Kristian Foden-Vencil, Oregon Public Broadcasting, Author at �鶹Ů�� Health News

Effects Of Surgery On A Warming Planet: Can Anesthesia Go Green?

Kristian Foden-Vencil, Oregon Public Broadcasting — Wed, 08 May 2019 09:00:34 +0000

It was early morning in an operating theater at in Portland, Ore. A middle-aged woman lay on the operating table, wrapped in blankets. Surgeons were about to cut out a cancerous growth in her stomach.

But first, an anesthesiologist — Dr.�� — put her under by placing a mask over her face.

“Now I’m breathing for her with this mask,” he said. “And I’m delivering sevoflurane to her through this breathing circuit.”

��is one of the most commonly used anesthesiology gases. The other big one is. There are others too, like nitrous oxide, commonly known as laughing gas.

Whichever gas a patient gets is inhaled, but only about 5% is metabolized. The rest is exhaled. And to make sure the gas doesn’t knock out anyone else in the operating room, it’s sucked into a ventilation system.

And then? It’s vented up and out through the roof, to mingle with other greenhouse gases.

The two frequently used gases are fairly similar medically; sevoflurane needs to be more carefully monitored and meted out��in some patients, but that’s not difficult, Chesebro said.

Generally, unless there’s a reason in a particular case to use one over the other, anesthesiologists simply tend to pick one of the two gases and stick with it. Few understand that

And that bothered Chesebro. He grew up on a ranch in Montana that focused on sustainability.

“Part of growing up on a ranch is taking care of the land and being a good steward,” he said.

Now he lives in the city with his three kids��and has gradually started to worry about their environmental future.

“When I look around and I see the stewardship on display today, it’s discouraging,” he said.

“I got depressed for a while, and so I hit the pause button on myself and said, ‘Well, what’s the very best that I can do?'”

He spent hours of his own time researching anesthesiology gases. And he learned desflurane is 20 times more powerful than sevoflurane in trapping heat in the Earth’s atmosphere. , whereas��sevoflurane breaks down in just one year.

Opening a big, black notebook filled with diagrams and tiny writing, he showed how he computed the amount of each gas the doctors in his group practice used. Then he shared their carbon footprint with them.

“All I’m doing is showing them their data,” Chesebro said. “It’s not really combative. It’s demonstrative.”

One of the doctors he shared his analysis with was Dr. Michael Hartmeyer, who works at the��with Chesebro.

“I wish I had known earlier,” Hartmeyer said. “I would have changed my practice a long time ago.”

Hartmeyer said he was stunned when Chesebro explained that his use of desflurane was the greenhouse-gas equivalent of ��for the duration of each surgical procedure. It’s “only”�� if he uses sevoflurane.��Hartmeyer noted that outside the operating room he drives a Prius, a hybrid electric car.

“You try to be good,” he said. “You take shorter showers or [don’t] leave lights on, or whatever else. But you know there’s always more that we could probably do. But this was, far and away, a relatively easy thing that I could do that made a huge impact.”

The anesthesiology carts that get brought into operating theaters tend to have a row of gases to choose from. Hartmeyer was able to switch pretty much overnight.

Other anesthesiologists made the switch, too. And it didn’t hurt that sevoflurane is considerably cheaper.

Hartmeyer’s change saved his hospital $13,000 a year.

When Chesebro shared his findings with the anesthesia departments at all eight�� in Oregon, they prioritized the use of sevoflurane. They now save about $500,000 a year.

Providence’s��chief executive, , said the hospital system didn’t change its use of the gas because of the money. It changed because the ��now says climate change is the��— and because of Chesebro.

Vance said Chesebro teared up in front of 2,000 people when talking about the gas, his children and the�� character created by .

“Unless someone like you cares a whole awful lot, nothing’s going to get better — it’s not,” said Vance, quoting the book “The Lorax.”

, an associate professor of anesthesiology at��, called Chesebro’s efforts remarkable and important.

She said several hospitals around the country have tried to make this shift, but with mixed results. Some just gave anesthesiologists the information and not much changed. Other hospitals took desflurane away, but that left many anesthesiologists feeling disrespected and angry.

Chesebro succeeded, she said, because he chose to persuade his colleagues — using data. He showed doctors their choice of gas plotted against their greenhouse impact. And it helped that he showed them over and over, so doctors could compare their progress to their peers.

“Providing ongoing reports to providers is the best way for this movement to catch on and grow,” she said. It can reinforce over time, she added, not just what their carbon footprint is, but also what progress they’re making.

Sherman said efforts such as Chesebro’s are sorely needed because the U.S. health sector is responsible for about .

“We clinicians are very much focused on taking care of the patient in front of us,” she said. “We tend to not think about what’s happening to the community health, public health — because we’re so focused on the patient in front of us.”

In an emailed statement, one of the largest manufacturers of both the anesthesia gases — — said it’s important to provide a range of options for patients. The company also said inhaled anesthetics have a climate impact of 0.01% of fossil fuels.

“The overall impact of anesthetic agents on global warming is low, relative to other societal contributors, especially when you consider the critical role these products have in performing safe surgical procedures,” the statement reads.

It’s a fair point, Chesebro said, but he has a counterargument.

“Well, if it’s there, it’s bad. And if I can reduce my life’s footprint by a factor of six … why wouldn’t you do it?'”

The surgery Chesebro was involved in that morning at Providence was a success. Chesebro estimates that by using sevoflurane on his patient, the amount of greenhouse gases produced was the same as in a 40-mile drive across the Portland region. If he’d used desflurane instead, he said, it would have been like driving the more than 1,200 miles from Seattle to San Diego.

Now Chesebro’s hospital bosses are hoping other doctors will follow his lead, research their own pet peeve and maybe solve a problem no one’s thinking about.

This story is part of a partnership that includes��,��and Kaiser Health News.

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

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Emergency Medical Responders Confront Racial Bias

Kristian Foden-Vencil, Oregon Public Broadcasting — Fri, 11 Jan 2019 10:00:54 +0000

A recent study out of Oregon suggests emergency medical responders — EMTs and paramedics — may be treating minority patients differently from the way they treat white patients.

