Check with the insurer first? Associated Press
After Kim Lauerman was diagnosed with ovarian cancer, doctors wanted to give her a drug that helps prevent infections and fever during chemotherapy. Her insurer said no. Story on Page 7.
2 HEALTH JOURNAL, SEPTEMBER 2019
Scientists rethinking Alzheimer’s LAURAN NEERGAARD AP MEDICAL WRITER
WASHINGTON — When researchers at the University of Kentucky compare brains donated from people who died with dementia, very rarely do they find one that bears only Alzheimer’s trademark plaques and tangles — no other damage. If they do, “we call it a unicorn,” said Donna Wilcock, an Alzheimer’s specialist at the university’s aging center. Contrary to popular perception, “there are a lot of changes that happen in the aging brain that lead to dementia in addition to plaques and tangles.” That hard-won lesson helps explain how scientists are rethinking Alzheimer’s. For years researchers have been guided by one leading theory — that getting rid of a buildup of a sticky protein called amyloid would ease the mind-robbing disease. Yet drug after drug has failed. They might clear out the gunk, but they’re not stopping Alzheimer’s inevitable worsening. Today’s treatments only temporarily ease symptoms. The new mantra: diversify. With more money — the government had a record $2.4 billion to spend on Alzheimer’s research this year — the focus has shifted to exploring multiple novel ways of attacking a disease now considered too complex for a one-sizefits-all solution. On the list, researchers are targeting the brain’s specialized immune system, fighting inflammation, even asking if simmering infections play a role. Most of these fresh starts are in the earliest research stages. It’s far from clear that any will pan out, but “the field is now much more open-minded than it ever was to alter-
native ideas,” Wilcock said. BREAKING THE PLAQUE AND TANGLE LINK No one knows what causes Alzheimer’s but amyloid deposits were an obvious first suspect, easy to spot when examining brain tissue. But it turns out that gunk starts silently building up 20 years before any memory loss, and by itself it’s not enough to cause degeneration. Sometime after plaques appear, another protein named tau starts forming tangles inside neurons, heralding cell death and memory loss. But again, not always: Autopsies show sometimes people die with large amounts of both plaques and tangles, yet escape dementia. So something else — maybe several other things — also must play a role. One possible culprit: The brain’s unique immune cells, called microglia (my-kroh-GLEE’-ah). No surprise if you’ve never heard of microglia. Neurons are the brain’s rock stars, the nerve cells that work together to transmit information like memories. Microglia are part of a different family of cells long regarded as the neurons’ support staff. But “it’s becoming clear they’re much more active and play a much more significant role,” said Dr. Richard Hodes, director of the National Institute on Aging. One microglial job is to gobble up toxic proteins and cellular debris. Recently, a mutation in a gene called TREM2 was found to weaken microglia and increase the risk of Alzheimer’s. Dr. David Holtzman at Washington University in St. Louis took a closer look — and says microglia may be key to how the amyloid-tau duo turns toxic. In donated human brains, his team found more tau tangles clustered
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around amyloid plaques when people harbored microglia-weakening TREM2 mutations. The researchers altered the TREM2 gene in mice and seeded their brains with a little human tau. Sure enough, more tangles formed next to plaques in mice with weak microglia than in those with functional immune cells, they recently reported in Nature Neuroscience. Why? Normal microglia seem to restrict amyloid plaques, which limits damage to surrounding tissue — damage that can make it easier for tau to take hold, he explained. While it was known that amyloid buildup drives tau tangles, “we never had a good clue as to how it is doing that,” Holtzman said. The new findings “would argue that these cells are sort of a missing link.” Separately, biotech company Alector Inc. has begun first-step patient testing of a drug designed to boost TREM2 and better activate microglia. THE GERM CONUNDRUM Could gum disease or herpes be to blame? The idea that infections earlier in life could set the stage for Alzheimer’s decades later has simmered on the edge of mainstream medicine, but it’s getting new attention. It sounds weird, but both the