July 21, 2008
Trying to Save by Increasing Doctors’ Fees
The New York Times reports on a new experiment by federal and state government agencies as well as many insurers around the country that propose to cut health costs by paying doctors more. Milt Freudenheim writes,
Cutting health costs by paying doctors more?
That is the premise of experiments under way by federal and state government agencies and many insurers around the country. The idea is that by paying family physicians, internists and pediatricians to devote more time and attention to their patients, insurers and patients can save thousands of dollars downstream on unnecessary tests, visits to expensive specialists and avoidable trips to the hospital.
Nationally, Medicare and commercial insurers pay an average of only about $60 a visit to the office of a primary-care doctor and rarely if ever pay for telephone or e-mail consultations. Many health policy experts say the payments are not enough to let the doctors spend more than a few minutes with each patient.
Robert Williamson, a 60-year-old Philadelphia man, recalls the cursory exam he received a few years ago from a harried doctor who, Mr. Williamson says, missed the danger signals and sent him home. A short time later Mr. Williamson had a stroke.
For want of a careful examination by a primary-care doctor, Mr. Williamson became one of countless Americans each year whose unidentified or under-treated illnesses escalate into medical conditions with catastrophic personal and economic costs. Besides incurring $30,000 in hospital bills paid by his employer’s insurer, Mr. Williamson had to stop working as a customer service representative at Philadelphia Gas Works and go on Social Security disability, at a current cost to taxpayers of $1,900 a month.
With Mr. Williamson’s new doctor, such an outcome would be much less likely.
“I give him my heart and diabetes readings by e-mail and phone, without getting up out of my chair,” Mr. Williamson said. “I can get better directions, at the very moment I need them. It’s life-saving.”
His current internist, Richard Baron, is one of more than 100 physicians in metropolitan Philadelphia taking part in the experiment, which is being conducted jointly by some of the region’s largest insurers. Dr. Baron still gets a fee of only about $64 for each office visit. But his five-doctor group will also receive $200,000 to $300,000 this year beyond their regular fees to keep better track of their 8,400 patients.
“We are trying to do more e-mail care and telephone care, which we haven’t been paid for in the past,” Dr. Baron said.
Insurers are conducting similar pilot projects in at least a half-dozen states, in experiments involving thousands of doctors and nearly 2 million patients. Many more are in the planning stages, at the urging of health policy experts and employers that provide medical benefits.
The big government health care programs, Medicaid and Medicare, are also studying the concept. A Medicaid experiment already under way in North Carolina saved the government program in that state about $162 million in 2006. That was 11 percent less than the state would have spent under the old system of reimbursement, according to an audit by Mercer, a consulting firm.
Earlier this month, as part of a bill to protect Medicare payments to doctors, the Senate overrode President Bush’s veto to authorize $100 million to finance a three-year Medicare pilot to further test the concept of spending more on primary care.
Under the various payment experiments, family doctors are encouraged to hire additional staff to help monitor patients’ treatment and follow-up, and to help patients stay ahead of problems by sending reminders when they are due for preventive tests like mammograms and colon exams.
For people like Mr. Williamson with serious chronic illnesses, the doctors take personal charge, answering patients’ phone or e-mail questions promptly. In emergencies, patients can show up at the office and see their doctors on short notice.
Such features add up to a model of primary care that proponents refer to as providing people with a “medical home” — a base where doctors, staff and patients pull together as one big health-care family. Or at least that is the ideal.
“It’s the latest new, new thing — testing whether medical homes can be a vehicle for pulling America upwards from the grossly inefficient swamp in which our health system is currently mired,” said Dr. Arnold Milstein, a senior consultant at Mercer who is also member of the Medicare Payment Advisory Commission, an independent Congressional agency.
The panel has recommended that Medicare expand its plans for a medical-home pilot project next year that is expected to pay primary-care doctors in eight states $30 to $40 a month extra for each person enrolled with a chronic illness.