Specifically, the scientists found that black patients in were 40 percent less likely to get pain medication than their white peers.

, head of emergency medical services programs at Oregon Health and Science University and the Oregon Institute of Technology, led the research, which was in December at the Institute for Healthcare Improvement Scientific Symposium in Orlando, Fla.

The researchers received a grant to produce the internal report for the Oregon Emergency Medical Services department and the Oregon Office of Rural Health.

Outright discrimination by paramedics is rare, the researchers say, and illegal; in these cases, unconscious bias may be at work.

A few years ago, was one of a very few black female emergency medical technicians working in Lenawee County, Mich. She said the study’s findings ring true based on her experience.

She remembered one particular call — the patient was down and in pain. As the EMTs arrived at the scene, Gregory could see the patient was black. And that’s when one of her colleagues groaned.

“I think it was something like: ‘Oh, my God. Here we go again,'” Gregory said. She worried — then, as now — that because the patient was black, her colleague assumed he was acting out to get pain medication.

“I am absolutely sure this was unconscious,” added Gregory, who now lives and works in Portland, Ore., where she founded a nonprofit to spread awareness about racial disparities in health care. “At the time, I remember, it increased my stress as we rode up on this person. Because I thought, ‘Now am I going to have to fight my colleague for more pain medication, should that arise?'”

Leslie Gregory, a Portland physician assistant, asks, “How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” She wants the CDC to declare the effects of racism a national health crisis. (Kristian Foden-Vencil/Oregon Public Broadcasting)

Unconscious bias can be subtle — but, as this new report shows, it may be one of the factors behind race-linked seen across the U.S.

The study looked at 104,000 medical charts of ambulance patients from 2015 to 2017. It found that minority patients were less likely to receive morphine and other pain medication compared with white patients — regardless of socioeconomic factors, such as health insurance status.

During a shift change at headquarters in Portland,�� EMTs and paramedics discussed the issue with a reporter as they got their rigs ready for the next shift.

Jennifer Sanders, who has been a paramedic for 30 years, was adamant that her work is not affected by race.

“I’ve never treated anybody different — regardless,” said Sanders.

Most of the emergency responders interviewed, including Jason Dahlke, said race doesn’t affect the treatment they give. But Dahlke also said he and some of his co-workers are thinking deeply about unconscious bias.

“Historically it’s the way this country has been,” Dahlke said. “In the beginning, we had slavery and Jim Crow and redlining — and all of that stuff you can get lost in on a large, macro scale. Yeah. It’s there.”

Paramedic Jason Dahlke says he can see how unconscious bias could slip into an emergency responder’s decisions and taint health care. He’s worked hard to be aware of it, in hopes of preventing those disparities in care. (Kristian Foden-Vencil/Oregon Public Broadcasting)

Asked where he thinks unconscious bias could slip in, Dahlke talked about a patient he just treated.

The man was black and around 60 years old. Dahlke is white and in his 30s. The patient has diabetes and called 911 from home, complaining of extreme pain in his hands and feet.

When Dahlke arrived at the patient’s house, he followed standard procedure and gave the patient a blood glucose test. The results showed that the man’s blood sugar level was low.

“So it’s my decision to treat this blood sugar first. Make sure that number comes up,” Dahlke said.

He gave the patient glucose — but no pain medicine.

Dahlke said he did not address the man’s pain in this case because by the time he had stabilized the patient they had arrived at the hospital — where it was the responsibility of the emergency department staff to take over.

“When people are acutely sick or injured, pain medication is important,” Dahlke said. “But it’s not the first thing we’re going to worry about. We’re going to worry about life threats. You’re not necessarily going to die from pain, and we’re going to do what satisfies the need in the moment to get you into the ambulance and to the hospital and to a higher level of care.”

Dahlke said he is not sure whether, if the patient had been white, he would have administered pain medicine, though he doesn’t think so.

“Is it something that I think about when I come across a patient that does not look like me? I don’t know that it changes my treatment,” he said

Asked whether treatment disparities might sometimes be a result of white people being more likely to ask for more medications, Dahlke smiled.

“I wonder that — if, in this study, if we’re talking about people of color being denied or not given narcotic medicines as much as white people, then maybe we’re overtreating white people with narcotic medicines.”

Research has found African-Americans more likely to be , and that might play a role in diminished care, too. Such distrust is understandable and goes back generations, said Gregory.

“How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” she asked.

Gregory wrote an to the Centers for Disease Control and Prevention in 2015, asking it to declare racism a threat to public health.

Past declarations of crisis — such as those focusing attention on problems such as smoking or HIV — have had significant results, Gregory noted.

But the CDC told Gregory, in its , that while it supports government policies to combat racial discrimination and , “racism and racial discrimination in health is a societal issue as well as a public health one, and one that requires a broad-based societal strategy to effectively dismantle racism and its negative impacts in the U.S.”

Kennel said false stereotypes about race-based differences in physiology that date to slavery also play a role in health care disparities. For example, despite a lack of any supporting science, some medical professionals still think the blood of African-Americans coagulates faster, Kennel said, citing a of medical students at the University of Virginia.

Another question in the survey asked the students whether they thought African-Americans have fewer pain receptors than whites. “An uncomfortably large percentage of medical students said, ‘Yes, that’s true,'” said Kennel.

On top of that, he said, EMTs and paramedics often work in time-pressured situations, where they are limited to ambiguous clinical information and scarce resources. “In these situations, providers are much more likely to default to making decisions [based] on stereotypes,” he said.

Disparities in health care are . Whites tend to get better care and experience better outcomes, whether they’re in a doctor’s office or the ER. But before Kennel’s study, nobody knew whether the same was true in the back of an ambulance.

And they nearly didn’t get to know, because the research required ambulance companies to release highly sensitive data.

“We were prepared to maybe not look that great,” said Robert McDonald, the operations manager at American Medical Response in Portland. AMR is one of the nation’s largest ambulance organizations, and it shared its data from more than 100,000 charts with Kennel.