germ that causes gum disease and different strains of herpes viruses have been found in Alzheimer’s-affected brain tissue. Researchers in New York are testing the herpes drug valacyclovir in 130 people with mild Alzheimer’s who have evidence of infection with certain herpes strains. And Cortexyme Inc. is enrolling more than 500 early-stage patients around the country to test a drug that targets potentially neuron-damaging substances produced by gingivitis bacteria. Whether the germ theory is a worthwhile pursuit was hotly debated at an international Alzheimer’s Association meeting in July. One skeptic, Dr. Todd Golde of the University of Florida, cautioned that germs’ mere presence doesn’t mean they caused dementia — they could be a consequence of it. Still, a 2018 study from Taiwan offered a hint that treating herpes infection might lower later dementia risk. And a U.S. study found certain herpes viruses affected the behavior of Alzheimer’s-related genes. “Maybe these are just opportunistic pathogens that have space to spring up in the brains of people affected with Alzheimer’s disease,” said Benjamin Readhead of Arizona State University, who co-authored that U.S. paper. But, “it looks at least plausible that some of these pathogens are capable of acting as accelerants of disease.” A COMMON DENOMINATOR One key commonality among emerg-
ing Alzheimer’s theories is how aggressively the brain’s immune system defends itself — and thus how inflamed it becomes. Inflammation is a normal part of the body’s response to illness and injury, one method of fighting infection or healing wounds. But when inflammation is too strong, or doesn’t go away, it’s like friendly fire that harms cells. Remember how some people have lots of plaques and tangles but no dementia? A few years ago Massachusetts General researchers found strikingly little inflammation surrounded all the gunky buildup in the resilient brains — but the Alzheimer’s-affected brains harbored a lot. Research since has found similar inflammatory effects with other forms of dementia — like vascular dementia, where tiny blood vessels that feed the brain are lost or blocked, and dementias caused by Lewy bodies or other toxic proteins. A growing list of genes linked to inflammatory processes also may play a role. A handful of drugs are being explored in the quest to tamp down inflammation’s damaging side without quashing its good effects. Take those microglia, which Holtzman said “may be a twoedged sword.” Early on, before there’s too much plaque, revving them up may be good. But later on, a hyperactive swarm around growing plaques spews out inflammatory molecules. In addition to their immune system job, microglia also secrete molecules that help nourish neurons, noted Kentucky’s Wilcock. The goal is to restore the natural balance of a healthy brain’s environment, she said, so microglia “can perform their essential functions without damaging surrounding tissue.” AMYLOID’S STILL IN THE PICTURE All those drug flops weren’t a waste of time. “Every time there’s a failure it’s absolutely clear that we learn a lot,” Emory University neurologist Dr. Allan Levey recently told the government’s Alzheimer’s advisory council. One lesson: Timing may matter. Most of the failed anti-amyloid drugs were tested in people who already had at least mild symptoms. Some studies seeking to prevent memory loss in the first place still are underway. Several anti-tau drugs also are being tested. Another lesson: Most people have a mix of different dementias, which means they’ll need a variety of treatments. “Now we have an opportunity, a real opportunity, to expand and try all these avenues,” said Alzheimer’s Association chief science officer Maria Carrillo. “The triggers as we understand them are broad.”
4 HEALTH JOURNAL, SEPTEMBER 2019
Say good-bye to the abdominal pooch FOR THE HEALTH JOURNAL
CUMBERLAND — Have you ever noticed that there is a space between the muscles of your belly and the right side doesn’t seem connected to the left side anymore? Do you feel like your abdominal wall muscles are so stretched out that you can’t even “suck in your gut” any more? Sometimes this happens and we lovingly refer to it as our pooch. But this is a medical condition called diastasis recti. “Diastasis” meaning separation and “recti” referring to the belly muscles called the rectus abdominis. This condition is very common and prevalent in pregnant and postpartum moms, but it is also very common in overweight individuals, especially when the extra adipose or fat tissue is carried around the belly region.
