1411 health

METRO

Your Guide to Health & Wellness

Keep Your Head in the Game What to know about concussions

Navigating Health Care Options Your guide to the Affordable Care Act

Going Gluten-Free Tips to change your diet

METRO

Your Guide to Health & Wellness

CONTENTS Your Health Migraine Surgery: One Giant Leap........... 2 5 Important Questions to Ask Your Healthcare Provider . ..................... 3 Gray Matters . ........................................... 4 A Child, a Patient, a Friend....................... 6 Concussion Management ........................ 8 Signs and Symptoms of a Concussion...... 9 The Heart of the Storm .......................... 10 The Allergens Among Us ....................... 12 Good Night’s Sleep ................................ 13 Find Out Which Vaccines You Need . ..... 14 Gluten: Hype or Plight ........................... 15

Navigating Care Options Health Insurance By Any Other Name.... 16 Affordable Care Act and Eye Care ......... 17

Changing Times in Healthcare

Photos: (Cover) Nastco & istock/thinkstock.com; (this page) matthewennisphotography/thinkstock.com

The Challenges of Recruiting Physicians in Rural Communities ......... 18 Transformers in Healthcare . ................... 20

The content of Metro Health + is for informational purposes only and should not be used as a substitute for professional medical advice. metro Health + by Bangor Metro • 1

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Your Guide to Health & Wellness

Migraine Surgery: One Giant Leap Migraines are more than headaches. Millions of people suffer from this affliction but there is new hope on the horizon. By Dr. David Branch

M

igraine disease affects more than 36 million Americans, making it more common than asthma and diabetes combined. It affects 10% of children and even more adolescents, which is when the majority of patients begin showing migraine disease. This disrupts much of their educational and sociological development, precluding a normal productive life. More

than 25% of all severely debilitating strokes that affect people under the age of 45 are due to migraine disease.

The World Health Organization lists migraine as among the world’s top 20 most debilitating disorders.

In the United States, migraine disease is a major cause of disability (9% of all disability) and productivity loss, indirectly costing the American public nearly $15 billion. This is in addition to the direct treatment costs, which are estimated at $16 billion, the majority of which is delivered to the worst of sufferers. These medications are intended to be lifelong, are often multiple, and never without side effects. Despite the fact that more than 30% of sufferers are dissatisfied with the success of their treatment, most medical therapies are directed towards managing the pain once the headache starts rather than reducing or eliminating them all together.

Migraine surgery has been a growing part of my practice for the past 12 of the 14 years I have spent in Bangor. When I began, there were only three other migraine surgeons in the country; now there are several hundred trained with many top residency programs including this in their curriculum. Most insurance companies are covering the surgery even though many still inexplicably regard it as investigational. So changing the paradigm of treatment for moderate to severe migraine sufferers from polypharmacy to surgery has been slow but sure, as five-year data continues to look as promising as that from year one.

Migraine surgery remains an underrecognized viable treatment option, not only because of economic pressures 2 • metro Health + by Bangor Metro

Photos: bevangoldswain & tetmc/thinkstock.com

Migraine Surgery

that favor medications and devices over nontaxable services, but also because of the wide disparity in patient and professional education. Pharmaceutical companies currently underwrite all of the major educational foundations that serve the public as well as the publications that disseminate information to headache specialists. Aside from our annual Migraine Surgery Symposium, where each year 30 to 50 new surgeons are trained, there has been no foundation in which to disseminate information about this proven technology that has been shown to eliminate headaches in 30-40% of patients, reduce disease severity by at least 50% in 85-90% of patients, and reduce annual cost of care by nearly $4,000 per patient per year.

As of the summer of 2014, Northeast Migraine Surgery is proud to announce the formation of The Migraine Surgery Foundation (MSF), which will serve to disseminate information about this treatment option, which has been eclipsed by the marketing and educational efforts of the current traditional medical paradigm. MSF will help educate the public and health care professionals as well as the health care industry. It will promote a cooperative effort on the parts of neurologists, primary care physicians, physician extenders, psychiatry, psychology addiction medicine, sleep medicine, physical therapists, and message therapists to better serve largely dissatisfied moderate to severe migraine patients.

In summary, it will help promote a service-based treatment with proven patient and societal benefits that otherwise has no central organization or industry investing in public awareness. Its purpose will be to change the current treatment paradigm from costly lifelong and often ineffectual “management” to the profoundly more humane and affordable elimination of the problem.

5 Important Questions to Ask Your Health Care Provider

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hoosing Wisely®, an initiative of the American Board of Internal Medicine (ABIM) Foundation, was designed

to educate people to ask their healthcare providers these five questions before getting any test, treatment, or procedure.

1. Do I really need this test or procedure?

2. What are the risks?

3. Are there simpler, safer options?

4. What happens if I don’t do anything?

5. How much does it cost?

By asking these five questions you can make an informed decision about if the test, procedure, or treatment your doctor is suggesting is right for

you. Visit www.choosingwisely.org to learn more.