In Michigan, the auto industry has been a major force behind one of the largest medical-home projects yet devised. Blue Cross Blue Shield of Michigan, which has 4.7 million members, plans to spend $30 million this year to help primary-care doctors offer such services. About 4,900 primary-care doctors are participating, said Dr. Thomas Simmer, chief medical officer of Michigan Blue Cross.
Advocates of the approach hope it will attract more doctors to primary care. Last year only 7 percent of medical school graduates chose family practice, a field with a median income of $150,000, according to the American Academy of Family Physicians. That compares with $406,000 for gastroenterologists and $433,00 for cardiac surgeons, as measured by the Medical Group Management Association.
The American Medical Association said that in its latest count, in 2006, there were slightly more than 251,000 practicing family physicians, general, practitioners, and internists in this country, compared with nearly 472,000 specialists.
“The pipeline of primary-care doctors has been running dry for several years,” said Dr. Barbara Starfield, a health policy expert at Johns Hopkins University. Many parts of the country do not meet the generally accepted standard of one primary-care doctor for every 1,000 to 2,000 people, Dr. Starfield said.
The Philadelphia pilot project is sponsored by three of the area’s largest insurers — Independence Blue Cross, Aetna and Cigna — as well as some local providers of Medicaid services, which together have agreed to spend $13 million on the program over the next three years.
Dr. Baron expects the project to add as much 15 percent to the annual revenue of his medical group. He declined to specify the practice’s total gross income last year, but said that each of the five physicians earned less than the $177,000 national median for internists.
To participate in the Philadelphia experiment, doctors must arrange for their offices to keep in close communication with their entire rosters of patients. Dr. Baron’s practice, besides the physicians, a business manager and clerical assistants, has added a patient educator, whom he said would cost $60,000 in salary plus $60,000 more for benefits and supporting technology. The group is also spending $25,000 for part-time services of a data analyst.
Employers predict that better early care will reduce their health costs in the long run. “We want to buy our care this way, we think it’s the right thing to do,” said Dr. Paul Grundy, I.B.M.’s director of health care technology and strategic initiatives.
Despite the hopes riding on the pilot projects, some experts are skeptical. “There is very little concrete rigorous evidence that the medical home will do all those wonderful things they want it to do,” said Mark Pauly, a health policy economist at the Wharton School of the University of Pennsylvania.
Even executives at Aetna and Cigna are cautious about betting on a payoff from the Philadelphia project, which was orchestrated by Pennsylvania’s Democratic Governor Edward G. Rendell and his office of health care reform.
It is uncertain whether there will be a direct return on the investment within a “reasonable time horizon,” said Dr. Don Liss, an Aetna medical director who is an internist himself. Still, Dr. Liss added, “a reasonable body of evidence suggests that improving primary care as a foundation for health care will improve quality and access to care.”
The Pennsylvania program will start expanding to other parts of the state this fall. It comes none too soon, in the view of Dr. Joseph Mambu, a family physician in Lower Gwynedd, a Philadelphia suburb. Trying to build a medical-home practice before the pilot project began, Dr. Mambu said he went into debt installing an electronic medical records system and establishing patient-friendly features like evening and Saturday office hours.
“Last year, I hit the red ink because of all the technology,” he said. “Unless we get help from the insurance companies and the government, the system is going down the toilet.”
But with the new medical-home money, Dr. Mambu said he expected to pay down his debts and start a patient wellness program. The insurance pilot project, he said, offers “a ray of hope.”
Means Testing, for Medicare
Writing for the New York Times, Tyler Cowen suggests that cutting back payments to the relatively wealthy is a more efficient way to allocate government benefits. For health care costs, this could be done by expanding Medicaid and making it an entirely federal program, and also by limiting Medicare. Cowen writes,
Right now, the United States is in the midst of a financial crisis, but even more pressing problems may lie ahead — and the presidential candidates aren’t addressing them.