This condition can also be found in the exercising population and is caused by faulty lifting mechanics or lifting too heavy. Although it can be cosmetically unappealing, diastasis recti can cause medical and health complications. This separation can make it hard to change positions and make it hard to breathe since your abdominal wall attaches to the diaphragm (which is the muscle that helps us breath). This gap in the abdominal wall can allow the pelvic and abdominal organs such as the bowel, uterus, and bladder to lack sufficient support resulting in prolapse, hernias, constipation, urinary incontinence and even back pain. How can you tell if you have this condition? By laying on your back with legs straight, put your fingers on your belly and sink into the belly button. Lift your
head off the bed and see if your fingers sink into the space. Continue to do this moving up and down the center line from your sternum to your pubic bone. If your fingers sink in to your belly at any point on this line, it’s likely that you have an abdominal wall separation. If you think you have diastasis recti, it is always best to be evaluated by a licensed medical professional. Once you get a diagnosis, you can start the recovery process. Begin with the following: • Don’t strain: Avoid lifting heavy objects as this increases the force put through the abdominal wall. • Avoid constipation: Allowing stool to sit in the colon adds weight and force to the abdomen and then you will ultimately have to strain to empty your bowels. • Be careful with exercise: Crunches, sit-ups, and planks as well as lifting weights that are too heavy can worsen
your separation. • Seek treatment from a physical therapist that specializes in spine, core and pelvis. These highly trained musculoskeletal experts can assist you in the healing process and educate you on proper core exercises to promote strength to decrease the gap between your abdominal muscles. Diastasis recti is a very common problem that most people choose to live with. However, if you have issues such as back pain or incontinence symptoms, conservative treatment options exist to help you gain control and decrease pain. Ask your health care professional if a referral to Progressive Physical Therapy would be beneficial. This article was submitted by Progressive Physical Therapy and Rehabilitation Center with offices in Cumberland and Romney and Keyser, West Virginia.
Robot winds its own way through beating pig heart WASHINGTON (AP) — Borrowing from the way cockroaches skitter along walls, scientists have created a robotic device that safely guides itself through the delicate chambers of a pig’s heart as it’s beating.
It is one of the first times researchers have shown that a truly autonomous surgical robot can navigate inside the heart, not controlled by a doctor with a joystick, according to a study in the journal Science Robotics .
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Heart surgeons routinely push a thin tube called a catheter through twisting and turning blood vessels to make repairs in the heart without open surgery. But how does a robotic version find its own way through moving heart tissue and with blood swishing in the way? Researchers at Boston Children’s Hospital turned the catheter’s camera tip into essentially an “optical whisker,” said cardiac bioengineering chief Pierre Dupont, the lead researcher. Just as cockroaches navigate along walls and rats reach out with their whiskers, the catheter maps its path through the heart, tapping periodically against the heart’s valve and wall ever so lightly — with about the force of a stick of butter sitting in your hand, Dupont said. The technology combines the camera’s images with machine learning to interpret what tissue it’s touching and how hard. “This robot is trying to walk along the wall of the heart until it gets to the valve,” Dr. Uma Duvvuri of the University of Pittsburgh Medical Center, who heads a robotic innovation lab but wasn’t part of the study. “That’s a pretty exciting development but this is still very, very preliminary.” The demonstration technology is still years away from any operating room, and isn’t designed to replace a surgeon, Dupont said. Instead, he said it might free up a surgeon’s time to focus on harder tasks, comparing it to a plane’s autopilot — and also reduce the time patients and medical staff are exposed to X-rays that currently are needed for navigation.
“The easiest part of autonomy in surgery is the technology,” Dupont said. “The hardest parts are the politics, the regulatory” approval and legal efforts. Dupont’s team tested the robotic catheter in 83 procedures in live pigs in a lab. The device found its target, on average taking seconds longer than a doctor threading a catheter into place. But Dupont said the robotic catheter will learn, just like humans, and get better and faster with more practice. Russ Taylor, a medical robotics specialist at Johns Hopkins University, called the technology clever and the study “a significant achievement, but I wouldn’t flag it as a breakthrough.” Robots with different levels of autonomy have been used in surgery for radiation therapy and orthopedics, said Taylor, who wasn’t part of the research. And Pittsburgh’s Duvvuri pointed to studies with a robot that can stitch tissues together without human help. Still, true autonomy, “in my humble opinion, it’s still a hammer looking for a nail,” said Duvvuri, who couldn’t think of an area where it would improve a procedure. And while the new study focused on a potential heart use, Duvvuri said adding that sensing technology to catheters could have other uses, such as helping to diagnose risky growths in the colon. Added Hopkins’ Taylor, “I see things evolving where the machine keeps undertaking more and more discrete tasks while working in partnership with the humans.”