Some people chalk up the disparities he found to differences in demography and health insurance status, but Kennel said he controlled for those variables.

So now that AMR knows about disparities in its care, what can the company do?

“My feeling is we’re probably going to put some education and training out to our folks in the field,” McDonald said.

In addition, he said, AMR is going to hire more people of color.

“We want to see more ethnicities represented in EMS — which has historically been a white, male-dominated workforce,” McDonald said.

AMR’s policies must change, too, he added. The company has purchased software that will enable patients to read medical permission forms in any of 17 different languages. And the firm is planning an outreach effort to communities of color to explain the role of EMS workers.

This story is part of a partnership that includes��,��and Kaiser Health News.

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Discreetly Tracking Down Sex Partners To Stop A Surge In STDs

Kristian Foden-Vencil, Oregon Public Broadcasting — Fri, 14 Sep 2018 09:00:21 +0000

The U.S. is in the middle of a steep and sustained increase in sexually transmitted diseases.

So how are public health officials responding?

In northwest Oregon’s Clackamas County, health officials have decided to ask anyone who comes in with an STD who their sexual partners are — and then track those partners down.

That job falls to two women: registered nurse Mary Horman and disease intervention specialist Liz Baca. They do most of the work over the phone, telling people they’ve had a partner (no name is revealed) who has tested positive for gonorrhea, HIV, chlamydia or syphilis.

It’s a difficult conversation. And many people can’t be reached via phone. So about once a week, Horman and Baca jump into a car and start knocking on doors.

“It can definitely be scary at times,” Baca said, “especially those rural areas where you’re really relying on the GPS to get you there, and sometimes there are roads that lead you to nowhere.” So far, they haven’t gotten lost.

Plenty of residents in the county’s outskirts own firearms, Baca said, and are comfortable displaying them if they feel they need to protect their property.

“I always try to make myself visible and not be fidgety,” she said. Her goal is to approach with as much warmth as possible, saying, “‘I have a nurse with me.’ Or, ‘My name is Liz, and I work for Clackamas County.'”

The women travel as a pair and never enter a home, she said. And they always carry a cellphone to keep the home office informed of their whereabouts.

On the afternoon I caught up with them, Horman and Baca already had been challenged by a dog and had to leave a trailer park empty-handed. They had the right location, but didn’t know which door to knock on. And they couldn’t just ask around, because neighbors might guess why the health department is tracking someone down, and that would be a breach of medical privacy.

They next called on a 64-year-old laborer, whom we’re identifying only as Larry for those same privacy reasons. He agreed to talk with them, in hopes of warning other people about the substantial��.

Liz Baca, a disease intervention specialist for the county, and Horman search for the right address in an Oregon neighborhood. Part of their job is to get information to people who may have a serious, treatable infection, yet not realize it. (Kristian Foden-Vencil/Oregon Public Broadcasting)

Baca and Horman explained how some diseases, like syphilis, are “” — meaning that as soon as Larry was diagnosed, the doctor had to inform the county, which is why they were at his door.

Larry told them he’s already had penicillin delivered intravenously and is healing fine.

The conversation got tougher as Baca tried to understand the extent of Larry’s infection by showing him graphic pictures of sores and rashes.

“So, another symptom of secondary syphilis is the loss of hair,” she explained. “So, you suddenly lose some hair. You’re thinking, ‘What’s going on?’ In a couple of weeks, it resolves. And you’re still infected. So do you recall any of these symptoms?”

“I do,” Larry said, smiling. “And I would probably say that the lesion, I think you called it, I think occurred — it was probably about 10 years ago.”

That means Larry was living with syphilis for at least a decade — without knowing it.

Many people who have syphilis are asymptomatic — meaning they are carriers of the bacteria but show no obvious symptoms. And that makes the infection tougher to fight.

Also, the fact that the disease was, for a time,��in much of the United States,��means some younger doctors don’t readily recognize the symptoms and signs.

Larry said that he used to have sex with multiple partners he found on Craigslist, but he can’t remember any names.

After such a long time, it’s too late to track down those people, Baca recalled, crestfallen. Still, she insisted, her time wasn’t wasted.

“Being out in the field, you find individuals and you get that public health intervention that is crucial,” she said.

Baca talks to a man who recently found out he’d been suffering from syphilis for at least a decade. (Kristian Foden-Vencil/Oregon Public Broadcasting)

David Harvey, the executive director of the National Coalition of STD Directors, echoed that the efforts of fieldworkers like Baca and Horman are vital.

“Disease intervention specialists are doing heroic work,” he said. “They’re helping to navigate and get people into care.”

Twenty years ago, Harvey said, there were as many as 4,000 disease intervention specialists like Baca in the U.S. Now, because of public health costs, the number is down to about 1,400.

Baca said she’ll continue the work, prioritizing high-risk populations — like men who have sex with men and pregnant women.

The public health officer for Clackamas County, Dr. Sarah Present, said��can cause serious neurological complications and even death.

“We have now multiple cases of congenital syphilis in our county — just in this year,” Present noted, “whereas that had been fairly unheard of for at least the last decade, if not more.”

Partly because of that surge in syphilis among babies, Clackamas now dedicates more resources to aggressively tracking down partners and encouraging testing, Present said — even if those notifications might lead to family strife.

“We do our absolute best to have the [first person diagnosed] talk to their partners for us,” said Present. “We don’t want to have to be the bad guys. However, we can be a partner for people who have the infections — and help them figure out the best way to control the spread of the disease further.”

A��released by Clackamas County earlier this summer shows rates of syphilis have increased 1,300 percent over eight years — in part, because the numbers involved used to be so small.

“Within the last year, we have seen our numbers dramatically increase to the point I’m quite concerned about it,” Present said.

And Clackamas is no outlier. A new report from the Centers for Disease Control and Prevention found that over the past several years, the number of gonorrhea cases has increased��, and syphilis cases are up 76 percent.

The director of the CDC’s national center for STDs,��, said the nation is sliding backward.