David Branch, MD has been President of Bangor Plastic and Hand Surgery since 2000.

metro Health + by Bangor Metro • 3

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A

Gray Matters

ccording to the Centers for Disease Control and Prevention (CDC), 800,000 Americans suffer strokes each year. CDC statistics show that among the six New England states, Maine has the highest stroke death rate, and Aroostook County has one of the highest rates of strokes within the state.

Virginia Joles of Mapleton knows firsthand what those statistics can mean.

In November 2011, Joles was working long and stressful hours. It was not uncommon for Joles to take projects home and work into the early hours of the morning. It caught up to her after a series of week-long employee meetings.

“I was taking notes at the last employee meeting and I felt weak, distant, and almost as if I was on the outside of a stage performance where no one could hear or see me. I tried to speak and could not get the words out,” says Joles.

Joles suffered from an ischemic stroke, which occurs when arteries are blocked by blood clots or by gradual build-up of plaque and other fatty deposits. About 87% of all strokes are ischemic.

These clots can be formed in an artery that supplies blood to the brain or, as in Joles’ case, can be formed elsewhere but break off and travel to the brain.

The other 13% of strokes are hemorrhagic, when the artery wall ruptures and blood leaks into the brain. This can happen due to an arteriovenous malformation (tangle of abnormal blood vessels) or when the wall bulges as occurs with an aneurysm or because of high blood pressure.

Paying attention to symptoms is critical to a positive outcome. Symptoms can include: numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion, difficulty speaking or understanding; blurred vision in one or both eyes; dizziness or loss of balance; or a severe headache with no known cause.

Two million brain cells die every minute during a stroke, increasing the risk of permanent brain damage, disability, or death. Recognizing the symptoms and acting FAST to get medical attention can save a life and limit disabilities.

F = FACE Ask the person to smile. Does one side of the face droop?

A = ARMS Ask the person to raise both arms. Does one arm drift downward?

S = SPEECH Ask the person to repeat a simple sentence. Does the speech sound slurred or strange?

T = TIME If you observe any of these signs, call 9-1-1 immediately.

“Today, I am fully recovered simply because my coworker recognized the signs of a stroke, my husband got me to the hospital quickly, and the team at The Aroostook Medical Center (TAMC) immediately took action. I have routine follow ups with my health provider, and I tell those around me to find balance in their lives, avoid stress, and get rest,” Joles says.

While some risk factors are beyond your control (being over age 55; gender–stroke is more common in men than women at younger ages, but more

A stroke can be considered a “brain attack,” occurring when normal blood flow to the brain is disrupted. It is the fourth leading cause of death in the United States, and the leading cause of adult disability. By Karen Gonya women experience strokes at older ages and more women die from strokes; having diabetes; a family history of stroke), others can be impacted by lifestyle and medical changes to your life.

Medical stroke risk factors include having a previous stroke, high cholesterol, high blood pressure, heart disease, atrial fibrillation, and carotid artery disease. A previous episode of transient ischemic attacks (TIAs), often called “mini” strokes, can also be a risk factor.

A TIA is caused by a temporary blockage of a vessel in the brain that causes the symptoms of a stroke. Although brief, a TIA is a sign of a serious condition that will not go away without medical help.

All of these factors can be controlled and managed with the help of your doctor.

Lifestyle changes such as quitting smoking, exercising regularly, watching what and how much you eat, and limiting alcohol consumption can make a big difference.

“I thought I was invincible. I never realized how important sleep is. Not only do we need good food and exercise, we need eight hours of peaceful rest for our body to recover from stress and strain. I was abusing myself, I just couldn’t shut down. But that has all changed now,” says Joles, who retired last year from her high stress job. Now, she goes to bed early and works part-time raising funds for cancer patient assistance and much needed equipment at TAMC. “It’s my way of paying back because they were there when I needed them.”

Karen Gonya is communications lead at The Aroostook Medical Center.

Photo: Andrei Malov/thinkstock.com

Your Guide to Health & Wellness

Meet Christopher Mitchell See Christopher’s story in page 6

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Your Guide to Health & Wellness

A Child, a Patient, a

Friend

Physical and occupational therapy options close to home. By Nicole Ayotte and Hilary Arsenault

Occupational therapist Hilary Arsenault works with Christopher Mitchell.

6 • metro Health + by Bangor Metro

once or twice per week to access the care his son needed. This is when they found us at Millinocket Regional Hospital (MRH) in 2011. Christopher was 7 and a half years old.

These issues made it difficult for his father to perform daily activities such as dressing, eating, feeding, and bathing. Due to the increasing fatigue that Christopher often experienced with

The most amazing progress Christopher has made is his ability to sit, and make eye contact to listen which allows him to sit at a desk at school just like the other kids.

