareholder.

Viela Bio’s potential new medicines include inebilizumab for neuromyelitis optica, a rare disease affecting the optic nerve and spinal cord of around five in 100,000 people. The drug has orphan drug status and could be filed for approval in late 2019 or early 2020.

However, the deal does not include anifrolumab, a promising treatment in final-stage clinical testing that AstraZeneca is developing for lupus, an chronic autoimmune disease with limited treatment options.

Bahija Jallal, head of AstraZeneca’s MedImmune biotech unit, said the drugmaker would remain strongly active in immunology. “Our strategy is very much to follow the science. In some cases, we will develop the science in-house and in other cases it will be developed elsewhere,” she said in a phone interview.

Viela Bio will be based in Gaithersburg, Maryland, and will be funded with $250 million from a consortium of investors led by Boyu Capital, 6 Dimensions Capital and Hillhouse Capital.

The new company’s chief executive is Bing Yao, currently head of respiratory, inflammation and autoimmunity at AstraZeneca’s MedImmune innovative medicines unit. Several other MedImmune staff will also move across to the new business, including Jorn Drappa, who will head up research.

It is not the first time AstraZeneca has shifted assets into a new biotech company in this way. In 2015, it spun out its early small-molecule anti-infective drugs into Entasis Therapeutics and in 2008 it shifted gastrointestinal research into a company called Albireo.

Reporting by Ben Hirschler, editing by Larry King

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Coca-Cola defeats U.S. lawsuit over Diet Coke ads

(Reuters) – A federal judge has dismissed a lawsuit claiming that Coca-Cola Co’s advertising for Diet Coke misleads people into thinking that consuming the soft drink assists in weight loss, and that it actually causes weight gain.

The plaintiff, Shana Becerra, claimed that she and others would not have bought Diet Coke, which was launched in 1982, but for the word “diet” and ads such as one showing the soft drink being poured by a bare-chested man with a well-muscled torso.

In a decision on Tuesday, however, U.S. District Judge William Alsup in San Francisco said 13 studies cited by Becerra were “equivocal” as to whether diet soda causes weight gain, and that she must prove it does to prevail.

He also noted that supermarkets do not display Diet Coke in the health food section, and said reasonable consumers would understand that any caloric savings would lead to weight loss only as part of a “sensible diet and exercise regimen” dependent on individual metabolism.

“Becerra has overstated the actual science,” Alsup wrote.

The judge separately rejected Coca-Cola’s argument that federal law preempted the lawsuit, which sought class-action status.

A lawyer for the plaintiff did not immediately respond on Wednesday to a request for comment. Coca-Cola did not immediately respond to a similar request.

Becerra, who lives in Santa Rosa, California, claimed that non-nutritive sweeteners such as Diet Coke’s aspartame interfere with the ability to metabolize calories, and raise the risk of cardiovascular disease and diabetes.

She sued on behalf of California residents for unspecified damages and an injunction against marketing Diet Coke as “diet.”

Coca-Cola relaunched the Diet Coke brand in January to stem falling sales, and added blood orange, cherry, ginger-lime and mango flavors in taller, thinner cans.

The case is Becerra v Coca-Cola Co, U.S. District Court, Northern District of California, No. 17-05916.

Reporting by Jonathan Stempel in New York; Editing by Susan Thomas

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New treatment shows promise to fight against serious inflammatory disease

February 27, 2018

Still’s disease is a serious orphan disease manifested by high fevers, skin and joint involvement, including paralysis, as well as damage to other organs such as the liver or spleen. It is caused by a deregulation of the immune system triggering an acute inflammatory response. Under the auspices of the University of Geneva (UNIGE) and Geneva University Hospitals (HUG), an international team has successfully tested a molecule inhibitor of interleukin-18, a protein involved in immune response. These encouraging results in terms of safety and efficacy are paving the way for a new kind of treatment, not only for Still’s disease, but other rare inflammatory diseases, too. Recently, a baby’s life was saved after the drug was administered as a last resort. Read the study in the specialist journal Annals of the Rheumatic Diseases.