“It is evident the systems that identify, treat and ultimately prevent STDs are strained to the near-breaking point,” he said.

Scientists say there are many reasons for the national increase — from the rise in antibiotic-resistant bacteria, to the ease of finding anonymous sex in an era of cellphone hook-up apps.

Public health departments in the United States��have��. In their effort to prevent the spread of disease, they are allowed to inspect, treat and quarantine anyone — even without consent. That power originates in English common law, which finds the rights of an individual can be limited for the common good.

The most famous example is perhaps the Long Island, N.Y.,��cook, Mary Mallon, better known as “.” She was an asymptomatic carrier — and transmitter — of typhoid in the early 1900s, and was forcibly isolated for years by New York public health officials.

Nobody’s advocating such draconian measures now, especially for sexually transmitted diseases. But public health departments can exercise significant power over certain infectious diseases (such as��) that are more broadly contagious because they are airborne.

Clackamas County and the two other counties that make up the Portland metro area have received substantial state and federal grants��to help pay for extra public health outreach.

They are taking several steps to stop the transmission of STDs — like strengthening prevention activities, enhancing screening, testing high-risk populations and educating the public. The counties also try to better support people who test positive; expand investigations; and unite community leaders on this important issue.

As Baca and Horman visited with Larry on his front porch, the man thought back to when he first realized he was very sick. Once he found out why his health was failing, he said, he started to take the infection seriously. “Because, really truly, for me,” he said, “it was going to be a matter of life and death.”

Getting the chance to save lives is why Baca and Horman do this work, they said, even if it’s uncomfortable sometimes.

A few minutes later, the women climbed back into the car they’d left parked in a spot where getting away would be easy — just in case Larry wasn’t so accommodating. They checked their map and the next name on their list.

“There are those areas where you’re entering a property and there’s no one in sight,” Baca said, “and dogs can be scary. You have to run very fast if you see them.”

This story is part of a partnership that includes , and Kaiser Health News.

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‘Bureaucratic Ninjas’ Slice Red-Tape To Battle Health Disparities

Kristian Foden-Vencil, Oregon Public Broadcasting — Mon, 07 Aug 2017 09:00:10 +0000

When a receptionist hands out a form to fill out at a doctor’s office, the questions are usually about medical issues: What’s the visit for? Are you allergic to anything? Up to date on vaccines?

But some health organizations are now asking much more general questions: Do you have trouble paying your bills? Do you feel safe at home? Do you have enough to eat? Research shows these factors can be as important to health as exercise habits or whether you get enough sleep.

Research has begun to show that a person’s to her health as her genetic code.

That’s why Shannon McGrath was asked to fill in a “” this spring when she turned up for her first obstetrics appointment at Kaiser Permanente in Portland, Ore. She was 36 weeks pregnant. (Kaiser Health News is not affiliated with Kaiser Permanente.)

“When I got pregnant I was homeless,” she said. “I didn’t have a lot of structure. And so it was hard to make an appointment. I had struggles with child care for my other kids; transportation; financial struggles.”

The form asked about her rent, her debts, her child care situation and other social factors. Based on her answers, Kaiser Permanente assigned her a “patient navigator.”

“She automatically set up my next few appointments and then set up the rides for them, because that was my No. 1 struggle,” McGrath said. “She assured me that child care wouldn’t be an issue and that it would be OK if they came. So I brought the kids and everything was easy, just like she said it would be.”

Her navigator helped McGrath get in touch with local nonprofits who helped her with rent, a phone and essentials for the baby — such as diapers and bottles — all in the hope that making her life easier might keep her healthier and, in turn, keep KP’s medical costs lower.

McGrath said her patient navigator, Angelette Hamilton, was a bureaucratic ninja, removing paperwork obstacles that kept her from taking care of herself and her family.

Patient navigators have been around for a while. What’s new is the form McGrath filled out and how hospitals are using the socioeconomic data the forms glean to serve patients. The details now go into a patient’s file, which means providers such as��have more information at a glance.

Angelette Hamilton works as a patient navigator at Kaiser Permanente Northwest, helping patients get social services. After Kaiser started offering patients this sort of support, one study found a 40 percent reduction in emergency room use.

“I find it incredibly helpful because it can be very hard to find out,” said Lambert, who is McGrath’s OB-GYN and works at Kaiser Permanente Northwest. “Having it coded right there — we have this problem list that jumps up — really can give you a much better understanding as to what the patient’s going through.”

Federal officials introduced new medical codes for the social determinants of health a few years ago, said��, director of the Office of Minority Health at the Centers for Medicare & Medicaid Services.

“More providers are beginning to recognize the impact that the social determinants have on their patients,” she said.

Nicole Friedman, a regional manager at Kaiser Permanente Northwest, agreed. But she goes one step further.

She hopes giving doctors more information about the home life of each patient will push health care in a new direction — away from more high-priced treatments and toward providing the basics that protect a person’s health.

“My personal belief is that putting more money into health care is a moral sin,” she said. “We need to take money out of health care and put it into other social inputs, like housing and food and transportation.”

Linking health organizations like KP with nonprofit social services such as the Oregon Food Bank will help governments and medical providers see where their money can make the biggest difference, Friedman said.

For example, spending more on affordable housing for homeless people can also have health benefits — in turn, saving the government money down the line.

Friedman said that when KP started addressing people’s social needs,��in emergency room utilization.

McGrath was initially skeptical when doctors offered to help her with things like rent and transportation.

“I didn’t want someone to see my situation and have it raise alarms,” she said.

But ultimately she was glad to have shared that information.

“I’m able to look at life and not feel overwhelmed or burdened,” she said, “or like I’ve got the whole world on my shoulders.”

This story is part of a partnership that includes , and Kaiser Health News.

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Emergency Room Use Stayed High In Oregon Medicaid Study

Kristian Foden-Vencil, Oregon Public Broadcasting — Wed, 19 Oct 2016 22:35:38 +0000

Will Medicaid expansion save the country money as people stop using expensive emergency rooms for primary care?