MRH offers pediatric services for physical, occupational, and speech therapy needs close to home. Christopher initially came to the MRH rehab department for PT services only, but after evaluating him and talking with his father about the services he was receiving at school, we all agreed that the boy would benefit from additional outpatient services with OT. Chris Sr. was excited to hear that he would only have to make one 30 minute trip a week to see both PT and OT. When Christopher was first introduced to PT at MRH, he needed excessive support from his wheelchair to keep him in a sitting position, he had a hard time keeping his head up and holding eye contact, had no control and little movement of his left arm and hand, and was unable to propel himself on the floor for play.

activity, PT and OT often treated him simultaneously to better accommodate Christopher and ease the commute to MRH on the family.

“It made it good that they had both PT and OT here [at MRH] so we could make the appointments on the same day and there were results because it was consistent,” says Chris, Sr. Here at MRH, when treating pediatric patients, we strive to provide family centered care. Involving parents in treatment sessions allows the opportunity to educate for follow through at home, which improves the child’s functional outcomes.

With these standards put in place, Christopher has made wonderful gains in rehab at MRH. After three years of treatment, he is now able to propel himself all over his house on the floor, he helps his father get him dressed, bathed, and needs little help with eating.

This may seem small to some, but to Christopher and his father, this has made a big difference in their lives.

Christopher’s doctors predicted that he may not ever be able to sit up on his own, communicate effectively, or have any use of his left hand and arm, but he has proven differently.

He is now able to pass objects from hand to hand and, in Christopher’s words, “I can pull covers off markers now by myself at school.” He is able to play independently on the floor at home.

The most amazing progress Christopher has made is his ability to sit, and

Photo: Courtesy of Millinocket Regional Hospital Rehabilitation department

C

hristopher Mitchell was born 3 months premature weighing 3 pounds 4 ounces. Soon after, he was diagnosed with Spastic Quadriplegia Cerebral Palsy, and at 18 months old started experiencing seizures.

He started receiving physical therapy at age 2 and had several different therapists throughout his early years. It was difficult to find pediatric physical therapists (PT) near his home in northern Maine.

When Christopher reached school age, he received occupational therapy (OT) throughout the school year, but his school did not provide PT to attend to his ever growing physical needs. Because of this, Christopher’s dad, Chris Sr., had to travel 1 hour and 45 minutes

make eye contact to listen which allows him to sit at a desk at school just like the other kids.

Christopher is a wonderfully funny, outgoing, and loving child who lights up a room when he enters. He has made a difference in our lives as therapists as much as we have in his.

It was truly a pleasure to have Christopher as a patient and he ended up not only being a great patient, but one of our friends. We look forward to seeing him, if and when he may need us again!

M obility is a beautiful thing.

Nicole Ayotte, MPT is a staff physical therapist at Millinocket Regional Hospital. Hilary Arsenault is an occupational therapist with Millinocket Regional Hospital.

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Your Guide to Health & Wellness

Concussion Management

Concussions are dangerous conditions that, in the past, were not always taken seriously.

Today, more is known about concussions and treatments are improving. By Skip Philbrook, PT No one should return to sport or vigorous activity while signs or symptoms of a concussion are present. Experts recommend that an athlete with a suspected concussion not return to play until he or she has been medically checked out by a health care professional trained in evaluating and managing concussions.

Experts also recommend that an athlete with a concussion not return to play on the same day as the injury.

David Orsmond, PT, CVT and Moriah Grant, OT, CVT are the concussion treatment team at Waldo County General Hospital. They are both certified vestibular therapists who treat mild brain injuries.

Grant is also finishing up her certification in craniosacral therapy, a light touch therapy that manipulates membranes within the nervous system to restore their normal function. Dysfunction of these membranes can contribute to headaches.

Among the other therapies available in the Concussion Management Program are manual therapy for neck and back pain and functional training which involves an individualized program of specific exercises that address the demands of your sport or work and help you regain your physical abilities as quickly as possible.

Patients in the Concussion Management Program have already seen some tremendous results, in some cases with only a few treatments. Ongoing therapy may be needed in other cases. The length

of the treatment is affected by both the severity of the concussion, the patient’s history, and possible number of previous concussions suffered by the patient.

Skip Philbrook, PT, physical therapist for 31 years, is clinical manager of Rehabilitation Services at Waldo County General Hospital.

Moriah Grant, OT, CVT performs craniosacral therapy on a patient.

8 • metro Health + by Bangor Metro

Photo: Courtesy of Waldo County General Hospital

W

e treat many athletes at the Orthopedic and Sports Physical Therapy Center at Waldo County General Hospital in Belfast. The emphasis on concussions has increased over the past few years, and luckily, school nurses and coaches have gotten better at recognizing and testing for concussions. No longer do you hear “he just got his bell rung” and after sitting out for a play or two, an athlete is put back in the game.

A concussion is a traumatic brain injury. It occurs when the brain is shaken into the skull, which causes changes in the way the brain functions. A concussion may happen as a result of a direct blow to the head or an indirect force such as a whiplash.