No matter who sits in the Oval Office next year, there won’t be many degrees of freedom in the federal budget. That’s because spending on entitlement programs is largely locked into place, and the situation will become much worse as Americans age and health care costs rise. Even if the government is conservative in its spending, just paying out promised benefits implies that tax rates will rise to a crushing level — a range of 60 to 80 percent of income — well before the end of this century.
The main problem is Medicare, which reimburses the elderly for many of their health care expenses. As Mark V. Pauly, professor of health care systems at the University of Pennsylvania, has said, “Medicare as we know it today cannot be sustained over the next 50 years and probably will run into financial difficulties within the next 15.”
There’s one important idea lurking in the shadows that neither campaign is keen to talk about: paying out government benefits more efficiently. To put it bluntly, it means paying out full benefits only to those who really need them, and cutting back on payments to everybody else. Most recently, this notion has been proposed by Peter H. Schuck, a Yale law professor, and Richard J. Zeckhauser, a Harvard political economy professor, in their book, “Targeting in Social Programs: Avoiding Bad Bets, Removing Bad Apples.”
“Means testing” — cutting back on payments to the relatively wealthy — is one way to better allocate benefits. For health care costs, this could be done by expanding Medicaid, which is focused on the needs of the poor, and making it an entirely federal program rather than one partly paid for by the states. At the same time, the government would need to limit the growth of Medicare, which is universally applied to all elderly people; as a segment of American society, the elderly are relatively wealthy. With limited resources, it would be better to reallocate health care subsidies toward the poor, whether they are young or old.
Furthermore, inducing the wealthy to pay for their own health coverage would create pressures to lower costs.
An alternative path is to put in place more means testing throughout Medicare. For instance, higher-income older Americans have already been paying larger Medicare premiums and receiving a lower prescription drug benefit; that’s part of what made it possible to expand the prescription benefit within budgetary constraints.
This could be taken much further. Of course, the idea of cutting some government transfers provokes protest in some quarters. One major criticism is that programs for the poor alone will not be well financed because poor people don’t have much political power. Thus, this idea goes, we should try to make transfer programs as comprehensive as possible, so that every voter has a stake in the program and will support more spending.
But even if this argument holds true now, it may not be very persuasive when Medicare costs start to push taxation levels above 50 percent. A more modest program, more directly aimed at those who need it, might prove more sustainable in the longer run.
Americans have supported the growth of many programs aimed mainly at the poor. Both Medicaid and the Earned Income Tax Credit have grown rapidly in size since their inception. The idea of helping the poor — and not having the government take over entire economic sectors — was the original motive behind welfare programs, in any case.
Furthermore, the argument for comprehensive and universal transfer programs does not meet the ideal of democratic transparency. If taking care of the poor is the real value in welfare programs, those programs should be sold as such to the electorate. We shouldn’t give wealthier people benefits just to “trick” them, for selfish reasons, into voting for greater benefits for everyone, the poor included.
Targeted social benefits have been used successfully around the world. Mostly for fiscal reasons, Finland, Sweden, Britain and Australia all have moved toward a greater use of targeted benefits for those who need them. Typically in these countries, higher earners receive lower pension benefits — and that helps to maintain strong and robust welfare states.
The biggest problem with such efforts is measuring and enforcing the rules that establish who receives a specified benefit and who doesn’t. Means testing in Medicaid causes many people to hide income and assets or to transfer assets to family members, so they can look poorer and still get benefits. This is a real problem, but the fiscal difficulties of staying on our current spending path may well be far worse.
Advocates of health care reform tend to be long on ideas for expanding care and access, but short on practical solutions for cost control. The argument is often made that single-payer health care systems in Canada or Europe are cheaper than health care in the United States. But Medicare is already a single-payer plan, yet its costs are unsustainable.
The best option is probably to tie the size of Medicare benefits to a person’s lifetime income, which is relatively easily measured and hard to game, rather than to one’s income or assets in any current year. In essence, higher earners would receive lower benefits instead of facing the prospect of higher taxes, as current trends predict. This policy reflects an ethic of individual responsibility — namely, that people who have earned well throughout their lives should be expected to take care of themselves, precisely so that the truly unfortunate can be helped.