Not in the first years, said a online in the New England Journal of Medicine.

The study found ER use among Medicaid patients in Oregon stayed high even two years after people gained coverage, and even as more patients visited doctors’ offices, too.

All eyes have been on Oregon to answer this question because eight years ago, Oregon tried an experiment. It wanted to expand Medicaid, but it didn’t have the money to cover every eligible resident.

So it held a lottery to give coverage to as many people as possible, in the fairest way possible. The result was something of a gift to researchers like , director of the Providence�� in Portland. “You couldn’t do this as a researcher,” Wright said. “You couldn’t design a study that randomly gave some people insurance and some people[none], because as a researcher, you don’t want to put someone in that position, just to study it.”

It wouldn’t be ethical to leave some people without coverage just to be a “.” But, since the state was doing it, it offered an invaluable chance to study the differences between people who have Medicaid and people who don’t.

It was the first randomized study on the impacts of health insurance, and it’s one of the largest, surveying 25,000 people.

The first findings reported earlier were that Medicaid��in many ways: it improved people’s financial security; they went to the doctor when they were sick and it reduced rates of depression.

Bill Wright (Kristian Foden-Vencil/Oregon Public Broadcasting)

“These are all things that are really important benefits of Medicaid expansion,” said Wright.

But another earlier study found Medicaid enrollees��by 40 percent over the first 15 months.

“That was a surprise to a lot of folks,” said Wright.

It was widely believed that having insurance would encourage people to get primary care in doctors’ offices or clinics, instead of waiting until they’re really sick and heading to the ER, where care is most expensive.

After that study, experts scrambled to explain what was happening. Some thought it was pent-up demand from a group that hadn’t seen a doctor in years because they didn’t have insurance.

Others thought people just hadn’t had time to establish a relationship with a primary care doctor. And that when they did, emergency department use would drop.

But now, after looking at two years of data, that’s not what this latest study found, said Wright, who is one of the researchers.

“There was no sign that this ED use went down. So this idea of pent-up demand sort of fading away, at least in the first couple of years, it didn’t happen.”

Quite the opposite.

“If your hope is that in the short term, the first couple of years, you’re going to see savings that come out of reduced ED use from Medicaid expansion alone. I don’t think I’d be super optimistic about that. I think that it is going to cost money in the short term,” he said.

Wright said there maybe savings in other areas, like an increased use of preventive services that could stave off problems that would become more expensive later.

And, Leslie Clement, with the Oregon Health Authority, said during the past two years, Oregon has seen avoidable emergency room use drop by 4 percent.

She said, that’s because the state is coordinating care better, by doing things like helping people get to their doctors’ appointments and take their medication.

“It is not just a ‘open up coverage and let people used health care services as they have done historically,’ ” she said. “But it’s reforming that system.”

The Oregon study can’t tease out much more information because the experiment had to stop when the state expanded Medicaid fully under the Affordable Care Act.

This story is part of a reporting partnership that includes��, and Kaiser Health News.

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Election Buzz: Critics Of Legal Pot Say Addiction Becomes ‘A Disease Of The Family’

Kristian Foden-Vencil, Oregon Public Broadcasting — Wed, 28 Sep 2016 09:00:34 +0000

If pot laws were colors, a map of the U.S. map would resemble a tie-dye T-shirt.��In some states, marijuana is illegal. In others, it’s legal for medical purposes. And still in others, it is even legal for recreational use.

Five more states could come into that last category this fall, as voters decide whether to legalize it in California, Nevada, Maine, Massachusetts and Arizona.

It was only six years ago that Arizona approved marijuana for medicinal use, and that’s a stark contrast to Oregon, where medicinal marijuana was legal for almost two decades before smoking pot for fun became OK last year.

Opposition to recreational use in Arizona has been organized and vocal. A group that includes two county attorneys sued, unsuccessfully, to get it off the ballot.

And then there are people like Debbie Moak, 59, who said she put her son in drug rehab when he was 20.��“A lot of these kids who are going to be impacted the most by this, they won’t be voting in this election,” said Moak, who lives outside of Phoenix. “This is where we need to be the adult in the room and protect the kids.”

Moak said pot led her son��to use harder drugs. Cocaine became his drug of choice, and he dropped out of college and eventually became��homeless.

“It tears a family apart,” she said. “Addiction becomes a disease of the family, and I’ve lived it, in the trenches. And I don’t want to see this happen for any other family.”

But Moak used to see that pretty much daily, back when she ran a nonprofit called Not My Kid that worked to keep young people off drugs. For nearly two decades, she spoke to parents in pain because they were unable to reach their children who were sinking deeper into drug dependency. Her own son��is now in his 30s and sober, but his recovery took years.

She opposes the approval of medical and recreational marijuana laws because she fears it will lead to more acceptance of the substance she views as tremendously harmful.

Coming at this from a completely different direction is 60-year-old food editor Martha Holmberg. She lives in Portland, Ore., and says she smoked a lot of marijuana in high school and college then didn’t touch pot again until she finished bringing up her daughter. Now it’s part of the��fabric of her social life.

“I don’t do it with people that I don’t know well,” Holmberg said. “But if I’m hanging out with girlfriends or we’re going over to a friend’s house, I will usually bring weed and say, ‘Hey, anybody want to get high?’ “

Oregonian Martha Holmberg says she used to smoke pot in high schol and college, but stopped for years while raising her family. With pot legal in Oregon and growin in acceptance, she’s returned to smoking occasionally. (Kristian Foden-Vencil/Oregon Public Broadcasting)

Some do and some don’t. “And it all flows very comfortably in that situation,” she said. “It’s not like the pot smokers have to go off to the corner.”

Holmberg recently hosted two women writing a pot cookbook. And they needed somewhere legal to try out recipes. The main issue: How much weed to include in each dish?

The equivalent for alcohol would be to figure out whether you make a Moscow Mule with a finger of vodka or a pint. Holmberg says they proved to be a little too cautious.