In its adult form, Still’s disease affects about 1 in 100,000 people each year, with its infantile form being ten times more common. This rare condition can take different forms: monocyclic, polycyclic or chronic, leading to attacks on several organs that may threaten the quality of life – or even life – of those affected. While the cause is still unknown, genetic factors have been identified in other, similar syndromes. Cem Gabay, a professor at UNIGE’s Faculty of Medicine and Head of the HUG Rheumatology Department, is one of the world’s leading specialists in these complex diseases and part of a European consortium whose aim is to better understand the causes and pathology of these inflammatory conditions.

An immune system disorder

Cytokines are small proteins involved in cell-to-cell interactions, whose role in triggering certain diseases is now becoming clear. One of them, interleukin-18 (IL-18), specialises in immune and inflammatory responses. “Recently, we successfully demonstrated the key role of IL-18 in Still’s disease”, says Professor Gabay. Patients with the condition have a very high level of this protein, correlating with the acute phases of the disease, and this rate fluctuates according to the inflammatory activity specific to this disease. “Our idea was therefore to block the harmful action. It is also worth pointing out that the treatments currently offered to patients are very empirical, so our goal was to finally give them a safe and approved treatment”, he explains.

While IL-18 is useful for protecting the body against external pathogens, too much of this protein leads to a harmful overactivation of the immune system, resulting in the various symptoms presented in patients. There is a naturally occurring inhibitor (“IL-18 binding protein”), whose function is to bind to IL-18 to form an inactive complex, but people with Still’s disease produce more IL-18 than its inhibitor, which triggers their symptoms.

Reusing an existing molecule

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A few years ago, a pharmaceutical company developed an injectable form of the IL-18 inhibitor, with the idea of offering treatment to combat rheumatoid arthritis and psoriasis. The tests proved inconclusive and the formula abandoned. “So we bought the rights to the drug and started working with Professor Gabay to assess its safety and efficacy in a clinical trial”, explains Andrew Sleight, CEO of AB2 Bio Ltd., the Lake Geneva startup that has the World Wide license of the drug.

The main objective of this study was to verify the safety of the drug and to confirm its efficacy on the clinical manifestations of the disease. Twenty-three patients, mostly suffering from forms of the condition that are particularly refractory to the usual treatments, were enrolled and divided into two groups: one receiving 80 mg, and the other 160 mg, via three subcutaneous injections per week for 12 weeks. Professor Gabay summarises the results: “We were initially reassured by the safety profile: there were very few serious side effects, only one of which was possibly related to the drug itself. In addition, 50% of patients in both treatment groups showed a positive response to the drug after three weeks of treatment, and their symptoms decreased over the entire 12 weeks of follow-up. In contrast, patients who didn’t have a positive 80 mg response did not have one with 160 mg either. These first results are extremely encouraging and mean we can plan a phase 3 trial to better evaluate the effectiveness of the drug.” Researchers are currently in phase 2, which aims to ensure the safety of the product and to determine the optimal dose. Phase 3, the next step envisaged by Professor Gabay’s team together with AB2 Bio Ltd., will aim to assess the actual efficacy of the drug.

Potential treatment of other orphan diseases

Patients with other orphan diseases associated with dysregulated production of IL-18 and its inhibitor, for which there is no effective treatment protocol, could also benefit from these results. In 2015, the life of a three-month-old girl was saved. Professor Gabay tells us what happened: “This child, who lives in the United States, had a rare inflammatory disease that was resistant to all treatment; she was in intensive care, and was going to die. Alerted by our American colleagues, we worked with AB2 Bio Ltd. to determine what dose she should be given. The Food and Drug Administration granted permission to use the drug in a last-ditch attempt to halt the disease. She rapidly responded to treatment and is now 3 years old, well and can lead a normal life with IL-18 inhibitor therapy. A glimmer of hope for other patients!”