HEALTH JOURNAL, SEPTEMBER 2019 5
Event features fish oil, vitamin D, cholesterol CHICAGO (AP) — Fish oil, vitamin D, novel drugs, new cholesterol guidelines: News from an American Heart Association conference reveals a lot about what works and what does not for preventing heart attacks and other problems. Dietary supplements missed the mark, but a prescription-strength fish oil showed promise. A drug not only helped people with diabetes control blood sugar and lose weight, but also lowered their risk of needing hospitalization for heart failure. Good news for everyone: You no longer have to fast before a blood test to check cholesterol. Don’t stop at the doughnut shop on your way to the clinic, but eating something before the test is OK for most folks, the guidelines say. They’re from the Heart Association and the American College of Cardiology and are endorsed by many other doctor groups. No authors had financial ties to drugmakers. Here are highlights from the conference: CHOLESTEROL Heart disease is the leading cause of death worldwide. High cholesterol leads to hardened arteries that can cause a heart attack or stroke. When guidelines were last revised five years ago, they moved away from just using cholesterol numbers to determine who needs treatment and toward a formula that takes into account age, high blood pressure and other factors to more broadly estimate risk. That was confusing, so the new guidelines blend both approaches, setting targets based on the formula and considering individual circumstances, such as other medical conditions or a family history of early heart disease. “It will never be as simple as a single cholesterol number,” because that doesn’t give a clear picture of risk, said one guideline panel member, Dr. Donald Lloyd-Jones of Northwestern University. If treatment is needed, the first choice remains a statin such as Lipi-
tor or Crestor, which are sold as generics for a dime a day. For people at high risk, such as those who have already had a heart attack, the guidelines suggest adding Zetia, which is also sold as an inexpensive generic, if the statin didn’t lower cholesterol enough. Only if those two medicines don’t help enough should powerful but pricey newer drugs called PCSK9 inhibitors be considered. Many insurers limit coverage of them — Repatha, sold by Amgen, and Praluent, sold by Sanofi and Regeneron — and the guidelines say they’re not cost-effective except for folks at the very highest risk. Finally, if it’s unclear whether someone needs treatment, the guidelines suggest a coronary artery calcium test, which looks for hardening of the arteries, to help decide. It’s a type of X-ray with a radiation dose similar to a mammogram and costs $100 to $300, which most insurers do not cover. LloydJones and others defended its use. “Half of people will have a zero calcium score and can avoid a statin very safely,” a quarter will score high and need treatment, and the rest will need to weigh options with their doctors, he said. The Cleveland Clinic’s Dr. Steven Nissen, who had no role in the guidelines, called them a big improvement but disagreed with “using a test that involves radiation to decide whether to give a drug that costs $3 a month,” referring to the price of statins. A cheap test to check for artery inflammation would be better, he said. FISH OIL, VITAMIN D Two major studies gave mixed results on fish oil , or omega-3 fatty acids. There are different types, including EPA and DHA. In a study of 26,000 healthy people, 1 gram a day of an EPA/DHA combo, a dose and type found in many dietary supplements, showed no clear ability to lower the risk of heart problems or cancer. But another study testing 4 grams a day of Amarin Corp.’s Vascepa, which
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is concentrated EPA, found it slashed heart problems in people at higher risk for them because of high triglycerides, a type of fat in the blood, and other reasons. All were already taking a statin, and there’s concern about the results because Vascepa was compared to mineral oil, which can interfere with statins, and may have made the comparison group fare worse. Still, some doctors said Vascepa’s benefits seemed large enough to outweigh that worry. The study that tested the lower amount of fish oil in the general population also tested vitamin D , one of the most popular supplements, and found it did not lower the risk of cancer or heart problems. “I think we need to accept that that’s a good test” and that the vitamin is not worthwhile, said Dr. Jane Armitage of England’s Oxford University. “We do not see any benefit.” “Don’t waste your money on those supplements,” which are not well regulated and are of varying quality, said Dr. Deepak Bhatt of Brigham and Women’s Hospital in Boston. DIABETES People with diabetes often die of heart disease or heart failure, and new diabetes medicines are required to be tested in large studies to show they don’t raise heart risks. One such medicine, Jardiance, surprised doctors a