“At the end of the evening people weren’t really very high,” she says. “I think some people were disappointed. We actually pulled out a vape pen for anybody who wanted to get high. But it was much better that way. People felt reassured.”

For some people in Arizona, the scene Holmberg described would be shocking. But the introduction of medical marijuana here in 2010 made it a lot more palatable for others. Like Lisa Olson, a mother of five who lives in Mesa, outside of Phoenix. She says pot helps��ease the symptoms of her multiple sclerosis.

How does her marijuana use fit in with family life? “Basically, the way we ended up handling it was a lot like alcohol,” she said. “So my kids certainly see me drinking a glass of wine with most dinners. They know that’s not for them. That’s for the adults.”

She thinks adults should be able to use pot recreationally, too. For someone like Olson, who had always abstained from drugs, that’s quite a change. Once she saw how much good marijuana did for her, she felt it shouldn’t only be reserved for people with a few specific ailments.

She’s passed this newfound openness onto her children. Jake Olson, 20, said the “just say no” message he got from school wasn’t necessarily true. He appreciated hearing that there are times when use in moderation is OK and shouldn’t be equated with heavier drugs.

“It’s really funny because, you know, most teenagers don’t figure out things like that through their parents,” he said. “But I am that exception. I am that person who learned that maybe not all bad things are bad, from my parents.”

Patrick Caldwell, who also lives in Oregon, says pot acceptance is gradually taking hold in his state. But he will still only bring marijuana to certain events and situations. (Kristian Foden-Vencil/Oregon Public Broadcasting)

Acceptance is growing in Oregon. But it’s been a gradual process. Patrick Caldwell has a Portland business selling pot containers. He is 29 and brings cannabis-infused sodas to parties. He said he might share one at, say, a bachelor party but not at a family picnic. Caldwell doesn’t want pot to be taken lightly.

“I want my nephews to be able to make their own informed decision about cannabis without being influenced by the fact that I so regularly use it,” he said.

He thinks people need to respect what they’re getting into. But he hopes that in a few years, bringing pot to a family picnic will be no different than bringing a six-pack.

This story is part of a partnership that includes , , and Kaiser Health News.

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From Pills To Pins: Oregon Is Changing How It Deals With Back Pain

Kristian Foden-Vencil, Oregon Public Broadcasting — Tue, 22 Sep 2015 10:47:16 +0000

When Portland resident Doris Keene raised her four children, she walked everywhere and stayed active. But when she turned 59, she says, everything fell apart.

“My leg started bothering me. First it was my knees.” She ignored the pain, and thinks now it was it the sciatic nerve acting up, all along. “I just tried to deal with it,” Keene says.

But eventually, she went to a doctor who prescribed Vicodin and muscle relaxants. – more than 900,000 people. The state currently leads the nation in nonmedical use of opioids. And about a third of the hospitalizations related to drug abuse in Oregon are because of opioids.

Keene says the drugs helped her, but only to a degree.

Doris Keene (right) at Portland’s Quest Center for Integrative Health. Keene says acupuncture treatments ease her pain at least as effectively as the Vicodin and muscle relaxants she once depended on. (Photo by Kristian Foden-Vencil/Oregon Public Broadcasting)

“My body was saying, ‘Well, if I take another one, maybe it’ll work.’ So, I mean, that’s just human nature. Especially when you’re in the kind of pain I was in. You get to the point after months and months of pain where you’re begging for anything – anything — to relieve the pain,” she says.

In the end, Keene says, she became addicted. Her doctor ended up cutting off her supply of pills.

“I got very upset. I said, ‘What do you mean? You gave them to me. Why’d you give them to me and then tell me that I couldn’t have them?’ I was begging,” she says.

Then Keene went to the , a pain management center in Portland.

Lying on a fold-out chair in a darkened room with several other people, Keene has about a dozen acupuncture needles in place.

“I come in here wearing back braces, and knee braces and a crutch, and Dr. Dave told me, ‘Get rid of them! They’re just weakening your muscles,’ ” Keene says. “And when I could walk out of here after the first acupuncture [treatment], I wanted to grab him and kiss him.”

is Keene’s “Dr. Dave,” and executive director of the Quest Center. He is board certified in and acupuncture, and says doctors need to stop thinking of opioids as a first line of defense against pain.

“There should be an array of things for people to choose from,” Eisen says, “whether it be chiropractic care, or naturopathic care, or acupuncture, nutrition, massage. Try��those things — and if they don’t work, you use opioids as a last resort.”

Doris Keene says acupuncture treatments ease her pain at least as effectively as the Vicodin and muscle relaxants she once depended on. (Photo by Kristian Foden-Vencil/Oregon Public Broadcasting)

Oregon wants more patients to take this approach. , coordinator of the Oregon Pain Management Commission, says Medicaid’s traditional way of dealing with back pain involved advising bed rest and prescribing painkillers.

“The only thing that might have been covered in the past was narcotics,” Taray says. “But treatments such as acupuncture, chiropractor, massage therapy, physical therapy and rehab would never have been covered.”

But starting in January 2016, the state will fund many of these back-pain treatments for patients who get their health care via Oregon’s version of Medicaid — the . While the treatments may cost more than a course of pain pills, the hope is that money will be saved by reducing the number of people who become addicted to opioids or abuse them. And pills as some people assume.

“Research is out there that suggests that with back conditions we’re spending a lot of money on health care treatments and services that aren’t improving outcomes,” Taray says.

Oregon also has not found overwhelming evidence that acupuncture, yoga or spinal manipulation work better than other options. But, as Taray points out, these alternatives don’t involve drugs.

This story is part of a partnership that includes , and Kaiser Health News.

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Medicare Says Doctors Should Get Paid To Discuss End-Of-Life Issues

Kristian Foden-Vencil, Oregon Public Broadcasting — Tue, 18 Aug 2015 11:08:18 +0000

Remember the so-called death panels?

When Congress debated the Affordable Care Act in 2009, the legislation originally included a provision that would have allowed Medicare to reimburse doctors when they meet with patients to talk about end-of-life care.