Coverage gaps will remain. What if you lose or squander all your savings, for example, just before you retire? But the real question concerns the opportunity cost of the money we are using to subsidize the health care of high lifetime earners. Given the number of problems in the United States today, it’s hard to believe that this is the best use for the money.
Don’t expect to hear much about targeted benefits anytime before November. Such proposals would acknowledge the painful but probably realistic notion that we don’t have many good ways to control health care costs.
Furthermore, balancing the budget is a popular goal, while cutting benefits is not. But if you’re asking which ideas are most likely to transform economic policy over the next 15 to 20 years, here is one place to start looking.
The Trouble with 'Healthy' Kid Foods
Time magazine reports on a Canadian study finding that 90% of foods professed to be healthy for children did not meet established nutritional standards. Kathleen Kingsbury writes,
Most parents already know that sugary sodas and greasy potato chips are not the healthiest food choices for children. But what about the hundreds of other widely available and kid-friendly packaged foods — pastas, frozen dinners, granola bars — that at least appear to be more wholesome?
A new Canadian study suggests that even these foods — most of which make nutritional claims on their packaging — aren't all they profess to be. University of Calgary researchers analyzed the nutritional benefit of more than 360 such products, often marketed as "fun foods," which are aimed at children either through kid-friendly package graphics or tie-ins with children's TV shows and movies. Three-quarters of these foods, for example, came in packages bearing cartoon images. Researchers did not include junk food in their analysis, but they found that nearly 90% of kid products still did not meet established nutritional standards. What's more, 62% of the foods that researchers deemed to be of "poor nutritional quality" made positive nutritional claims on the package — such as being low-fat, containing essential nutrients or being a source of calcium. "If a parent sees a product that makes specific nutritional claims, they may assume that the whole product is nutritious," says author Charlene Elliott, a communications and culture professor at the University of Calgary. "Our study has shown that that is definitely not true in the vast majority of cases."
Elliott's study, funded by the Canadian Institutes of Health and published in the July issue of Obesity Reviews, shows that successful grocery shopping requires real savvy. For one thing, parents should not be swayed by packaging; researchers found that 8% of the nutritionally deficient items carried some type of official mark or seal of nutrition on the front of the package. About one-fifth of products implied health by showing images of cartoons playing sports. Elliott warns that even if some of the claims on the packaging are true, the foods may still be detrimental to overall well-being.
To judge the overall value of each food, researchers used nutritional standards set forth by the Washington-based nonprofit Center for Science in the Public Interest and adapted from guidelines by the National Alliance for Nutrition and Activity, a coalition of more than 275 American nutritional and health organizations, including many state health departments. While acknowledging that not all foods marketed to children can be nutritionally perfect, the guidelines establish acceptable limits for fat, sugar and sodium content. Foods were determined to be of poor nutritional quality if more than 35% of total calories came from fat, or if they contained more than 35% added sugars by weight. The sodium content cut-off for full meals was 770 mg; for pizza, sandwiches and main dishes, it was 600 mg; and for individual servings of cereal, soup, pasta or meat, the sodium limit was 480 mg. By law, food labels must contain enough information to allow consumers to calculate all measurements.
The food industry has long been under fire for advertising directly to children. They're an irresistibly lucrative target — children under 12 are estimated to spend more than $25 billion a year themselves, and may influence another $200 billion that is spent. But there's no doubt that some of that spending contributes directly to childhood obesity — 32% of American youngsters are overweight, and 50% of the calories kids under 18 eat come from fat or added sugars. Public-interest groups and Congress have urged companies to stop targeting ads to children, and many, including McDonald's, General Mills and Kraft Foods, have taken some steps to comply, by, for example, eliminating cartoons and other kid-centric tactics in their marketing. But consumer advocates say the industry hasn't gone far enough. "We need globally agreed restrictions, implemented through national regulation," says Emily Robinson, campaigns manager for Consumers International, which operates in 115 countries. If companies are left to police themselves, Robinson laments, they'll simply continue with the same minor initiatives announced so far. She adds: "We fear this piecemeal approach is confusing." Ask any parent in a local grocery-store aisle, and she'll probably agree.