Many times the symptoms disappear with rest. But no two concussions are the same and sometimes the symptoms last for weeks or even months. This is when a physical therapist or an occupational therapist can help. Either can perform an examination to assess the individual’s symptoms and limitations, then design an individualized treatment program.

Physical therapists and occupational therapists can help with: • Stopping dizziness • Improving balance • Reducing headaches • Decreasing neck/back pain • Helping the return to sport or work

Signs and Symptoms

of a Concussion

I

f you or someone you know experiences any of these symptoms following a head injury, seek medical attention immediately.

• Appears dazed • Confused • Clumsy • Answers questions slowly • Personality/behavior changes • Forgets events prior to injury • Forgets events after injury • Loss of consciousness • Headache • Nausea • Balance problem • Double vision • Sluggishness • Feels “foggy” • Sleep pattern changes • Cognitive changes • Light/sound sensitivity

Photo: Willard/thinkstock.com

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Your Guide to Health & Wellness

The Heart of the Storm

The first snowfall can be pretty exciting. However, winter can be a dangerous time for those with undiagnosed heart health issues. By Christina Roberge and Elizabeth Meginnis

10 • metro Health + by Bangor Metro

other exercise, you should warm up your muscles to get them ready for a strenuous work out.

• Dress appropriately with layers that don’t constrict your movement or vision, and wear a hat. Heart failure causes most deaths in cases of hypothermia. Staying warm will help maintain circulation and body temperature.

• Start early and go out often. Fresh snow is lighter than packed snow and easier to remove than a large accumulation. When snow is deep or heavy and wet, shovel small amounts (1-2 inches) at a time.

• Go slow and take many breaks. (Shovel for 5-7 minutes and rest 2-3 minutes.)

• Drink lots of water to prevent dehydration. Even in cold weather your body needs to plenty of water during physical activity.

• Watch for signs of trouble: chest pain; pressure or burning that radiates down your arms, neck, or back; light headedness; dizziness; nausea; and unusual or prolonged shortness of breath. If you experience any of these symptoms stop and call 911. Even if you’re not sure, it’s a good idea to check in with a health professional.

Remaining active all year-round is the best way to prepare for the exertion of winter snow removal. If you’re struggling to find an activity that’s suitable for your physical condition talk with your doctor. Something as simple as walking around your house or taking the stairs instead of the elevator can make a difference.

Christina Roberge, RRT, works at Maine Coast Memorial Hospital in the Cardiac Rehab Department. Elizabeth Meginnis, CNA, works at Maine Coast Memorial Hospital in the Cardiac Rehab Department.

Photo: zest_marina/thinkstock.com

A

ngina and heart attacks can be triggered by the physical exertion involved in shoveling snow. Hospitals will frequently see an increase in the number of admissions for cardiac events after a snow storm.

Shoveling snow can be more strenuous than running on a treadmill; the combination of the cold air and activity can increase heart rate and blood pressure, and reduce circulation leading to a restriction of the blood vessels. These symptoms can be exacerbated if you have other risk factors for heart disease including: living a sedentary lifestyle, high blood pressure, diabetes, high cholesterol, and smoking. Patients with pre-existing coronary artery disease are especially vulnerable, and having a stent does not ensure your safety.

Before you shovel, just like taking on any exercise program, you should talk with your doctor to see if you’re at risk. If at all possible, recruit your children, grandchildren, or a neighbor to help you; use a snow blower; or hire someone to plow if the job is especially big.

If you have to shovel, follow these tips to keep yourself safe: • Avoid heavy meals before and soon after shoveling, and don’t consume alcohol before you head out. Eat a small snack instead of a large meal. You definitely need energy to shovel, but digestion can put additional strain on your heart. Alcohol can increase your sensation of warmth and underestimate the extra strain your body is under.

• Warm up before starting to shovel by walking in place for a few minutes. Just like any

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Your Guide to Health & Wellness

The Allergens Among Us

T

he incidence of asthma and allergies are on the rise, due in part to our warming environment and our clean living. Warming increases the duration and amount of pollen production. Exposure to bacteria helps our immune system develop protective antibody IgG, rather than allergic antibody IgE. The medical profession recognizes the role of inflammation. The understanding of the interconnection between different body parts enables us to better control out of control asthma and allergies. While some mucus is normal, limiting the amount of inflammation limits excess mucus production.

Viral infections, allergies, cigarette smoke, and gastroesophageal reflux disease (GERD) produce excess mucus, which causes headaches, ear popping, clogged sinuses and ears, interference with sleep,

indigestion, and shortness of breath.

Post nasal drip causes coughing and throat clearing, which aggravate GERD and hiatal hernias. GERD symptoms presenting at night obstructs the nasal passages, which interferes with sleep, resulting in tiredness, fatigue, crankiness, and eventually depression. It is hard to be effective at work or in the classroom when one awakens exhausted in the morning.

The nose and sinuses are connected to the lungs, so if you are stuffy and have clogged sinuses, it is often hard to breathe, which worsens asthma. Your lungs are only as good as your nose!