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Following The Fire: Montana Scientists Seize Chance To Scrutinize Smoke Exposure

Jean Loesch and her family live in Seeley Lake, Mont., which saw the longest and most intense smoke from Montana’s wildfires last summer. Loesch has 10 children, adopted or in her foster care, and they are learning what it’s like to have lingering respiratory problems.

The smoke from the fires was so thick outside, Loesch said, the family couldn’t see the trees across the street, so they stayed inside. It was still really hard to breathe.

“These guys were miserable,” she said. “I think each one of them ended up having to go to the doctor.” Everyone needed inhalers.

The family is typically pretty healthy, but not this year. Loesch got pneumonia and the kids had bloody noses. And now, even with the smoke long gone, the children continue to have trouble with their lungs.

“They’ll wake up hacking,” Loesch said. “They’ve all been sick. I’ve had to take them in for upper-respiratory infections.”

Seeley Lake is in Missoula County, which had several large wildfires that lasted from the end of July through mid-September — weeks longer than usual — and led to the worst season on record for wildfire smoke.

Researchers don’t know a lot about what that kind of extended smoke exposure does to the average person. Most previous studies have focused on indoor wood-burning stoves, urban air pollution and the effects on firefighters.

But the way the smoke piled up and stuck around a whole town this summer was new. Seeley Lake is in a valley. Every day, as the sun set and evening temperatures dropped, cold air traveled down from the mountain and trapped the smoke from the nearby Rice Ridge fire on the valley floor. This phenomenon is called a temperature inversion.

As the wildfires burned on, and nights grew longer and colder, the inversions grew stronger. Over time, the accumulating smoke made it harder for the sun to break through and warm the ground. That intensified the effect.

The experience was really tough on residents, and it handed scientists an unusual opportunity to learn much more about the health effects of breathing smoke.

Rachel Hinnenkamp, an epidemiologist with the state health department, has been tracking how many people went to emergency rooms complaining of respiratory-related symptoms during the 2017 wildfire season.

For people who live in Missoula and Powell counties, that number more than doubled in 2017 compared with the year before — from 163 in 2016 to 378 in 2017.

“That’s a statistically significant increase,” Hinnenkamp said.

Researchers can’t say whether all those ER visits were directly related to the Rice Ridge Fire, but Hinnenkamp said most visits happened about a month after the air in the region first became heavy with smoke.

The more a person is exposed to polluted air, the worse it is for their health.

“The smoke that we saw this year in Seeley Lake was like nothing we’d ever seen,” said Sarah Coefield, the air quality specialist for the Missoula City-County Health Department. It’s her job to quantify just how bad the air was.

Missoula County Health Department air quality specialist Sarah Coefield tracks smoke moving through western Montana all day. (Nora Saks/Montana Public Radio)

Pollution from wildfire smoke is typically measured as the concentration of fine particulate matter, she explains. The EPA says a daily average concentration of more than 35 micrograms per cubic meter of polluted air is unhealthy.

The county’s air quality monitors max out at 1,000 micrograms. In Seeley Lake last summer, Coefield said, the monitors maxed out 20 times. “So there were 20 hours that we don’t know what the actual number was over a thousand,” she said.

Most public health guidelines aim to protect groups that are the most vulnerable to wildfire smoke in the short term — children, pregnant women, older people and those with chronic heart and lung diseases.

But the off-the-charts summer in Seeley Lake is bad news even for people who aren’t at high risk, said Chris Migliaccio, an immunologist and assistant professor in the University of Montana’s School of Pharmacy.

“Usually these exposures are maybe a couple weeks at high levels,” Migliaccio said. “This was over a month at really unprecedented levels. We have no idea what the long-term effects are.”

He’s part of a team of UM researchers trying to fill in those gaps in knowledge. Working with the county health department, they’ve started tracking a group of Seeley Lake residents, documenting changes in their physical and mental health over time.

One thing Migliaccio predicts the scientists might see is an uptick in respiratory infections — because those fine particulates in wildfire smoke can damage and even kill cells in the lungs that get rid of the harmful substances people inhale. And that leads to more people having a compromised immune system.