Tomato Safety Scare Hurt Consumers' Confidence; Many Support New Tracing System for Produce
The Los Angeles Times reports on the toll the salmonella scare had on consumers and the agricultural industry with tomatoes: It cost the industry about $100 million and left people questioning the safety of foods. Ricardo Alonso-Zaldivar writes,
The tomato scare may be over, but it has taken a toll — it's cost the industry an estimated $100 million and left millions of people with a new wariness about the safety of everyday foods.
An Associated Press-Ipsos poll finds that nearly half of consumers have changed their eating and buying habits in the past six months because they're afraid they could get sick by eating contaminated food.
They also overwhelmingly support setting up a better system to trace produce in an outbreak back to the source, the poll found.
The people who feel that way include the growers.
Virginia's East Coast Brokers, one of the largest tomato growers in the country, has been hammered by slumping demand and falling prices, although Virginia tomatoes were cleared early on, said sales manager Batista Madonia III. He said he's frustrated by the government's inability to find the root cause of the outbreak despite a nearly two-month long investigation.
The salmonella outbreak has sickened more than 1,200 people in 42 states since the first cases were seen in April.
"I guarantee in that time frame, more than 1,000 people were injured slipping on a banana peel," said Madonia.
Although federal officials lifted the tomato warning Thursday, the cause of the outbreak remains unknown. Hot peppers are under suspicion, and tomatoes have not been cleared everywhere.
While the poll found that three in four people remain confident about the overall safety of food, 46 percent said they were worried they might get sick from eating contaminated products. The same percentage said that because of safety warnings, they have avoided items they normally would have purchased.
Christy Taylor, a first-grade teacher from Sacramento, Calif., said she has all but given up on supermarket produce and is buying most of her fresh fruits and vegetables at the local farmers' market instead.
"I see the same farmers every single week," said Taylor, 30, the mother of 2-year-old twin girls. "You meet the people and you see where the (produce) is coming from."
Her twins love tomatoes, she said, and chomp on them as if they were apples. But until the mystery of the tainted food is solved, "I feel a little bit more comfortable, a little more safe, doing the local farmers' market," she said.
Eighty-six percent in the poll said produce should be labeled so it can be tracked through layers of processors, packers and shippers, all the way back to the farm. The lack of such a system frustrated disease detectives working on the salmonella outbreak. However, the industry is divided over mandatory tracing technology, and Congress is running out of time to act on any major food safety changes before the election.
The poll found that 80 percent of Americans said they would support new federal standards for fresh produce. Meat and poultry have long been subject to enforceable federal safeguards, but fruits and vegetables are not, although produce increasingly is being implicated in outbreaks.
The high level of uneasiness should not be taken lightly, said Michael R. Taylor, a former senior federal food safety official who now teaches at George Washington University.
"When you have almost half the population avoiding certain foods because of safety concerns, that's very significant from the standpoint of economic impact for the people selling the food, and from the standpoint of peace of mind for consumers," said Taylor.
In addition to the salmonella outbreak, this year has seen the largest ground beef recall in history, raising consumer concerns reflected in the poll.
The survey found gender, racial and economic gaps on attitudes about food safety.
Women, who do most of the shopping, were more concerned than men. For example, 39 percent of men said they were "very confident" that the food they buy is safe, but only 23 percent of women said they felt that way. However, men and women agreed on the need for better federal oversight.
In Congress, a leading advocate of food safety reforms said the industry would do well to listen to consumers on the need for tracing.
"We live in an age of technology where you can bar-code a banana," said Sen. Richard Durbin, D-Ill. "We've got to work this through with the industry and come up with something that's reasonable. The more confidence consumers have, the more goods they will purchase."