But then Sarah Palin argued that such payments would lead to care being withheld from the elderly and disabled. Her comment ignited a firestorm among conservatives and helped fuel the opposition to the legislation.

Her assertions greatly distressed��Dr. Pamelyn Close, a palliative care specialist in Los Angeles.

“It did terrible damage to the concept of having this conversation,” she said.

Amid the ensuing political uproar, Congress deleted the provision. And the lack of payments and concerns about the controversy further discouraged doctors from initiating these talks, according to Close.

“We just are not having these conversations often enough and soon enough,” Close said. “Loved ones who are trying to do always the right thing, end up being weighed with tremendous guilt and tremendous uncertainty without having had that conversation.”

When done right, according to Close, these counseling sessions often delve into end-of-life treatment options and legal documents, such as advance directives and living wills. The issues to be covered are complex and typically require a series of discussions.

Right now, Medicare only pays doctors for this sort of advanced care planning if it happens during the first visit for new Medicare enrollees. But the government recently has again proposed that Medicare reimburse doctors for including these conversations in their practice, whenever they occur.

Already, some private insurance companies are starting to do just that.

Meanwhile, the��, a conservative Christian organization, has formally opposed Medicare’s proposal.

“By paying doctors for these conversations, what we’re doing is opening the door to directive counseling and coercion,” said Catherine Glenn Foster, an attorney with the group. Foster says her organization supports end-of-life counseling and planning, but not in a doctor’s office.

“A doctor is not really the person you’d want to be having it with – particularly not a general practitioner who would not be able to advise on the nuances of end-of-life care in the first place,” she says.

But patients seem to want these talks. A 2012 study by the California HealthCare Foundation found that��of Californians would like to have an end-of-life conversation with their physician, but fewer than one in 10 has done so.

Many doctors who initiate the discussions often do so on their own dime. More often, they don’t have them at all, said��, an internist with Cedars-Sinai Medical Center in Los Angeles.

“When a doctor has patients scheduled every 15 minutes, it’s difficult to have a face-to-face conversation about values and goals related to the end of life, which is one of the most sensitive topics that you can possibly discuss with a patient,” Stone said.

, an internist with the Center for Ethics in Health Care at the Oregon Health and Science University in Portland, says the informality with which such conversations are held now means that family members may not be included. Having the discussion as part of a formal doctor’s appointment can change that, she said.

“What it does is, it gives this really important conversation dignity and standing,” she said.

In Oregon, doctors have been squeezing end-of-life discussions into regular medical appointments for decades, under less-than-ideal circumstances. Over the last five years a quarter of a million Oregonians filed their wishes with a state registry. They use what’s known as a , which stands for Physician Orders for Life Sustaining Treatment. A version of it has been adopted by some other states, including New York and West Virginia.

Jo Ann Farwell, a retired Portland social worker who was recently diagnosed with a brain tumor, completed the form after talking to her doctor.

“I had surgery and had a prognosis of four to six months to live,” she said, after she was diagnosed with a brain tumor.

She did it, she said, to make sure her last hours are as comfortable as possible.

“I wouldn’t want to be on tube-feeding,” she said. “I wouldn’t want to be resuscitated, or have mechanical ventilation, because that would probably prolong my dying, rather than giving me quality of life.”

In the 1990s, health care workers all over Oregon recognized that the wishes of patients weren’t being consistently followed. So the health care establishment worked with the state and with ethicists to prioritize end-of-life talks; the result was the POLST form.

, a Democrat from Portland, has introduced the Medicare reimbursement legislation every session since 2009. Until now, he says, the federal government hasn’t placed any value on helping people prepare for death, and he finds that ironic.

“The Medicare program will pay for literally thousands of medical procedures, many of them very expensive and complex, even if the person is at the latest stage of life and it may not do any good,” Blumenauer says.

From a purely financial point of view, the change could save money. But Blumenauer says that’s not what’s driving him.

“I don’t care what people decide,” he says. “If they want to die in an ICU with tubes up their nose, that’s their choice. What we want is that people know what their choices are.”

Farwell, the brain tumor patient, well remembers when her sister was dying from cancer.

“She never talked about death or dying,” Farwell said, “never talked about what she wanted at the end. It was very, very difficult for me to try to plan and give her care.”

Farwell wants her sons to be in a better position when it comes to carrying out her wishes.

The federal government is now accepting public comment on the Medicare reimbursement proposal. It’s expected to make a decision in November.

This story is part of a partnership that includes KPCC, Oregon Public Broadcasting, NPR and��.

KHN’s coverage of aging and long term care issues is supported in part by a grant from .

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An Explicit Contract Makes Surrogacy Viable For An Oregon Woman

Kristian Foden-Vencil, Oregon Public Broadcasting — Thu, 09 Jul 2015 10:36:24 +0000

During the past few years, Oregon has quietly become a prime location for women willing to carry children for those unable to get pregnant. There are several reasons for that: lenient laws, a critical mass of successful fertility clinics and a system for amending a birth certificate pre-birth.

But surrogacy arrangements are often informal agreements, and they��. A surrogate may face unexpected medical bills, or the intended parents may change their mind.

Yet Mardi Palan is excited about becoming a surrogate, and that’s due in part to a very thorough��she has signed governing the terms of her surrogacy. It includes Palan’s compensation, standards she must meet and a wide array of protections for her. “The contract needs to be black and white, because there has to be some clarity at one point in the process regarding expectations,” said John Chally, the director of the NorthwestSurrogacy Center in Portland, where Palan signed up.

Mardi Palan cuts a client’s hair at Gilly’s Salon in Portland. Palan plans to use the $30,000 she could get for carrying twins, for a downpayment on a home. (Photo by Kristian Foden-Vencil/Oregon Public Broadcasting)

Palan is 30 and a hair stylist. She hopes to carry twins for a gay couple from Israel. She has a partner and a 1½-year-old son.

“I carried my son really well, and I really enjoyed being pregnant,” she says. “People mentioned surrogacy as an option to make money on the side and do something really nice for someone else.”