few years ago by lowering the risk of heart attacks and strokes. A second medicine, Invokana, later showed similar benefits but with some worrisome side effects. A new study tested a third drug, Farxiga, in more than 17,000 diabetics with other heart risk factors and found a lower rate of hospitalization for heart failure or death from heart-related causes — 5 percent among those on the drug versus 6 percent in a placebo group after four years of use. That’s on top of the drug’s known benefits for controlling diabetes. Certain infections and a serious buildup of acids in the blood were more common with Farxiga but these were rare and are known complications of the drug. It costs about $15 a day, about the same as similar medicines. Farxiga’s maker, AstraZeneca, sponsored the study and many study leaders consult for the company. One independent expert, Dr. Eric Peterson, a Duke University cardiologist and one of the conference leaders, said doctors have been eager to know if the earlier studies suggesting these drugs might help hearts were a fluke. Results from the new study, the largest so far, “could make this class of drugs much more standardly used” for diabetics with high heart risks or heart failure, he said.
6 HEALTH JOURNAL, SEPTEMBER 2019
Here’s something to smile about MARINA VILLENEUVE ASSOCIATED PRESS
AUGUSTA, Maine — It can be hard to keep smiles healthy in rural areas, where dentists are few and far between and residents often are poor and lack dental coverage. Efforts to remedy the problem have
PHARMACY TOPICS by John Stanley
WE SELL LANDFILL STICKERS Higher levels of belly fat associated with lower vitamin D levels in obese individuals, according to data presented at the European Society of Endocrinology annual meeting. Obesity is a global epidemic and contributes to an estimated 2.8 million deaths per year worldwide. Vitamin D deficiency is typically associated with impaired bone health but in recent years has also been linked with higher risks of acute respiratory tract infections, auto-immune diseases and cardiovascular diseases. Low vitamin D levels could therefore have wideranging and undetected adverse effects, although more research is required to confirm the role of vitamin D in these conditions. A link between low vitamin D levels and obesity has previously been reported, but whether this effect is more associated with the type and location of fat was undetermined. Presented as a service to the community by
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produced varying degrees of success. The biggest obstacle? Dentists. Dozens of countries, such as New Zealand, use “dental therapists” — a step below a dentist, similar to a physician’s assistant or a nurse practitioner — to bring basic dental care to remote areas, often tribal reservations. But in the U.S., dentists and their powerful lobby have battled legislatures for years on the drive to allow therapists to practice. Therapists can fill teeth, attach temporary crowns, and extract loose or diseased teeth, leaving more complicated procedures like root canals and reconstruction to dentists. But many dentists argue therapists lack the education and experience needed even to pull teeth. “You might think extracting a tooth is very simple,” said Peter Larrabee, a retired dentist who teaches at the University of New England. “It can kill you if you’re not in the right hands. It doesn’t happen very often, but it happens enough.” Dental therapists currently practice in only four states: on certain reservations and schools in Oregon through a pilot program; on reservations in Washington and Alaska; and for over 10 years in Minnesota, where they must work under the supervision of a dentist. The tide is starting to turn, though. Since December, Nevada, Connecticut, Michigan and New Mexico have passed laws authorizing dental therapists. Arizona passed a similar law last year, and governors in Idaho and Montana this spring signed laws allowing dental therapists on reservations. Maine and Vermont have also passed such laws. And the Connecticut and Massachusetts chapters of the American Dental Association, the nation’s largest dental lobby, supported legislation in those states once it satisfied their concerns about safety. The Massachusetts proposal, not yet law, would require therapists to attain a master’s degree and temporarily work under a dentist’s supervision. But the states looking to allow therapists must also find ways to train them. Only two states, Alaska and Minnesota, have educational programs, and they aren’t accredited. Minnesota’s program is the only one offering master’s degrees, a level of education that satisfies many opponents — dentists generally need a doctorate — but is also expensive. “I would have to relocate to another state to go to school, and if you need to work and you still have a job, why would you do that?” said Cathy Kasprak, a dental hygienist who once hoped to become a therapist under Maine’s 2014 law. Some dental therapists start out as hygienists, who generally hold a two-