Also, the cough associated with a cold frequently aggravates GERD symptoms, which worsen asthma. This creates a vicious cycle which can last for months.

The basic principles for allergy treatment still apply. For example, learn the multiple triggers that cause mucus pro-

duction and inflammation. Make lifestyle changes to avoid these triggers as much as practical. Try different over-the-counter antihistamines to prevent mucus, such as Benadryl (diphenhydramine), cetirizine, fexofenadine, and loratidine. These preventive meds need to be taken one hour before exposure to the substance to which you are allergic to prevent symptoms. They are so safe they can be taken several times per day as needed. Their major side effect is difficulty urinating. Benadryl is the only one to often cause drowsiness as it enters the brain. The others do not.

Different forms of steroids, such as prednisone, are the most effective antiinflammatory agents. They provide relief in a few hours and are usually without side effects when used on a short-term basis.

Prednisone tablets are very cost effective.

New combinations of a steroid and a long acting bronchodilator together in one inhaler are very effective for controlling asthma symptoms. These rarely have side effects, but are expensive.

New biological treatments for asthma have been shown to be very effective for patients who need frequent bursts of prednisone. Researchers are investigating multiple biologics that prevent the inflammatory cascade that causes asthma.

In addition to providing traditional allergy care, we encourage people to participate in drug trials, which provide opportunities to use current medications for different diseases and new treatments for other diseases. Every new medication is the result of volunteers participating in drug trials. The studies provide subjects with medications and medical care for study-related illness at no cost.

Paul Shapero, MD specializes in allergies, asthma, and immunology. He practices at Evergreen Woods in Bangor.

12 â&#x20AC;˘ metro Health plus + by Bangor

by Bangor Metro Metro

Photo: NZswissmedia/thinkstock.com

Watery eyes, runny noses, and trouble breathing are symptoms that millions of people endure every day. Fortunately some relief can be found if you know where to look. By Dr. Paul Shapero

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Good Nightâ&#x20AC;&#x2122;s Sleep

Your Guide to Health & Wellness

Sleep is critical for good health. Sleep apnea can rob you of restful slumber. By Marilyn Doe

Photo: karammiri/thinkstock.com

D

o you fall asleep during the sermon, watching TV, using the computer, or even worse, have you ever caught yourself nodding off while driving? Do you have a new diagnosis of atrial fibrillation, uncontrolled hypertension, or diabetes?

If so, you may also have obstructive sleep apnea, a common and serious sleep disorder that leads to shallow breathing, or ceasing breathing all together, causing numerous awakenings during night. You may not be aware of these awakenings, but they cause oxygen levels to drop dramatically, stressing internal organs.

Common signs and symptoms of sleep disorders are snoring, cessation of breathing (which is typically witnessed by someone else), awakening unrefreshed, mood disorders, morning headaches, and excessive daytime sleepiness.

Make an appointment with your physician for an evaluation that may lead to a decision for a sleep study.

Traditional treatment for sleep apnea is utilizing a Continuous Positive Airway Pressure (CPAP) device that acts as an air splint to keep the airway open. There are many patient comfort features on the CPAPs. Other considerations for the treatment of sleep apnea are weight loss, dental devices, and surgical procedures.

Marilyn Doe is the owner and president of Sleep Well in Brewer.

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Your Guide to Health & Wellness

Recover close to home in the PVH Swing Bed Program • Hospital physicians monitor your progress • Diagnostic services are readily available • Nursing and rehab staff come to you • Social activities • Private rooms • Great meals

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Find out which

Vaccines

You Need

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mmunizations are important for adults as well as children. Here’s a look at what vaccines are recommended for various age categories.

Visit www.cdc.gov to learn more.

In addition to an annual flu vaccine, young adults (ages 19-26) should get the following vaccines:

Tdap vaccine to protect against tetanus, diphtheria, and pertussis (whooping cough) if you didn’t receive it as an adolescent.

Human papillomavirus (HPV)

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vaccine to protect against certain cancers and other diseases caused by HPV if you didn’t receive it as an adolescent. It is recommended for women up to age 26, men up to age 21, and men ages 22-26 who are immunocompromised or who have sex with men.

Meningococcal vaccine to protect against meningococcal disease for first-year college students living in residence halls.

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Seniors’ immune systems weaken over time, putting people at higher risk for certain diseases. In addition to seasonal flu (influenza) vaccine and Td or Tdap vaccine (tetanus, diphtheria, and pertussis), seniors should also get:

Pneumococcal vaccine, which protects against pneumococcal diseases that cause infections in the lungs, blood, brain, and ear (for all adults over 65 years old, and for adults younger than 65 years who have certain chronic health conditions, such as heart disease, diabetes, lung disease, or who smoke).

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Zoster vaccine, which protects against shingles (for adults 60 years or older).