July 20, 2008
Ruling Gives South Dakota Doctors a Script to Read
The Washington Post reports that doctors in South Dakota must now tell women seeking an abortion that they will terminate a "unique living human being." The Court of Appeals for the 8th Circuit last week lifted a preliminary injunction that prevented the language from taking effect. Peter Slevin writes,
In a victory for antiabortion forces, doctors in South Dakota are now required to tell a woman seeking an abortion that the procedure "will terminate the life of a whole, separate, unique living human being."
On another front, South Dakota voters will be asked in a Nov. 4 referendum to consider broad limits on abortion for the second time since 2006. The ballot measure includes exceptions for rape, incest and the woman's health that were not part of the 2006 wording rejected by voters.
Antiabortion forces in South Dakota have been trying for years to halt the procedure and to build a winnable challenge to Roe v. Wade, the 1973 Supreme Court decision legalizing abortion nationwide.
A law that took effect July 1 requires doctors to ask a woman seeking an abortion if she wants to see a sonogram of the fetus. About 700 abortions are performed in South Dakota each year.
The doctors' script that officially took effect Friday has been tied up in court since 2005, when Planned Parenthood challenged a law that instructed physicians what to tell abortion patients. Under the law, doctors must say that the woman has "an existing relationship" with the fetus that is protected by the U.S. Constitution and that "her existing constitutional rights with regards to that relationship will be terminated." Also, the doctor is required to say that "abortion increases the risk of suicide ideation and suicide."
The message must be delivered no earlier than two hours before the procedure. The woman must say in writing that she understands.
"The law is one more terrible, terrible barrier," said Sarah Stoesz, president of the regional Planned Parenthood office. She described the rules as "unprecedented interference in the doctor-patient relationship and unprecedented interference in a woman's life."
Stoesz also called the impetus for the law "ideological" and "non-science-based."
Mailee Smith, staff counsel at Chicago-based Americans United for Life, praised the regulations. "We do think it's a good law, because it does provide a woman with the broadest spectrum of information," she said.
While 32 states have informed consent regulations, Smith said, South Dakota alone includes the reference to a fetus as "a whole, separate, unique living human being."
More Smokers Seek Help With Quitting Since Latest Cigarette Tax Took Effect
The Chicago Tribune reports on how consumers will be affected regarding the recent cigarette tax increase in New York. Lisa Anderson writes,
If you think it's expensive to visit New York City, it's become even pricier to light up here.
The Big Apple now carries the nation's highest-priced cigarettes: $10 a pack, more than twice the nation's average price of $4.22. In Chicago it's about $7.50 a pack. But New York also boasts a lower proportion of adult smokers than the rest of the country — 17.5 percent compared with 19.7 percent nationally.
When it comes to smoking, apparently money talks. Dr. Thomas Frieden, the city's health commissioner, certainly thinks so. After a decade in which smoking prevalence stayed the same, the city's smoking rate dropped 21 percent among adults and 52 percent among public high school students in the five years following cigarette tax increases in 2002. Following last month's addition of a new state cigarette tax of $1.25 a pack, Frieden expects more of the city's 1 million smokers to quit.
Free patch for quittersMaurice Garrick, 34, is one of them. The unemployed chef said the price increase has persuaded him to end his pack-a-day Newport habit. "I just have to do it. It's too much money, way too much," said Garrick. He also availed himself of the free nicotine patches the city has been supplying since 2003.Last week, Frieden reported that calls to the city's 311 help line by smokers seeking assistance with quitting tripled in the week the price increase took effect, compared with the comparable 2007 week. In addition to those 2,700 callers, about 1,600 New Yorkers picked up free nicotine patches on June 3, the day of the price hike.
"The extra push of a higher price results in many smokers stopping smoking forever," said Frieden.
Not so Allison Smith. "If [the price increase] is meant as a deterrent, then the people I know haven't even heard the message," the 29-year-old banker said.
Fighting fire with taxesBut studies have shown that cigarette price increases are among the most effective ways to reduce smoking not just among adults but among young people, according to Danny McGoldrick, vice president for research at the Campaign for Tobacco-Free Kids, a Washington, D.C.-based non-profit. State and local tax increases are important because the federal cigarette tax per pack remains at 39 cents after President George W. Bush's 2007 veto of a bill that would have raised that tax by 61 cents a pack.