year degree, do cleanings and screenings, and offer patients general guidance on oral health. Some advocates of dental therapists argue they should need only the same level of education as a hygienist — a notion that horrifies many opponents. Some lawmakers in Maine, which will require therapists to get a master’s from an accredited program, are optimistic about Vermont’s efforts to set up a dental therapy program with distance-learning options. It’s proposed for launch in fall 2021 at Vermont Technical College with the help of a $400,000 federal grant. Nearly 58 million Americans struggle to afford and make the trip to dental appointments in thousands of communities short on dentists, according to the Kaiser Family Foundation. One of the biggest benefits of dental therapists, proponents say, is that they can make preventive care easier to get by lightening the load of dentists, whose appointment slots are often stolen by complex procedures. Even in states where therapists must practice in dental offices, like Minnesota, they can shorten travel times by opening slots for simple procedures closer to home, a small but growing body of evidence shows. Christy Jo Fogarty, Minnesota’s first licensed advanced dental therapist, said the nonprofit children’s dental care organization she works for saves $40,000 to $50,000 a year by having her on staff instead of an additional dentist — and that’s not including the five other therapists on staff. Dental therapists make $38 to $45 an hour in Minnesota, according to the Minnesota Dental Association. Dentists, meanwhile, average over $83 an hour, according to the Bureau of Labor Statistics. According to state law, at least half of Fogarty’s patients must be on governmental assistance or otherwise qualify as “underserved.” She has also achieved the level of “advanced” therapist, meaning she has practiced with at least 2,000 hours of supervision and can make outreach trips on her own, to places like Head Start programs and community centers. “Why would you ever want to withhold these services from someone who was in need of it?” she said. Ebyn Moss, 49, of Troy, Maine, went without dental appointments for seven years before breaking a tooth below the gum line in 2017. Moss has since had four teeth pulled, a bridge installed, a root canal, two dental implants and seven cavities filled at a cost of $6,300, and expects to shell out another $5,000 in the next year — a bill Moss is paying off with a 19% interest credit card and $16,000 in annual income. “That’s the cost of choosing to have
teeth,” Moss said. Now, Moss gets treated at a dental school in Portland — a two-hour drive for appointments that can last 3 1/2 hours. A dental therapist nearby would have made preventive care easier in the first place, Moss said. The ADA and its state chapters report spending over $3 million a year on lobbying overall, according to data from the National Institute on Money in Politics. The Maine chapter paid nearly $12,000 — a relatively hefty sum in a small state — to fight the 2014 law that spring. Some opponents of dental therapists argue they create a segregated system that gives wealthy urbanites superior care and puts poor, rural residents on a lower tier. Dental groups in Nevada and Michigan had argued lawmakers should instead boost Medicaid reimbursement to encourage dentists to accept low-income patients. Some see less noble reasons for opposition: competition and potential loss of profits. “They’re afraid if dental therapists come in to take care of the poor, they’re going to compete for their patients,” said Frank Catalanotto, a dentistry professor at the University of Florida. Despite signs of more openness, successes aren’t uniform. Legislation failed in North Dakota and Florida this spring. Bills are pending in Kansas, Massachusetts and Wisconsin, as well as Washington, where therapists could be authorized to practice outside reservations. “Available data have yet to demonstrate that creating new midlevel workforce models significantly reduce rates of tooth decay or lower patient costs,” ADA President Jeffrey Cole said in an email. But the recent authorization of dental therapists in so many states may indicate the lobby’s influence and the arguments of other opponents are beginning to lose power. “There is no justification, no evidence to support their opposition to dental therapists,” said dental policy consultant Jay Friedman. He and some cohorts suggest dental therapists may need only as much education as a hygienist and argue they shouldn’t be working primarily in clinics. Such rules don’t help vulnerable groups like poor children in rural schools, he said. “It’s no longer a question of if dental therapists will be authorized in every state,” said Kristen Mizzi Angelone, manager of the Pew Charitable Trusts dental campaign, which has waged its own push for dental therapists. “At this point it’s really only a matter of when.”