14 • metro Health + by Bangor Metro

Gluten: Hype or Plight

Small changes to go gluten-free

By Katherine O. Musgrave

D

o you suspect you are gluten sensitive? Identification of the problem may be confusing and may require the assistance of a registered dietitian. The symptoms are frequently similar to those of irritable bowel syndrome, Crohnâ&#x20AC;&#x2122;s disease, and other dysfunctions of the digestive system. But one can completely eliminate gluten and see if the symptoms subside.

Gluten is present in wheat, barley, and rye. That means it is in many items in our food supply. Although gluten does not occur in oats, it may get in oats during processing.

To obtain a gluten-free diet, one should eliminate bread, pasta, crackers, cookies, and commercially baked desserts. In addition, one should read the ingredient list of all processed foods, since most thickened products, gravies, puddings, and convenience foods include wheat starch. Many products include such items as spelt (an ancient form of wheat), triticale (a genetically modified grain), or modified food starchâ&#x20AC;&#x201D;all containing gluten.

Many companies are now offering gluten-free mixes, but the cost is greater than if one learns to get energy from other starchy foods such as potatoes cooked in the peeling, brown rice, and corn grits. Cornstarch may be used to thicken gravies. Dried beans and lentils provide excellent combinations of complex carbohydrates and protein. Including an egg or cheese with these plant proteins, plus a large serving of greens, cabbage, or carrots can make a good supper, especially if you add a dessert of vanilla ice cream with blueberry sauce.

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Katherine O. Musgrave PhD, RD, retired professor of food and nutrition at the University of Maine, Orono.

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METRO

Your Guide to Health & Wellness

Health Insurance

by Any Other Name

The Marketplace, Obamacare, and the Affordable Care Act (ACA) are terms you may have heard and may not completely understand. You may be wondering, “How does the Affordable Care Act affect me and my family?” By C. Shawn Yardley

Fact 1: Everyone wants and needs good health. Healthy people make better parents, better students, better employees, and healthier communities.

More information and a straightforward tool to help you calculate what financial help may be available to you is available at www.healthcare.gov.

Fact 5: All insurance plans must cover the care you need, including doctor visits, hospital stays, preventive care, and prescriptions, much of which is provided with no out-of-pocket costs.

Fact 6: If you currently qualify for sliding fee payment program or hospital charity care, co-pays may still be required. The sliding fee and charity care provide reduced or free care but only for services provided at that medical practice or hospital. They usually do not include specialty care or prescriptions.

Fact 2: Access to quality health care, including preventive care, makes for good health and economic sense.

A healthier workforce is good for business by improving productivity and reducing labor costs.

Fact 3: Uninsured people usually put off getting medical care because they can’t afford it. Consequently, they may have poorer health and utilize higher cost treatment when they are sick. In many cases, those costs are passed along to people who are insured.

Fact 4: Through the Health Insurance Marketplace, low-cost and free plans are available. Insurance through the Marketplace may come with a subsidy and assistance with deductibles and copays, reducing out-of-pocket expenses.

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Fact 7: The costs mentioned in Fact 6 above might very well be more than the monthly premium for Marketplace insurance after you factor in the subsidy on your premium. Furthermore, you may still be entitled to additional benefits from sliding fee programs. The Marketplace subsidy won’t replace your eligibility for sliding fee programs.

Fact 8: There is no sales pitch or fine print when you are looking into health insurance through the Marketplace.

There are only side-by-side comparisons of the insurance plan options offered by the private insurance companies that are participating in the Marketplace.

Fact 9: No one can be denied coverage because of a pre-existing condition.

Fact 10: When you file your income taxes in April 2015, you will be held accountable by the IRS to have enrolled in affordable health insurance coverage.

If you choose not to enroll, you may have a tax penalty. In future years, that penalty increases significantly.

You may expect the process of applying for financial assistance and selecting an insurance plan to be intimidating.

Fortunately, there is a lot of help available.

Community action programs and federally qualified health centers provide inperson assistance or you may receive help over the phone by calling 1-800-318-2596.

Visit the Maine Health Access Foundation site www.enroll207.com to find support.

The bottom line is that it’s critical you get accurate and reliable information when looking for an insurance plan. If you currently do not have health insurance, or if you struggle to pay for the insurance you do have, remember help is available.

The Marketplace, Obamacare, and the Affordable Care Act are all names for one thing: A plan that gets you and your family quality, affordable health coverage. We are responsible for our health. The Affordable Care Act gives us new tools to fulfill these responsibilities.

C. Shawn Yardley is a consultant on the Affordable Care Act for Sebasticook Family Doctors, located in Canaan, Dexter, Dover-Foxcroft, Newport, and Pittsfield.

Photo: Nomadsoul1/thinkstock.com

I

f you are sick, you might go to a walkin clinic or an emergency room. If you do not have health insurance, you would still get care but you would probably get a big bill as well.