"A 10 percent increase in price reduces adult smoking prevalence by about 2 percent, but decreases youth smoking prevalence by 6 to 7 percent," he said. But the most effective solution goes further, says McGoldrick. "When you raise the price, invest in cessation programs that we know work and go smoke-free, you get the most dramatic impact."
In that respect, he said, New York City, with a combined state and local tax of $4.25 per pack, smoke-free legislation and an investment in cessation programs with support from the state, has become the national leader in that trifecta. New York state, which spends $85.5 million annually on tobacco prevention, meets 89.2 percent of the Centers for Disease Control and Prevention's minimum annual funding recommendation and ranks 7th in the U.S.
Chicago, which adopted a comprehensive smoking ban in 2006, has a combined city, county and state tax of $3.66 per pack—the second highest in the country. However, McGoldrick said, the state of Illinois, which imposed a statewide smoking ban this year, falls short on tobacco cessation funding. Ranked 39th in the U.S., Illinois is spending $8.5 million in fiscal year 2008 or 13.1 percent of the CDC's minimum annual recommendation.
On the other hand, in South Carolina, the state excise tax on cigarettes is the lowest in the country at 7 cents per pack. The state ranks 45th in the nation in terms of funding tobacco prevention.
Music as Medicine for the Brain
US News reports on how some neurologists are prescribing music for conditions from Parkinson's and Alzheimer's to stroke and depression. Matthew Shulman writes,
Rande Davis Gedaliah's 2003 diagnosis of Parkinson's was followed by leg spasms, balance problems, difficulty walking, and ultimately a serious fall in the shower. But something remarkable happened when the 60-year-old public speaking coach turned to an oldies station on her shower radio: She could move her leg with ease, her balance improved, and, she couldn't stop dancing. Now, she puts on her iPod and pumps in Springsteen's "Born in the U.S.A." when she wants to walk quickly; for a slower pace, Queen's "We Are the Champions" does the trick.
Music therapy has been practiced for decades as a way to treat neurological conditions from Parkinson's to Alzheimer's to anxiety and depression. Now, advances in neuroscience and brain imaging are revealing what's actually happening in the brain as patients listen to music or play instruments and why the therapy works. "It's been substantiated only in the last year or two that music therapy can help restore the loss of expressive language in patients with aphasia" following brain injury from stroke, says Oliver Sacks, the noted neurologist and professor at Columbia University, who explored the link between music and the brain in his recent book Musicophilia. Beyond improving movement and speech, he says, music can trig ger the release of mood-altering brain chemicals and once-lost memories and emotions.
Parkinson's and stroke patients benefit, neurologists believe, because the human brain is innately attuned to respond to highly rhythmic music; in fact, says Sacks, our nervous system is unique among mammals in its automatic tendency to go into foot-tapping mode. In Parkinson's patients with bradykinesia, or difficulty initiating movement, it's thought that the music triggers networks of neurons to translate the cadence into organized movement. "We see patients develop something like an auditory timing mechanism," says Concetta Tomaino, cofounder of the Institute for Music and Neurologic Function in New York City. "Someone who is frozen can immediately release and begin walking. Or if they have balance problems, they can coordinate their steps to synchronize with the music," improving their gait and stride. Slow rhythms can ease the muscle bursts and jerky motions of Parkinson's patients with involuntary tremors.
Actually playing music, which requires coordinating muscle movements and developing an ear for timing, can also bring dramatic results, says Rick Bausman, a musician and the founder and director of the Martha's Vineyard-based Drum Workshop. The workshop uses traditional drum ensembles, in which groups of participants play percussion pieces, as one form of therapy for patients with a variety of cognitive and physical disabilities, including Parkinson's disease. Bausman teaches participants to play along with traditional Afro-Caribbean beats like the Haitian kongo and Cuban bembe using congas, bongos, and djun-djun drums. "Participants report that their control of physical movement improves after playing the drums, their motion becomes more fluid, they don't shake quite as much, and their tremors seem to calm down," says Bausman.