“I can’t tell you, ‘You will be susceptible. You will get the flu.’ But because of these exposures, you’re probably at an increased risk,” he said. “We haven’t done these studies. And that’s something we want to follow with this Seeley Lake cohort. Let’s follow them. Let’s see how they do this winter.”

Right now, the biggest hurdle to getting that information is funding. The health scientists are applying for grants to keep their research going. They hope to track people for years, to find out whether the health effects of extended smoke exposure dissipate — or linger.

This story is part of a partnership that includes Montana Public Radio, NPR and Kaiser Health News.

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Refusing To Work For Medicaid May Not Translate To Subsidies For ACA Plan

Work requirements for Medicaid coverage. Insurance plans that don’t meet health law standards. Changes to Medicare drug lists. As the ground continues to shift on health care coverage, I answer readers’ queries this week about these three different types of plans.

Q: I’m in a state that is looking into work requirements for Medicaid. At sign-up time, can I simply tell the exchange that I intend to be ineligible for Medicaid by refusing to work and get the premium tax credit to buy a private plan on the insurance marketplace?

Federal health law regulations don’t clearly address the situation you describe, but the short answer is probably not, said policy analysts.

In general, people who are eligible for Medicaid — the federal-state health program for low-income people — or employer coverage can’t qualify for federal tax credits that help pay for premiums on plans sold on the health insurance exchanges.

This year, Kentucky and Indiana became the first states to receive federal approval to require some Medicaid recipients to put in 80 hours each month at a paid job, school or volunteer work, among other activities, to receive benefits. Nearly a dozen other states have made similar requests.

If you refuse to work, does that make you ineligible for Medicaid? The rules aren’t clear, said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

States might argue that someone in your situation is eligible for Medicaid, you just have to fulfill the work requirements, said Timothy Jost, an emeritus professor of law at Washington and Lee University in Virginia who is an expert on the health law.

There are other actions people could take — or fail to take — where this issue might come up. “You could argue that someone is not eligible because they haven’t completed the Medicaid application or provided the required documentation,” Jost said. “There are any number of requirements, but I can’t imagine someone saying they didn’t do those things and so they’re not eligible for Medicaid.”

Whatever the rules, it’s unlikely that many people will be in a position to consider taking this stance. To qualify for premium tax credits, your income must be between 100 and 400 percent of the federal poverty level (about $12,000 to $48,500 for one person in 2018). But you’d also have to be eligible for Medicaid, generally with an income limit of 138 percent of poverty (about $16,750) in states that expanded coverage to adults. In addition, the Medicaid work requirements in your state would have to apply to you.

Q: I lost my job last year and my employer coverage ended in January. I bought a new plan through the marketplace that went into effect last month. I just received policy information, and it states that because the plan does not cover major medical services, I may have to pay additional taxes to the government. I was told that the plan didn’t cover major medical but wasn’t told about any taxes. Will I be fined next year?

It sounds like you bought a plan that doesn’t comply with the Affordable Care Act’s requirements, and if that’s the case you may indeed have to pay a penalty for not having comprehensive coverage when you file your taxes next year.

The tax law repealed the individual penalty for not having health insurance, but that provision doesn’t take effect until 2019. So, for 2018, you may be charged the greater of $695 or 2.5 percent of your household income.

The federal- and state-run marketplaces established by the ACA sell only comprehensive plans that cover 10 essential health benefits, including “major medical” services like hospitalization and prescription drugs.

But some insurance broker websites call themselves marketplaces too, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. These companies may sell other insurance products like short-term or accident coverage alongside comprehensive plans that comply with the law.

Ever since the health law was passed, “There have been opportunistic companies trying to take advantage of consumer confusion to make money,” Corlette said.

If you aren’t happy with your plan, you may still be able to switch. Losing your employer coverage qualifies you for a 60-day special enrollment period to pick a new plan. Since it appears you’re still in that window, you may be able to choose a comprehensive plan.

To ensure you’re using your state’s official marketplace, go to healthcare.gov and click on “see if I can change.” That will take you to your state marketplace, even if you live in one of the dozen or so states that run their own exchanges.