For many people who work full-time yet still find their income insufficient to pay the monthly bills, health insurance can seem like an unaffordable luxury. So how can the Affordable Care program help? Making good decisions, including those regarding your health care, begins with the facts, so here they are:

METRO

Your Guide to Health & Wellness

Affordable Care Act and Eye Care Eye health is an important part of general health care, particularly for children. Thanks to the Affordable Care Act, eye care for children is a reality. By Philip Goldthwait

T

Photo: Digital Vision. & Nastco/thinkstock.com

here is no doubt that the U.S. government’s effort to increase the quality and affordability of health care, while decreasing costs and protecting the public through the Affordable Care Act (ACA), has been extremely controversial. Lawmakers, doctors, insurance companies, and patients have been scrambling since 2010 to prepare for (and understand) the biggest overhaul in health care since Medicare and Medicaid were introduced in 1965. Indeed, in some respects, it has raised more questions than it has answered.

But one thing is certain. Despite a rocky start, the ACA is picking up steam.

On January 1 of this year, 2.1 million

Americans had enrolled for coverage; by July 31, it had quadrupled to 8 million.

Under the ACA any health care plan that is “qualified” to be on the health care exchange must provide 10 essential health benefits to its enrollees. One of those essential benefits is the pediatric vision benefit, which mandates an annual comprehensive eye exam, treatment, and materials from birth through age 18.

One problem: The ACA language is vague about exactly what this benefit should be, and it can vary from state-tostate depending on how each state’s exchange plan is structured and defined.

For example, one of Maine’s exchange plans, Maine Community Health Options (MCHO), covers standard frames and lenses up to $150 for enrollees under the age of 18, but this benefit is subject to deductible and coinsurance.

Also, the ACA mandates that there should be “no annual limit on any Essential Health Benefits (EHB).” Plans that have an allowance, in which employees are given a specific amount to apply toward eyewear products of their choice and have the option to pick high-end materials with add-ons, may run up against limits to this mandate.

So, you can expect different interpretations of the “no out-of-pocket” limit rule. Remember, all insurance plans that “qualify” under the ACA and are part of the Health Insurance Marketplace must have the 10 EHBs. Now, because all plans must have the same basic coverage, with no discrimination toward individuals with pre-existing conditions, theoretically it will streamline costs, improve efficiency, reduce waste, and ultimately lower health care costs.

I’ll leave it up to the politicians and numbers guys to figure out if this actually will be the case. We should know in about five to 10 years! I hope this sheds some light on the ACA and one of the 10 EHBs—vision!

Dr. Philip Goldthwait is the owner of Goldthwait Vision Care in the Bangor Mall. He has been providing eye care to the people of Maine for the past 17 years.

metro Health + by Bangor Metro • 17

METRO

Your Guide to Health & Wellness

The Challenges of

Recruiting Physicians to Rural Communities he next time you visit a family medicine clinic there is a high probability that you will be seen by a physician assistant or nurse practitioner, commonly referred to as non-physician providers. You might also be seen by a physician that graduated from a foreign medical school who is practicing medicine on a J-1 visa in an underserved community.

Both non-physician providers and foreign medical graduates allow hospitals and clinics to continue to provide coverage in the midst of a growing national shortage of physicians. One out of three practicing physicians in the United States is over the age of 55 and increasingly at risk for retirement during the next 10 to 15 years.

Starting in 2010, about 3 million baby boomers a year began reaching retirement and will continue to do so over the next 15 years. One need not be a math whiz or a psychic to realize our growing senior citizen population, with its associated complex medical care, will place a significant

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strain on our health care systems. Physician recruitment will become even more challenging during the next few years.

Despite the national shortage of physicians and an aging physician workforce, Maine has found ways to successfully recruit physicians, and not just to the larger urban centers of Portland and Augusta. Statistically, most physicians prefer to live and practice in larger metropolitan areas or the surrounding suburbs, so how do you recruit to Presque Isle, Caribou, Houlton, Lincoln, or Dover-Foxcroft? According to Jane Ham, director of the Maine Recruitment Center (MRC), while there is no quick answer or secret method for rural recruitment, the candidate’s impression of the community is critically important in the recruitment and retention of physicians.

“The candidate and family need to be able to see themselves living and thriving in the community,” says Ham. “Physicians choose rural practices because they want to make a difference. Rural communities offer a lifestyle that the physician is seeking, community engagement, safety, and sense of belonging for their family.”

The MRC, operated under the canopy of the Maine Hospital Association, runs a website that lists all physician employment opportunities for member hospitals and their affiliated practices. By highlighting and marketing Maine physician opportunities nationally, potential physician candidates can learn about multiple job opportunities from people who live and work here in Maine and then make their choice based on their individual clinical and family preferences. By allowing physicians to evaluate multiple offers in Maine they (hopefully) end up choosing the best fit. For small rural hospitals without a large budget for recruitment, the MRC meets a critical need and provides recruitment services at a much better cost than expensive national recruitment firms that know very little about Maine and often next to nothing about the individual hospital or rural community.