HEALTH JOURNAL, SEPTEMBER 2019
Doctors say insurers increasingly interfere TOM MURPHY AP HEALTH WRITER
After Kim Lauerman was diagnosed with ovarian cancer, doctors wanted to give her a drug that helps prevent infections and fever during chemotherapy. Her insurer said no. Anthem Blue Cross told Lauerman the drug wasn’t necessary. She eventually got it after an infection landed her in the hospital, but that led to another problem: She missed several chemo sessions. “The insurance has been great until I got to a point that I really needed something for survival,” Lauerman said. Doctors say they worry about the growing influence insurers have over patient care. Some are finding that they need more approvals from insurance companies for routine things like medical scans or some prescriptions, which can postpone care for a few days or even weeks. Insurers say advances in medical care are prompting them to review more cases before deciding on coverage. They say the checks are not meant to delay or stifle care, and they see them as a way to talk to doctors about the best approach and to guard against unnecessary treatment. “It’s not the end of the conversation,” said Kristine Grow, a spokeswoman for the insurer trade group America’s Health Insurance Plans. Stuck in the middle are patients who may wind up with breaks in treatment. Those interruptions can stir anxiety and, in some cases, influence the success of their care. Lauerman worries her advanced cancer may return because her treatment was cut short. Doctors wanted her to get chemotherapy and the drug Neupogen to boost infection-fighting white blood cells. But they had to end the second round of chemo early after she developed an infection. The 57-year-old Alpharetta, Georgia, resident also had surgery and now gets regular scans and blood work to check whether her cancer has returned. Federal privacy laws prevent Anthem from commenting on Lauerman’s case. But spokeswoman Lori McLaughlin said the insurer does cover Neupogen. That decision can depend on several factors including the patient’s health, the treatment plan and guidelines from cancer groups, she said. No independent research tracks how frequently insurance issues delay or curtail care nationally, but doctors say
they’ve seen a marked increase in difficulties over the last few years. Dr. Ray Page says more than 90% of his patients need an insurer’s approval before he does a positron emission tomography, or PET, scan to try to figure out where cancer has spread. The Fort Worth, Texas, doctor said his patients rarely had to wait for such approvals five years ago. “That patient is putting their life in my hands, and they need to be able to trust me,” he said. “When you have these outside interferences telling me I can do this and I can’t do that ... that very quickly erodes the trust.” Dr. Barbara McAneny said insurer-created delays have become common in many types of cancer care except for routine follow-up visits. That includes people waiting for pain medication prescriptions. “When patients have chronic pain and you make them go without their pain medication for several days ... waiting for the wheels of insurance companies to turn, it is cruel,” said the Albuquerque, New Mexico-based oncologist and former president of the American Medical Association. Outside cancer care, doctors say coverage for routine tests like MRIs has become difficult. Autoworker Lance Hopkins lived with neck pain that spread down his body for weeks earlier this year while he awaited insurance approval of an MRI exam. The 55-year-old Monson, Massachusetts, resident said his doctor needs the exam to find a suspected pinched nerve, but his insurer had only approved less precise tests. “What really stunk is my granddaughter had a fishing derby and I couldn’t even hold a fishing pole to help her,” he said. “All I could do is sit there and watch.” Insurers base their reviews and coverage decisions on treatment guidelines established by medical societies, said Dr. Michael Sherman, chief medical officer for Harvard Pilgrim, which offers employer-sponsored and individual coverage mostly in New England. They have to guard against potential problems such as addiction to pain medications, radiation exposure from too many medical scans or unscrupulous doctors who have their own imaging devices and want to make money. They also try to rein in costs. “If we can’t do that, and we see premiums continue to go up ... people won’t be able to afford insurance, let alone health care,” Sherman said.
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