Q: I picked a Medicare Part D drug plan that covered all the drugs I take. But as soon as I got my first Novolin R prescription filled, they notified me that they don’t cover it anymore. Can they just switch it like that?

Medicare drug plans can change their list of covered drugs, called formularies. If they’re doing so at the start of the new calendar year, as appears to have happened in your case, the plan may notify you of the change when you fill the prescription for the first time in the new year.  At that time, the plan would typically give you a 30-day “transition” refill so you can switch to another drug that’s on the formulary, according to Juliette Cubanski, associate director of the Program On Medicare Policy at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

If you and your doctor think it’s important that you have Novolin R and not another drug that is similar, you can ask your plan to make an exception to allow you to continue to take the medication.

To go that route, you would need to get your doctor to “make the case for why that formulary drug is not the right drug” for you, said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.

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Twenty states sue federal government, seeking end to Obamacare

(Reuters) – A coalition of 20 U.S. states sued the federal government on Monday over Obamacare, claiming the law was no longer constitutional after the repeal last year of its requirement that people have health insurance or pay a fine.

Led by Texas Attorney General Ken Paxton and Wisconsin Attorney General Brad Schimel, the lawsuit said that without the individual mandate, which was eliminated as part of the Republican tax law signed by President Donald Trump in December, Obamacare was unlawful.

“The U.S. Supreme Court already admitted that an individual mandate without a tax penalty is unconstitutional,” Paxton said in a statement. “With no remaining legitimate basis for the law, it is time that Americans are finally free from the stranglehold of Obamacare, once and for all,” he said.

FILE PHOTO: A sign on an insurance store advertises Obamacare in San Ysidro, San Diego, California, U.S., October 26, 2017. REUTERS/Mike Blake/File Photo

The U.S. Justice Department did not immediately respond to a request for comment on whether the Trump administration would defend the law in court.

The individual mandate in Obamacare was meant to ensure a viable health insurance market by forcing younger and healthier Americans to buy coverage.

Republicans have opposed the 2010 law formally known as the Affordable Care Act, the signature domestic policy achievement of Trump’s Democratic predecessor Barack Obama, since its inception.

Paxton and Schimel, both Republicans, were joined in the lawsuit by 18 states including Arizona, Florida, Georgia, Utah and West Virginia. It was filed in U.S. District Court in the Northern District of Texas.

Reporting by Eric Beech in Washington

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Free clinic opens for Yemenis impoverished by war

SANAA (Reuters) – Volunteer doctors are offering free medical services for a week at a clinic in the Yemeni capital Sanaa to treat people impoverished by a war which has killed thousands and wrecked the economy.

The initiative, dubbed “Breeze of Hope,” is the first by a group of nurses and doctors to conduct electrocardiograms, x-rays and other procedures that Sanaa residents cannot afford.

Yemen has been hit by three years of civil war between the internationally recognized government backed by a Saudi-led military coalition and the Iran-aligned Houthi movement which controls the capital.

Key infrastructure has been bombed by Saudi-led air strikes while imports have been constricted by a near-blockade aimed at cutting off weapons supplies to the Houthis.

Amid a dispute between the government and the Houthis over who should receive public sector salaries and as the local currency has shed much of its value, many employees — including some medical staff — have not received wages in over a year.

A volunteer nurse checks a patient at a charitable medical center which is offering free medical services to support those in need in Sanaa, Yemen February 26, 2018. REUTERS/Khaled Abdullah

For them, a chance at free healthcare is a rare boon.

“I came here because I don’t have the means or ability to go to a hospital,” said one patient, Mohammed Fuad.

Slideshow (5 Images)

“Our financial situation is difficult, and there are no salaries because of the war. That’s why we’re obliged to come to this charitable medical center.”

Mohammed al-Aqabi, the head of the initiative, said the help provided rare hope amid the gloom of war.

“The main purpose of running this center is to address the country’s catastrophic circumstances of war and destruction,” he said.

The organizers say they hope to repeat the initiative elsewhere in the capital and in other areas of the country soon.