Indeed, research on the effects of music therapy in Parkinson's patients has found motor control to be better in those who participated in group music sessions—improvisation with pianos, drums, cymbals, and xylophones—than in people who underwent traditional physical therapy. But gains were no longer evident two months after the sessions ended, so the best results require continued therapy. To stay motivated, Tomaino recommends seeking out both therapeutic drumming groups like Bausman's and social dance classes. Patients can also create music libraries for CDs or MP3 players that can be used to facilitate walking.
Because the area of the brain that processes music overlaps with speech networks, neurologists have found that a technique called melodic intonation therapy is effective at retraining patients to speak by transferring existing neuronal pathways or creating new ones. "Even after a stroke that damages the left side of the brain—the center of speech—some patients can still sing complete lyrics to songs," says Tomaino. With repetition, the therapist can begin removing the music, allowing the patient to speak the song lyrics and eventually substitute regular phrases in their place. "As they try to recall words that have a similar contextual meaning to the lyrics, their word retrieval and speech improves," she says.
The technique appears to activate areas on the right side of the brain, suggesting that these areas pick up the slack for the damaged left side, according to Gottfried Schlaug, a Harvard neurologist whose ongoing research uses functional MRI scans to study language recovery in stroke patients. "It's startling to see these images," says Sacks, "one would not expect to see such plasticity in the human adult brain."
Trevor Gibbons, 51, can vouch for the brain's flexibility. A patient at Beth Abraham Rehabilitation Center in the Bronx, where Tomaino heads the music therapy program and where Sacks first began treating chronically ill patients decades ago, Gibbons has been able to restore his speech after suffering a devastating spinal injury from a four-story fall and a stroke in 2000. The former carpenter says that before he began vocal training and playing piano with music therapists at the clinic, he couldn't speak or move and would lie for days in bed, depressed. Following intensive sessions three times a week over several years, Gibbons not only recovered his speech but also has written more than 400 songs, recorded three CDs, and performed at a benefit fundraiser for Beth Abraham at Lincoln Center. (Pre-stroke, says Gibbons, he sang only in his church choir.) His depression has improved, too. "It gave me motivation and a chance to look forward to live another day," he says.
Like Gibbons, patients often report more positive moods following sessions. This may be because of an increase in the production of neurotransmitters like norepinephrine and melatonin, suggested a 1999 study by researchers from the University of Miami School of Medicine. Several studies have shown that calming music can lower blood pressure rates, and last year a Spanish investigation showed that listening to music prior to surgery decreased anxiety, heart rate, and levels of the stress hormone cortisol as much as the anti-anxiety drug diazepam. Stress and anxiety relief, in fact, may be one reason music can help people with Alzheimer's and dementia uncover memories that seemed irrecoverable, experts say. Researchers reported in 2006 that enhanced memory recall accompanied significant reductions in anxiety when Alzheimer's patients listened to the "Spring Movement" from Vivaldi's Four Seasons.
Set at ease by familiar melodies, they may be more apt to communicate, too. Even people at advanced stages of the disease sometimes see improvements in attention and alertness, sociability, and overall functioning following music therapy. The reason, experts suspect, is that music stimulates areas deep within the amygdala and hippocampus, where emotion and long-term memory are processed. Both are less prone to the degenerative effects of Alzheimer's than the outer cortex, the hub for complex thought. Music played at a wedding, a religious service, favorite songs from childhood, or concerts from the teenage years or young adulthood can serve as cues to recover memories, says Suzanne Hanser, founder of the music therapy department at Berklee College of Music in Boston and a practicing therapist at the Dana-Farber Cancer Institute.
Not everyone will respond, and it may take several sessions to see any effect, says Hanser. She finds that simple stress reduction techniques such as facial massage or muscle release exercises can often enhance the music's magic.