Hospitals and clinics in rural communities need to play to their strengths

not their weaknesses. So you don’t have a shopping mall? No cinema? That’s why L.L. Bean and Netflix do mail order! What about the fantastic trout stream and the beautiful rivers and lakes for canoeing and kayaking? You don’t have to disclose your secret spot for blueberries or moose hunting, but letting the physician candidates envision the perks of a rural lifestyle may be all they need to make the move.

Physicians from the baby boomer generation were workaholics—many put in 70 plus hour weeks, year after year. Not so for the new generation of physicians.

Research tells us that they are much more concerned about a work-life balance. A 2009 article in the Journal of Social Science and Medicine, published by Elsevier, listed familiarity, sense of place, community involvement, and self-actualization as key factors for physicians choosing and staying in small rural communities.

Small hospitals and small towns need to ask themselves, “How welcoming are we to newcomers and outsiders?” Successful recruitment “takes a village.” Was the spouse and family truly welcomed and warmly greeted? Families are more likely to put down roots if they quickly develop personal friendships and find ways to connect in the community. Because of this hospitals are now developing intentional retention plans to help support providers and their families.

This lesson from physician recruitment can be applied broadly in rural communities across Maine. By building welcoming communities we acknowledge that our greatest resource is our people. When communities come together with intention and creative discussion there is the potential for new relationships, partnerships, and renewal.

Brad Clark is the director of marketing, community and physician relations at Mayo Regional Hospital in DoverFoxcroft.

Photo: Jacob Wackerhausen/thinkstock.com

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In demand physicians are learning the joys of rural hospitality. By Brad Clark

METRO

Your Guide to Health & Wellness

Transformers in Health Care

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ou may be familiar with the Transformer toys and cartoon that spawned the silly but highly profitable movies about muscle cars and other anabolic vehicles that transform in a matter of seconds into evil-fighting robots who have a soft side for aimless but well intentioned young men and beautiful young women. If you watched the latest movie in 3-D you know that the special effects were dizzying!

The transformation of health care is less dramatic and much more gradual, but no less dizzying. And it is vitally important in its potential to positively affect the health care delivery system and outcomes for patients.

This transformation has been described by Paul Grundy of the Patient Centered Primary Care Collaborative as a move from the “Master Builder” model to the “Patient Centered Medical Home (PCMH)” model.

The traditional “Master Builder” model relied heavily on the intelligence, knowledge, motivation, and memory of the doctor at the center of the model. This resulted in some very good care but unless the doctor was exceptionally talented and tireless, gaps in care were inevitable.

It has also proven to be a costly model.

In the U.S. we spend 40% of the world’s health care dollars on 5% of the world’s population and rank about 35th on the scale of best outcomes. In addition, the burden that the doctor bore resulted in a physician-centered model. Appointment schedules were built around our needs as providers, we were protected and isolated by our staff, and there was little direct access to us by our patients. The patient/doctor interactions tended toward a paternalistic experience with the doctor telling the patient what is best for them. Combine all of this with a payment model that rewards volume rather than quality and the weaknesses of this model become apparent.

In a PCMH model, a team of caregivers, each led by a primary care provider,

20 • metro Health + by Bangor Metro

Health care has undergone major changes lately, all to the benefit of the patient, who is now an active part of a team approach regarding treatment.

embraces its responsibility to help every one of their patients and their community to maximize wellness. Barriers to accessing the provider are removed; the system is designed to focus on the needs of the patient and fatherly advice is replaced by shared decision making augmented by best evidence. Care is delivered in a variety of settings (home, community, church, doctor’s office), by a variety of caregivers (primary care physician, health coach, care manager, clinical pharmacist, family member), using a variety of communication methods (face to face, phone, secure email, texts, video).

Perhaps the most critical aspect of transformation is the one that pertains to the role of the primary care provider.

Previously, the role of doctor was an unassailable position at the top of the clinical ladder. Four characteristics defined that position: Autonomy: It was quite unusual for anyone to look at exactly what care was being provided in the office, much less measure outcomes.

Authority: Doctors were the unquestioned experts whose word was the final one.

Assertion: In the past, because we lacked data we simply made estimates or guessed at what might be best for patient care and practice management, and ensuing efforts were aimed at supporting that assertion.

Control: Because of the importance of our work and the unique nature of our relationship with our patients we often feel that we have to control of all aspects of their care. However, we now know that this leads to inefficiencies and error and that task delegation and sharing of responsibility are keys to improving quality.

Our challenge as providers is to move from autonomy to collaboration, so that we all work together in the best interests of our patients and community. We must trade authority for evidence, because if the

By Dr. Noah Nesin

entire team (including the patient) understands the reasoning behind a decision or a process, it will be embraced much more quickly and comprehensively.

The care team functions best when we have shared goals augmented by rich communication and buoyed by mutual respect. These attributes are best achieved through open evaluation of our work together, so that we are on a path of constant improvement, with the clear aims of improving care, reducing unnecessary costs, and doing it in a patient-centered manner.

If we are successful in this transformation, we will have our own successful sequel, and it will be better than the original.

Noah Nesin, MD, chief medical officer, Penobscot Community Health Care.

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