Reporting By Sanaa Bureau, Editing by William Maclean

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Trump’s Perfect Score On Brain Test Spawns DIY Cognitive Exam

When Donald Trump aced a cognitive test in January, scores of people tried to take it, too, based mostly on media reports that invited them to match wits with the president.

Casual users puzzled over line drawings of animals, while others wondered what it meant if they were bad at subtracting by sevens.

That was a mistake, according to the scientist who created the Montreal Cognitive Assessment, or MoCA, a popular screening tool designed to spotlight potential problems with thinking and memory. The MoCA was never meant for general use and it requires a health professional to monitor the test and interpret the results.

Media coverage challenged people “to test yourself to see if you fare as well as Mr. Trump, but that wouldn’t give them the accurate response,” said Dr. Ziad Nasreddine, the Lebanese-Canadian neurologist who holds the copyright to the MoCA. “You need a trained person to administer this test.”

But with interest in the test so high, Nasreddine and his colleagues saw an opportunity. Weeks after Trump posted his perfect MoCA score (30/30), the researchers started working on a new tool, dubbed the “mini-MoCA,” an online, self-administered exam for people worried about possible cognitive decline.

“We thought, ‘OK, why shouldn’t we take the lead and develop the test?’” said Nasreddine, who had been pondering such a move for several years. “It’s good timing to offer something for families and concerned individuals that they can self-test themselves.”

Such a test could potentially expand detection of mild cognitive impairment, or MCI, the earliest stage of dementia. Up to 1 in 5 people age 65 and older have MCI, and more than half progress to dementia within five years.

Learning about problems early allows affected people to arrange their finances, seek out clinical trials and otherwise make plans for future care, said Heather Snyder, senior director of medical and scientific operations for the Alzheimer’s Association.

“I’d do big picture and talk about why early detection is so important,” she said.

But several screening tests — more than a dozen — are available. None of them provides a definitive diagnosis and, like them, any new web-based self-assessment, including the mini-MoCA, could have its limitations, experts suggest.

“Is it a good idea? I think there’s some value for people to get some sense of how they’re doing,” said Dr. James Galvin, founding director of the Comprehensive Center for Brain Health at Florida Atlantic University. “But whatever result comes out of a test, they still need to discuss it with a health professional to put it in perspective.”

Much of the mini-MoCA’s success will depend on how the new tool is designed. It must be sensitive enough to highlight potential problems, but not so broad that it generates high numbers of false-positive results, said Dr. Dean Foti, a clinical assistant professor of neurology at the University of British Columbia.

“You have to really consider being overly sensitive and causing unnecessary anxiety in people,” he said.

Nasreddine said his team is working now to validate the mini-MoCA, which will be a scaled-down version of the original tool. The MoCA was developed more than 20 years ago to help detect MCI. It has been translated into several versions and multiple languages and is used in all of the National Institute on Aging’s Alzheimer’s Disease Centers.

The original MoCA is a 10-minute, 30-question exam. Instead, the mini-MoCA will be a five-minute, six-question test, Nasreddine indicated. Like the original test, it will include exercises focused on naming objects and animals, verbal fluency, calculation, clock time, abstraction and memory.

And, like the original, if people score fewer than 26 of 30 possible points, they’d be urged to consult a doctor for further screening.

Nasreddine is testing the first version of the mini-MoCA in 50 patients at the Neuro Rive-Sud memory clinic, comparing their scores on the new test with those from the original exam, long regarded as a valid screening tool for MCI.

If the results are good, he’ll move to a second stage with more patients and stricter criteria.

All told, the process could take up to eight months. Nasreddine is considering charging $1 or $2 per test to fund future research. Many tests that screen for dementia are free.

“We have to make sure that the precision and the purpose of the test are well-explained to the public with the limitations for interpreting the results,” Nasreddine said. “I think it will be a useful tool for the public to help guide and inform them about their cognition.”

KHN’s coverage of end-of-life and serious illness issues is supported in part by the Gordon and Betty Moore Foundation.

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