Palan’s contract covers what’s expected of her and a multitude of contingencies. The basics are that Palan will get about $25,000 if she successfully delivers one child, and an additional $5,000 for twins. She says she’ll use it for a down payment on a home.

The contract also deals with ethical issues. It states, for example, that Palan is not selling the children, nor agreeing to terminate her parental rights. That is because none of her genetic material is involved in the pregnancy. The two eggs will come from a donor, and the sperm will come from the two fathers in Israel.

“The analogy is that I’m the soil and someone else is the seed and someone else is the water, so we come together to make the child,” she says.

The contract says Palan is getting paid for “services rendered” and compensation for any pain and emotional distress she may suffer.

Palan’s lawyer, Marlene Findling, says it’s a good contract. “By far the vast majority of these contracts go really smoothly. This contract does protect her.”

And there’s a lot at stake. The intended parents are paying more than $100,000 for their child, or children.

Doctors will get about $45,000.

The NW Surrogacy Center will get about $23,000.

Chally wrote the contract. He says he’s tried to include every possible situation, even if it seems painfully direct — like when it says Palan will get $2,500 if she loses her uterus.

But, he adds, “As with most of those things, those contracts don’t describe relationships between people.”

Chally says he works hard to make sure surrogates aren’t turned into commodities. That takes a lot of work, because 70 percent of Chally’s clients come from overseas. He has worked with people from 23 countries.

Palan went out to breakfast and dinner with the couple from Israel. She was worried they wouldn’t like her tattoos, rainbow hair or nose stud. But they’re artists, and she says they took her appearance in stride.

Chally says it’s critical for surrogates to get along with prospective parents. He’s turned away unsociable couples seeking a surrogate.

“Surrogates want to know who [the parents] are,” he says. “They want to know what kind of relationship the two of them have. They want to see the joy in their eyes about realizing that there’s a pregnancy. They frankly want some time and attention during that process, as a manifestation of their care and concern for her, as she’s doing a truly remarkable thing for them.”

The contract goes on to stipulate Palan’s behavior with requirements designed to help keep the fetus from harm.

For example, she’s subject to random drug, alcohol and nicotine testing at a clinic. She can’t clean a litter box, get a tattoo or have an X-ray.

Another interesting clause in Palan’s contract is that she has agreed not to travel across the border to Washington during her pregnancy. Washington allows surrogacy for only a limited set of reasons, and surrogacy for financial gain is illegal there.

Sister Sharon Park, of the Washington State Catholic Conference, says, “The potential for exploitation of surrogates is huge, especially when money gets involved.”

For her part, Palan feels protected and empowered by the contract. She started hormone injections July 4 and expects to have two embryos implanted in August.

This story is part of a reporting partnership with , and��.

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Mental Health Privacy Questions Arise In Rape Case At University Of Oregon

Kristian Foden-Vencil, Oregon Public Broadcasting — Mon, 09 Mar 2015 20:35:36 +0000

The privacy of students who get care at university clinics is in doubt after the mental health records of a women who says she was raped at the University of Oregon were accessed by the school in the course of defending itself against a lawsuit.

The unidentified student is suing the university for mishandling her assault. She says she was raped by three basketball players last year. The University of Oregon found the players responsible, kicked them off the team and out of school.

But there was no court case. Nobody was found guilty of any crime. And it was only discovered later that one of the players had been suspended from a previous college team over allegations of another sexual assault.

Those are some of the reasons . Here’s where the privacy issues surface:

The student got therapy at the university’s health clinic. In preparing to defend itself against her complaint, the university accessed those records and sent them to its attorney.

Kelsey Jones, 21, is a student at the University of Oregon who works with the . She says the case has shaken students’ confidence in the mental health care they receive on campus, and she won’t go to the campus clinic.

“It’s very concerning for a lot of people,” Jones says. “It’s ten times harder now to seek that help and feel safe and feel okay to share 100 percent of what you’re feeling.”

Two employees at the university’s counseling center were also disturbed by the school’s actions, and they fired off to the university community. One of the authors, therapist Jennifer Morlok, said her job was threatened and she felt the school was forcing her to violate her professional ethics.

The university administration would not talk on tape for this story. But in court papers, officials argued that since the student went to the school’s health clinic, her health records belong to the school and therefore could be accessed.

In addition, they argued that because she claimed emotional distress –a medical claim – the school was entitled to her medical records under a law known as FERPA – the Family Educational Rights and Privacy Act.

Steve McDonald, and an attorney for the Rhode Island School Of Design, says in this case the medical privacy law known as HIPPA doesn’t apply, and the school is within its rights under FERPA.

“I would think in almost any case anywhere in the country in a fear and emotional distress claim, those records would be relevant, and you would get them through some process,” McDonald says.

Under FERPA, at a university run health clinic, the university can access student medical records — if they’re relevant for a legal defense. That may come as a surprise to anyone who assumes that doctor-patient privilege is the same regardless of where the care is received.

Another FERPA expert, Gonzaga Law School professor Lynn Daggett agrees the university is within its rights. She says the situation allows universities to avoid an important legal process, simply because the therapist is a university employee. “The way the school would access the records in the situation with a private therapist is that during discovery, before trial, they would ask her to voluntarily agree or issue a subpoena for them,” Daggert says.

“She would have every right to make a motion to the court to quash or modify the subpoena, have the court look at her medical records in camera, which means in secret in the judge’s chambers, and have the court sort through what appropriately would be shared with the school and what would not be.”

The issue has caused such a stir, the US Department of Education spokeswoman Denise Horn weighed in on the need to protect confidentiality in a statement emailed to reporters.

“FERPA would permit the treatment records to be disclosed in litigation between the student and the institution if the records are relevant for the institution to defend itself.”

But the statement concludes: “The Department of Education urges higher education institutions to not only comply with FERPA, but also to respect the expectation of confidentiality that all Americans hold when talking to a counselor or therapist.”

Back on campus, student Kelsey Jones remains unsatisfied with the legal explanations: “Whether it’s legal or not legal, I think it’s morally and ethically not right.”

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